Mark Newbold

What should we expect of our medical leaders?

This is a question I have been asking myself more and more in recent months, sparked by a nagging worry that holding docs to account for balancing budgets or hitting targets might not be fair or appropriate, or indeed the best use of a scarce resource.

It is taken as read nowadays that medical leadership is ‘a good thing’. And it is. But what exactly should we be expecting of those brave souls who step forward?

When it all started about two decades ago, the main role was the provision of advice (often colloquially termed ‘clinical common sense’) to management. I recall though, that as clinical management became established, a view developed that without budgetary control, there was no real power. Power lay with the one who held the purse strings, it was believed, and all aspiring medical leaders were told ‘make sure you have control of the budget’.

This did happen, but interestingly it was normally managed day-to-day by the manager. And if it became overspent, it was normally the manager who was held to account. A similar thing happened when targets were introduced – the clinical director was nominally responsible but the manager was usually the one who was performance managed, and suffered the consequences if achievement was not up to scratch!

And it has largely remained this way, so that presently we have a rather illusory situation whereby the clinical director nominally holds the budget, while the manager manages it and is held to account over it.

My current view is that generally it is not a good use of a doctor’s time and expertise to ask them to take on the role similar to that of a senior general manager. After all, we have managers who are specifically trained to do this. And in fact, holding the purse strings confers only one sort of power, and it is a sort that soon vanishes when times are hard and the need to save outweighs the ability to spend.

Real power comes from respect and credibility, the intellect to understand complexity, and the ability to influence colleagues, superiors, and subordinates in a constructive way. The truly effective medical leader can understand the clinical issues, scan the clinical horizon widely and far forward in time, and understand the implications for their own service or organisation. They can then go on to devise a strategy, gain support and buy-in, and oversee the implementation of it.

Clinical strategy is therefore a key role for medical leaders, and a vital one in these changing and uncertain times. Another one must be the achievement of good clinical outcomes. The effective clinical director will be measuring and monitoring valid indicators of clinical efficacy, and working with colleagues to understand areas of weakness and bring about improvement.

Finally, senior management cannot run a successful organisation without sage advice from doctors. Insight into future developments, help in understanding health issues and how to address them, advice on best use of resources, and an understanding of where the ‘clinical view’ lies on big issues of the day. And ‘yes’, advice on those budgets, and in particular how to stretch them still further without creating adverse consequences for safety, care quality or patient outcomes.

A very different beast then to a general manager. A complementary role that can underpin a very effective partnership between clinician and manager.

Have I got this right?

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3 Responses to “What should we expect of our medical leaders?”

  1. JD says:

    I think the relationship you outline is the right one. At the end of the day, if a budget is overspent it probably means that patients are getting more, and sometimes better care. It is the role of the manager to draw the line on spending, and balancing the books, with input from the lead clinician. The priority of the doctor has to be optimal care.

  2. milly says:

    Since becoming a CD 18 months ago, my views on this have changed and basically I’m with you now. My job is to draw together good ideas on service development, expansion etc, and once I’ve done the first half of the business case, it’s my divisional manager’s job to fill in the money half. The monthly spreadsheets, target summaries etc are basically their job, and I’m just there to sensecheck them as far as I’m concerned…

  3. Rahul Mukherjee says:

    The point about budgetary control and medical leadership is really well made and definitely at times of crisis, the true medical leader and innovator tend to become more “powerful” in terms of influence as opposed to the purse-string holder. It would be nice if true medical leaders worked more effectively with purse-string holders.
    In this context, a related issue (not exactly within the scope of the blog) is the budgetary transperancy (taking the NHS as a whole). Medical leaders and innovators with some grasp of distributive justice issues (not just anyone wearing a “consultant” or even a “professor” badge who is mentally just an advocate of their narrow silo) do need to understand budgetary flows and trends to be able to design more sustainable services in keeping with changing needs and expectations.

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