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Standing up for devalued managers

1 December 2010

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Stuart Gidden

MiP Editor

An old Chinese proverb says: “May you live in interesting times”. Professor Chris Ham CBE, Chief Executive of influential healthcare think tank The King’s Fund, has certainly been fortunate in this regard. Since he took up his new role in April this year, the landscape of healthcare policy has changed dramatically, with the formation of a new coalition government, the implications of drastic spending cuts and of course Andrew Lansley’s radical white paper on health in July.

The King’s Fund is a charity funded by fees paid for events and projects it undertakes, as well as donations. A major player in the research and analysis of the health system in England, it works closely with ministers and organisations to shape policy with the aim of improving the health service.

A leading expert in health reform and management – he was Professor of Health Policy and Management at Birmingham University from 1992, and served as Director of the Department of Health’s Strategy Unit from 2000 to 2004 – even Professor Ham (pictured) was taken aback by the extent of the proposals unveiled in Equity and Excellence, and the pace of change.

“I think we were all surprised – certainly I was – by quite how quickly the government moved, with the white paper coming out within two months of the election and the speed of implementation of the plans,” says Professor Ham. “In particular, what I didn’t see coming was the proposed abolition of strategic health authorities and primary care trusts (PCTs), and therefore the devolution of all commissioning responsibility to consortia. That was the biggest surprise of all.”

Indeed, The King’s Fund’s response to the white paper warned that the reforms were “too far, too fast” and urged the health secretary to pilot GP commissioning first, before rolling it out gradually. Given the breakneck timelines to the proposals, just why does he think Mr Lansley has been so keen to move so rapidly?

Professor Ham believes it has much to do with the ambition of a new government. “Ministers have said on record that they want to learn from the mistakes of the Blair government. Tony Blair himself has said very clearly that he felt the first term was wasted under new Labour; only in the second term did he really become radical and bold in the way that he felt he should have been much earlier on. I suspect that’s had quite a big influence on people like Andrew Lansley,” he says.

But if the NHS will benefit from GP consortia taking over commissioning, why delay this move? Professor Ham believes the danger lies in the uneven landscape of primary care. “We fully support GPs having a role in commissioning but we think the pace of implementation needs to be adjusted to the readiness of GPs and commissioning consortia to take on the huge responsibilities that are being offered to them,” he says.

“Some are willing to do that quite quickly and probably have the skills to do so; others will take quite a bit longer. So to move as quickly as this across the whole country, without allowing for different degrees of expertise, is a very risky strategy.”

Implications for practice managers
Does he foresee strong involvement from practice managers in the new primary care? “Practice managers will have a significant role to play, because it’s not just what the consortia will be doing – it’s what the practices will have to do as members of consortia,” he says. “Clearly the performance of consortia will be influenced very strongly by how well individual practices are able to contribute, and that’s down to practice management as well as GP leadership. So that will make a very big difference.”

Some managers have expressed concern that the plans are so GP-focused that they feel excluded. Professor Ham believes consortia will need to adopt a big-tent approach to succeed. “While the name on the door is ‘GP commissioning’, we hope that will really be a label covering the whole primary care team, including managers,” he says.

“Most GPs we work with recognise they can’t do everything themselves; they are going to be heavily reliant on good managers at a practice level and a consortia level. There might be a few who don’t recognise that but I would say that’s the exception rather than the rule.”

Will the establishment of consortia have an impact on the practice manager’s role? Professor Ham considers this, before acknowledging there are “a lot of uncertainties” here. In his view, the interplay of different practices could be the major factor that affects managers.

“What you could argue is that this is the latest attempt to achieve greater organisation within primary care, perhaps to reduce the isolation of individual practices and to get them working much more within a ‘system of care’,” he says. “One implication of that could be that instead of individual practices taking responsibility for their management support, over time you could see that migrating more towards a commissioning consortium, because that will become a more significant player in the landscape of primary care. There could be an argument for commissioning consortia supporting practices much more directly, including around their management support.”

“Endangered species”
By abolishing PCTs, is the government undervaluing the need for strong non-clinical management? “Absolutely,” says Professor Ham. “We’ve felt very strongly that the government really doesn’t understand that you can’t run the health service without having excellent managers at all levels.”

Another concern in The King’s Fund white paper response is how the transition from PCTs to consortia will be managed effectively at a time of cutbacks to management costs. At the same time, says Professor Ham, there is the additional risk that consortia may simply be reassembled with similar management staff at a cost of “hundreds of millions of pounds” in redundancy payouts.

But this is not the first time The King’s Fund has clashed with the government over the role of managers. “One of our concerns with what Ara Darzi said in the NHS Next Stage Review back in 2008 was that there was too much emphasis on the medical leadership aspect of it, without the recognition that you need management support there as well,” he says. By way of example, he points to “high-performing” healthcare establishments outside the UK, such as the Mayo Clinic and Kaiser Permanente in the US: “In those organisations you see management and clinical leadership go hand in hand,” he says.
The think tank recently established its Commission on Leadership and Management in the NHS, which will examine the current state of management at all levels of the health service. A report making recommendations will be published in the spring.

“Over the last year or so it seemed that managers have been almost an endangered species within the NHS, there’s been so much criticism of management costs and bureaucracy and the like,” says Professor Ham. “But the counter argument – as to why you need to invest in leadership and management – has not been well made. We are concerned about that and that’s why we’re taking the lead ourselves.”

Peer pressure
Despite a measured scepticism over certain aspects of the white paper, Professor Ham remains positive, and in particular expresses enthusiasm for the potential of “peer leadership for quality improvement” in primary care, which he believes will become increasingly important.

“I think one of the exciting opportunities for commissioning consortia is for GPs who take on leadership roles to themselves do much more around quality improvement of primary care practice, because the contribution that practices make will influence how well consortia do. So there’ll be a new dynamic I think –for the first time you’ll have one group of GPs challenging another group of GPs where they think there’s unwarranted variation in the quality of what’s done.”

It would be an interesting development, but perhaps our readers will be wary. After all, it sounds like that could be one more conflict to manage.