Why should doctors be involved in management? Given the complexity of mental health services and the considerable challenges for more change, it is hardly credible that the intended benefits for individual patients can be realised without some clinicians taking active roles as managers. Many of these challenges have been identified clearly in the National Service Framework for Mental Health - Five Years On (Reference ApplebyAppleby, 2004). The key priorities are explicit but are broad and many will be difficult to implement. Moreover, with constant political, social and technical changes comes the need not just to adapt but to anticipate and predict the future based on an intelligent analysis of an otherwise bewildering environment. Inevitably, newer, more flexible ways of working are starting to emerge. But this does not happen by chance. The need for medical leadership and management has never been greater.
Perhaps these are just the things that will attract more of us into management. There is a great deal to be done and formal roles as clinical or medical directors provide significant opportunities to influence and lead change and improve the ways we work for the benefit of our services and also ourselves.
Unfortunately, for some medical managers, perhaps many, their ability to do a good job has been compromised by failure to provide the conditions for success. Getting this right is essential if psychiatrists are to be engaged effectively in planning and improving services. Why is it that the effectiveness of medical management, and the importance with which it is regarded, is so variable between trusts? From across the North East, Yorkshire and Humber areas medical and clinical directors have begun to examine this issue. We number about 20 in total and have been meeting as a group for about 4 years.
We hope the preliminary findings from our study will stimulate further discussion not just among the psychiatric profession but with chief executives, and more broadly with other managers and other disciplines. Unless we act soon to get the right forms of leadership to influence developments appropriately, there is a real danger that our services, and indeed our profession, will get left behind.
The study
In early 2005, the Executive Committee of the Northern and Yorkshire Division of the College agreed a ‘concordat’ with the National Institute for Mental Health North East, Yorkshire and Humber Development Centre. The latter would provide the resources for work of agreed importance. As a result, the time of an expert investigator (E.R.) was made available to undertake a brief survey of the problems facing psychiatrists in medical management roles and potential solutions.
Semi-structured interviews were conducted with a range of individual medical managers using questions suggested by the medical managers’ group. The results were presented to the group which endorsed the following findings.
Findings
We categorised the findings into four broad-based themes: clarity, capacity, capability and context.
Clarity
Big differences were found in how clear doctors in management were about what they are supposed to do. We found great variation in job descriptions and roles of medical managers, including medical directors. For example, some respondents had specific roles with specific job descriptions whereas others did not. The uncertainty was greater for those with posts below trust board level. Even the job titles lacked consistency and clarity with the terms ‘ clinical director’, ‘lead clinician’, ‘clinical lead’ and ‘associate medical director’ being used interchangeably. More importantly, it was often not clear to the medical manager (or indeed those around them) what was expected of them.
This uncertainty extended to career progression. Many medical managers worried about the lack of any career or succession planning. A lack of clear identity was often articulated in terms of feeling neither a consultant nor a manager.
As for solutions, the following were recommended as a minimum:
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• the identification of core, agreed functions of a medical manager;
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• the availability of effective mentorship and support (including the development of peer group networks) to reduce isolation;
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• the identification of career and succession opportunities for medical managers.
Capacity
Interestingly, there was considerable variation in the scope of different jobs and the time allocated to do them, with little apparent correlation between the two. Sometimes capacity was ‘created’ by offering extra money (in the form of salary or benefits) with no real time in which to do the job. Unfortunately, the results were predictable. Although some management posts may be accommodated by reorganising clinical work or providing additional support (such as more secretarial or junior doctor time), when clinical commitments remained largely unchanged, performance of the management role suffered. Those with substantial commitments require substantial time commensurate with the workload.
In addition, it is clear that having the right capacity also means having a number of other things to hand, including good information and information technology, supportive colleagues (at least some) and enough space in which to work and meet. Indeed, support structures, such as a good physical environment and (readily available) help from others, were said to be major factors in the ability of the medical manager to perform effectively.
However, the major concern expressed was lack of time to do the job properly. Experience showed that essential tasks could not be performed well in notional extra sessions without real time during the working week when people are available. Examples of such essential tasks are:
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• following up the outcomes of appraisal and supervision diligently;
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• dealing with the pastoral and development needs of new consultants (including international recruits);
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• engaging effectively with planning and development;
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• thoughtful addressing of important strategic issues that may help avoid future crises.
Capability
Mental health services are becoming increasingly complex as a result of increasing demands, the growth of services, changing national policy and the increasing need to work collaboratively in multi-agency environments. Hence, if services are to develop and deliver continuing improvement, the medical workforce needs to be constantly updated, motivated and engaged in adapting its knowledge and skills to best effect. Competent medical management is crucial to achieve this. Medical managers in psychiatry must have the opportunity to acquire the skills needed to undertake difficult roles in this complex and changing world (Department of Health, 2005).
Personal development activities were available for all respondents but they tended to be locally identified, funded and delivered with a lack of accreditation and quality assurance. As a rule, the learning opportunities were neither a core set of linked activities with defined outcomes, nor were they overtly linked strategically to organisational development.
Furthermore, a majority of respondents acknowledged their preferred mode of learning was in a single professional group with learning activities facilitated by other consultant psychiatrists. For those who are new to management this is perhaps understandable but arguably it may also significantly limit their development as medical managers. How can we ensure that key skills in working across organisational and professional boundaries are acquired and improved?
The importance of developing skills in appraisal, negotiation, delegation and leadership was usually fully appreciated by medical managers, but many were unsure of how to go about it. Matching the skills of other professional managers, and understanding them sufficiently to collaborate, influence, negotiate and sometimes lead them, would seem to require more inter-disciplinary training in management.
Context
Respondents agreed that success as a medical manager depends in great part on the organisational context in which work is undertaken and the extent to which mutually supportive relationships with key colleagues are enjoyed. Critical success factors identified included strong partnerships with other colleagues which allowed the development of agreed organisational vision, similar objectives and complementary roles.
One of the key difficulties is the need to bridge the two different worlds of clinical colleagues and senior managers.
It is not surprising that managing the tension constructively between these two groups of professionals can be a considerable challenge (Reference Garelick and FaginGarelick & Fagin, 2005). There is clearly a need to be in touch with the day-to-day problems and difficulties of front-line clinical staff but also to understand and relate these problems to the wider organisational and strategic context in seeking practical solutions. In essence, this means being available to listen to the concerns of clinical colleagues and being able to take appropriate and effective action when needed. The crucial question is whether the organisational culture and structure facilitate or inhibit this.
Conclusion
If we are to make the most of current opportunities for mental health services, we must ensure that we are able to work effectively alongside clinical and managerial colleagues to ensure that all services match the best standards and that these best standards continue to improve. As a profession, we need to influence appropriately the structure and configuration of service models and to engage those who commission our services to secure the necessary investment, now and in the future. If, and when ‘payment by results’ happens, as expected in mental health services, we are likely to see a shift of investment to services that perform best. This means that no service can afford to fall behind.
The case for truly effective medical management has never been greater, but the results of this study and the experiences of others indicate the current situation needs to change. Crucial to this is the identification of potential medical managers and the establishment of clear opportunities for career progression. Furthermore, there is a need to define a set of core functions for medical managers and to establish effective mentorship and support mechanisms.
The strategic importance of medical management in today's services is difficult to overestimate, but for the right foundations to be in place, trust boards and we as a profession must take it more seriously. It is no longer acceptable to hope that a medical or clinical director with an unclear role, inadequate time, meagre support and little or no preparation for the job will deliver clinical engagement, clinical governance, strategic advice, sort out the vacant posts and deliver new ways of working, let alone service redesign, crisis management and helping struggling colleagues.
The question is what should the psychiatric profession do to move this forward? The College's recent appointment of a Vice-President with responsibility for management is to be welcomed and indeed the Management Special Interest Group has continued to work hard for issues such as these to be given due consideration. In addition, November 2005 saw the first national conference on medical management in mental health services - it will, one hopes, not be the last. But is all this enough? Whatever else we do, we must continue to enter into dialogue with other health service managers, other professions and other organisations to ensure that previous failings are never repeated and that psychiatry plays its full and rightful part in improving services for those who use them and those who work in them.
Declaration of interest
None.
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