Unfinished business: The development of medical management roles in the UK NHS
by Ian Kirkpatrick
Chair in Management and Deputy Dean of School, York Management School, University of York
For some time, in the UK National Health Service (NHS) and more widely there has been an ongoing drive to co-opt doctors and other clinical professionals into management and leadership roles. This has involved some doctors becoming full time managers, or part time ‘hybrid’ professional managers, such as clinical director roles, clinical leads or even directors sitting on the boards of NHS organisations.
These changes have ran in tandem with the development of new medical competency frameworks, a proliferation of education and training initiatives – for example, the NHS Leadership Academy - and the formation of peak associations such as the Faculty of Medical Management and Leadership. In short, it would appear that clinical leadership has moved from ‘the dark side to centre stage’ (Ham et al., 2011).
However, it remains unclear how far the objective of persuading more doctors to leave aside their clinical work and commit to management roles has been realised. In an earlier review of this topic Dickinson et al. 2013) conclude that there are ‘many barriers to involving doctors effectively in leadership roles’ and that ‘in most organisations a step change is needed’ to overcome them”.
Our latest research explores this concern about whether a step change has occurred. Specifically, we used NHS Directory of NHS managers, published by Wilmington Healthcare Ltd [https://wilmingtonhealthcare.com/] to map the population of medical managers in the NHS and recent trends in its development. This database contains information on all NHS managers, relating to 100 job roles in over 450 organizations. It spans almost 30 years, although for ease of comparison, we focused only on eleven years of data (from 2007 to 2018).
We found that in 2018, there were 27,484 managers in NHS, 6,090 of whom (or 22%) were doctors by background. On average, women made up a majority (around 57%) of all NHS managers, although not in the case of medical managers (MM’s) where they accounted for only 23.3%.
Turning to the question of the types of management roles performed by doctors, in 2018, the top five roles (in descending order of magnitude) were: Clinical Lead (2,609); Clinical Director (1,665); Medical Director (579); Non-Executive Director (184); and Chair of CCGs (173). For the most part MMs were less mobile than managers in general, with the vast majority of doctors only having worked (as managers) in one organisation.
Given major reorganisations in the NHS, especially in primary care, it was hard to accurately measure trends over time. Therefore, as a further step we focused on a more limited comparison of MM roles in 151 acute care trusts in England between 2007 and 2018.
Surprisingly this analysis revealed that, while the average number of managers in each trust rose, the proportion of MMs fell by 14%: from 18.97%, on average, to 16.83%. A similar trend was also noted for clinical leads, where numbers fell by 8%, between 2014 and 2018.
However, while these figures indicate that the population of MMs has not grown as much as might be expected or hoped, other trends suggest that doctors in these roles appear to have consolidated their position. For example, we found that the range and diversity of MM roles had increased over time. While in 2007, the average number of roles in each acute trust occupied by doctors was 7.3, by 2018 it had risen (by almost 19%) to 8.68. Secondly, we noted a significant change in the seniority of MMs. The number of doctors in strategic apex roles (including board membership) increased from 321 in 2007 to 564 in 2018, or, as a proportion of all MMs, from 10.5% to 18.12%. We also found that the tenure and experience of MMs had increased significantly. While in 2007, their average experience was 2.84 years, by 2018 this had risen to 3.85 years (a 36% increase).
To conclude, at face value these findings might seem surprising and perhaps also disappointing. Despite efforts to push medical leadership in the NHS to the centre stage, the overall level of involvement in management roles has not shifted dramatically. This might be testimony to the familiar obstacles that face doctors entering these roles: poor financial incentives, limited training and competition from general managers with specialist expertise. A period of austerity and workforce shortages might have further undermined the ability (of increasingly busy) doctors to step outside their normal clinical roles.
Nevertheless, our findings give some cause for optimism. Doctors are now more involved in strategic management roles in acute trusts. They are also more experienced and perhaps better able to influence decisions and healthcare outcomes. As such, while medical management is still unfinished business in the NHS, it has arguably become more embedded, influential and effective. Going forward our research will explore these possibilities with a view to further strengthening the evidence base, especially on the links between medical leadership and improving clinical outcomes.
References
Dickinson, H., Ham, C., Snelling, I., & Spurgeon, P. (2013). Are we there yet? Models of medical leadership and their effectiveness: An exploratory study. Southampton: NETSCC, HS&DR.
Ham, C., Clark, J., & Spurgeon, J. (2011). Medical leadership: From dark side to centre stage. London: The King's Fund.