Why do clinicians and managers struggle to work together?

With an army of more than 1.5 million staff, a £116bn budget and millions of patients to look after, it’s crucial that the NHS is well managed. But three years ago the landmark Francis report warned of serious problems. “Clinicians must be engaged to a far greater degree of engagement in leadership and management roles,” it said. “The gulf between clinicians and management needs to be closed.”

Has the relationship between clinical and managerial staff improved since then? Last year, research by the Nuffield Trust suggested financial pressure was compounding the problem, with many staff worried that “relationships are likely to deteriorate over the coming year”. The report concluded: “There is a long way to go.” We asked clinicians and managers to share their personal experiences of this fragile relationship.

Manager: ‘When I first started it was hard to get clinical staff to work with people like me, but things are changing’

I find it quite rare that clinicians and managers don’t get on. There’s not really a big difference. It’s just that they’re being pushed in very different ways.

National targets cause quite a lot of trouble, because you end up having a really tricky middle-management layer. They’re getting shouted at from above, from the senior director level, to meet their key performance indicators (KPIs). They’re also getting shouted at from clinicians, who see the KPIs as dehumanising.

For me, the sort of issue that I come up against is trying to release staff to do improvement work. I end up being the middle man; I want to get clinical staff out of their workplace for a few days, but I can also see from a management perspective that taking people out for that much time is not an option.

You get really weird setups, where consultants are managed by somebody who’s paid maybe half their salary. They think: “I know you’re my manager, but I also know you can’t tell me what to do, and I’ll do whatever the hell I want.” It becomes difficult for managers to change things and implement new ways of working. They’ve got to be skilled in the art of emotional intelligence. It’s almost manipulation – they need to impart ideas into people’s brains without a direct command.

When I first started, it was hard to get clinical staff to work with people like me – and to want to engage with change and improvement. But recently, we’re finding that staff are coming to us and saying: “We’re struggling, can you come and help us?”

My manager was about to risk my patient’s life for the sake of a government-inflicted target

A&E nurse: ‘One manager risked a patient’s life for the sake of a target’

We have managers who you rarely see in person. They are simply a barking voice on the other end of the phone. They harass you endlessly when a patient is coming close to breaching the four-hour target in A&E. I get relentless phone calls; if they actually let me get off the phone and do my job I could focus on managing and preventing breaches.

It’s rare that they ever come down as a supporting presence in the department. Some of them have a clinical background, but you rarely see them rolling their sleeves up and digging in to help us out. I feel alienated from managers.

Once, I was working with critically unwell people and a patient was coming up to a four-hour breach. We’re fined for each breach. Someone in a suit approached, took the brakes off the patient’s trolley, and started to push them out. He said: “This patient is about to breach, we need to get him to the ward.” The response was: “This man’s blood pressure is dangerously high. You won’t make it to the ward.” This manager was about to risk the patient’s life for the sake of a government-inflicted target.

Clinical manager: I’ve got a very responsive senior management team

I’m fairly lucky, I don’t have a heavy-handed senior management team and they’re very responsive. If I go along and say I have an issue, they listen. I didn’t set out to be a clinical manager, but managerial responsibilities come with the grade. The advantage is I know what the job is; I’ve had to do it.

I work in a small health board so it’s reasonably easy to communicate with each other. People are around and we’ve got good face-to-face relationships. I think when you’ve got a much bigger organisation, it’s harder to do that.

NHS manager: ‘The health service runs because managers and clinicians get on’

Running the NHS is an incredibly complicated operation, so I guess it’s not surprising if there’s a lack of understanding about what managers are doing all day. But most of the time, the NHS runs because managers and clinicians get on – not despite the fact that they don’t.

Sometimes it’s the managers who are seen as making the tough decisions and implementing the policies no one likes. But actually, in the parts of the NHS that are really succeeding, those decisions will always be made in partnership with clinical colleagues and leaders. And they’ll always have what’s right for patients and their families at the heart of it.

Managers share an awful lot of the same motivations as doctors, nurses, therapists and scientists. They have a lot more in common with clinical staff than we’re given credit for.

Junior doctor: ‘I don’t know who my manager is’

I’ve worked with some managers who are diabolically awful, and it makes it really hard to get your work done. As a junior doctor, it’s difficult to interact with senior management. We’re not invited to any of their meetings; we’re not consulted on anything.

Recently, I worked in a hospital where they sacked all the phlebotomists because they needed to save money, and said: “Well, the junior doctors can take those bloods anyway.” We can, but there’s only so many things you can do at a time. So they get done sporadically through the day, when you’ve got two minutes to spare. It means that if your results don’t get back until 8pm, then a lot of older people won’t be able to get home afterwards, so they’re stuck in hospital for another night, wasting money. If any junior doctor had been invited to the meeting where they decided that, we could have warned them. But there’s no relationship with management, and there’s no consequences if they get things wrong.

Consultant: ‘Managers see things from a very different angle: it’s all numbers and targets’

At the moment, it’s very much: “Here’s your list of patients, get on with it.” People start to resent that after a while. The fundamental change that needs to happen is that managers have more exposure to patients, and doctors have more exposure to management.

Managers see things from a very different angle: it’s all numbers and targets. Operations might get cancelled because somebody in the booking office has put together an operating list without knowing the details of the case, the complexities of it, and how fast or slow that particular surgeon is. It would make sense if doctors had a lot more input into how every day is run, what equipment is procured, and so on. People do try to engage, but it’s incredibly difficult to make those changes.

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Why do clinicians and managers struggle to work together?

MPs demand hard line against clinicians who do not report FGM

The government should impose harsher punishment on professionals who decide not to report female genital mutilation in children, saying they are “complicit in a crime being committed”, according to a group of MPs.

The failure of the UK to make a single prosecution against FGM despite changes in legislation that make it mandatory for professionals to report FGM is “beyond belief” and is leading to “the preventable mutilation of thousands of girls”, according to a damning report from the home affairs select committee.

The committee says it is alarmed by reports that clinicians are ignoring the requirement to report child cases of FGM to the police, which was put in place last year, and urges NHS employers and royal colleges to “take a hard line against such attitudes”.

It states: “Existing disciplinary procedures for professionals who ignore the duty on mandatory reporting are insufficient and ineffective and it is unacceptable that some clinicians appear to refuse to accept it as their responsibility. The duty to report must not be seen as optional. A decision not to report puts children’s lives at risk and is complicit in a crime being committed.”

The committee risks reigniting a row with health professionals, some of whom have argued that mandatory reporting is counter-productive and compromises patient confidence.

The first annual statistics gathered on FGM released in July revealed there had been 5,700 new cases of female genital mutilation recorded in England in 2015-16, and provided hard evidence that the practice was happening on UK soil, with 18 cases recorded as happening in the UK. There are an estimated 134,600 women with FGM born in countries where FGM is practised and living in England. More than 20,000 girls a year are thought to be at risk of FGM in the UK.

FGM – the practice of removing some or all of a girl’s outer sexual organs, which can lead to serious and lifelong health complications – has been illegal in the UK since 1985 but it took 29 years before the first prosecution was brought to trial. The defendants were found not guilty. Since 2010, only 29 cases of FGM offences have been referred to the CPS, with a number of cases still live. The report compared these result to other countries: in a similar period there have been 40 FGM-related trials in France, six in Spain; two in Italy and Sweden; and one each in the Netherlands and Denmark.

“It is beyond belief that there still has not been a successful prosecution for an FGM offence since it was made illegal over 30 years ago,” stated the report. “That is a lamentable record and the failure to identify cases, to prosecute and to achieve convictions can only have negative consequences for those who are brave enough to come forward to highlight this crime.”

There was a “strong case” for routine medical examinations of children deemed to be at particularly high risk of FGM, said the committee. The practice had resulted in “large number of successful prosecutions in relation to FGM in France” but would require “a radical change in practice in the UK” and risked being “unnecessarily traumatic”.

The report also criticised the quality of data being gathered on FGM, although some progress had been made. Despite publicity surrounding the Government’s Summit on FGM in 2015, there was still “a paucity of information on the scale of FGM, on its trends over time and on the number of girls at risk”, stated the report. It called for a government FGM Unit – similar in scope to the Forced Marriage Unit – to collect data and report on progress in police investigations.

Police said on Wednesday that 33 children had been referred to safeguarding services, an 11-year-old girl was taken into police protection and a man and woman detained at Heathrow airport following a police operation that targeted flights to countries with high rates of FGM. Officers spoke to 5,000 people about UK law during Operation Limelight, according to the National Police Chiefs’ Council, but the report said “much more needs to be done to detect and prevent girls from being taken out of the UK to undergo FGM”.

Alison Macfarlane, a professor of perinatal health at City University London and author of a report on the prevalence of FGM in the UK, said the current methods of collecting data on FGM were “completely meaningless”. She added: “Ferocious penalties against doctors who don’t report FGM gets nobody anywhere. It is a sideshow from the positive things that are being done to prevent FGM, and it will deter women and girls from going to the doctor for help they may need.”

The Royal College of Midwives said that while a prosecution was “an important element” in the fight against FGM, many survivors were finding it difficult to access health care and psychological support. “We must address the need for culturally appropriate physiological services for survivors of FGM,” said the college’s professional policy adviser, Janet Fyle. “They are not being provided at anywhere near the levels required,” she added.

Equality Now, which has advised the government on FGM policy, said it did not support medical examinations of girls and did not think an FGM unit would be beneficial as “past experience showed that this did not work very effectively”. Mary Wandia, End FGM programme manager, said: “Every girl at risk of FGM should be protected in every possible way – particularly by those with a duty of care. If there is a failure to prevent this – or any incidence of child abuse – then the person who failed should be held to account.”

Nimko Ali, an anti-FGM activist and survivor, said she was confident that data collection and mandatory reporting – as well as a raised awareness about FGM – would result in a prosecution and welcomed the call for professionals to face disciplinary procedures if they failed to report FGM. “That prosecution will take time, but what is more important is that these policies are preventing girls from being cut in the first place, she said.”

MPs demand hard line against clinicians who do not report FGM

Clinicians, not bed movement, need to dictate discharges

In addition to this, most new hospitals built under PFI (private finance initiatives) have, on average, 30 per cent fewer beds, principally because the companies that run the hospitals are keen to cut costs. This has added further pressure to the remaining accommodation. Most hospitals in Britain currently operate at about 100 per cent occupancy rate. In contrast, most hospitals in Europe operate at 80 per cent.

It’s easy to see why, if the hospital is full and there are sick people waiting, you have to operate a one-in, one-out system. The only option is to turf someone less sick out of their bed and send them home, regardless of the time of night. Meanwhile, rates of the superbug MRSA and the infection Clostridium difficile, which causes vomiting and diarrhoea, are more than 40 per cent higher in hospitals with 90 per cent bed occupancy than in those with less than 85 per cent. And of course an outbreak in a crowded hospital, can result in whole wards being closed. Thus there is further pressure on the remaining beds.

If we stop late-night discharges, there will be a corresponding backlog of patients in A&E. But equally, sending vulnerable people home late at night when there is no guarantee that the social care they need is in place or their families are ready to step in is unacceptable. This needs some clear, sensible direction from those in charge of the health service. I, along with doctors, nurses and countless patients and their relatives, hope that they find a way to put a stop to this practice. Then we can all rest easy in our beds.

Bad news for fraudsters who con the elderly

I’m delighted to hear that the Sentencing Council is introducing guidelines that will see tougher jail sentences handed out to fraudsters who target the elderly and vulnerable.

While working in dementia care and with people with learning disabilities, I have come across heartbreaking cases of people being conned out of their entire life savings. But as the Sentencing Council acknowledges, sometimes even relatively small sums of money can have a devastating impact on the victims.

The guidelines coming into force on October 1 mean that at last judges will now be able to take into account the extent of the victim’s suffering – not just the size of the sums of money involved – when deciding the punishment. About time, too.

Don’t ignore anorexia

It often surprises people to learn that of all the psychiatric conditions, the most deadly is anorexia. Despite high‑profile deaths, such as that of the singer Karen Carpenter, the public still struggles to understand the seriousness of eating disorders.

Although the risks associated with anorexia have long been known, research by Oxford University published last week illustrated the extent of the danger. Life expectancy for those with the condition is worse than for those who smoke 20 cigarettes a day. It’s estimated that between 5 and 20 per cent of sufferers will eventually die from it.

It’s an area I feel passionately about because of the lack of sympathy it garners from other people, including some doctors. There is a sense that – more than with any other mental health condition – sufferers should pull their socks up. Everyone else can eat normally, so why can’t they?

It is more than 20 years since the late Diana, Princess of Wales spoke out about her own eating disorder. More recently, the actress Christina Ricci has followed suit. And yet the level of ignorance is astounding. It’s not simply that sufferers want to be thin, as though it’s some perverse form of vanity; it is a desperate, unconscious attempt to deal with deep-seated emotional problems.

Ensuring that there are adequate services and provision to help these people should be an absolute priority.

Max Pemberton’s latest book, ‘The Doctor Will See You Now’, published by Hodder, is available from Telegraph Books for £8.99 plus £1.10 p&p. To order, call 0844 871 1515 or go to books.telegraph.co.uk

Clinicians, not bed movement, need to dictate discharges