Tuesday, 17 March 2009


I've had to spend a lot of time of late mixing with managers. This used to be seen as fraternising with the enemy but increasingly I do see it as A Good Thing because there's then the opportunity for managers to appreciate what life's like for clinicians at the coal face (so make more valid and helpful decisions for us) and for clinicians to interject in to decision making to minimise how unhelpful decisions are implemented.

Part of the managers' agenda is "clinical engagement" and motivating clinical staff to improve things, as managers desire/are tasked to do/are required to evidence.

Some things really are about just showing that we do what we do. Our PCT knows what we do. The commissioner for our services was a senior manager within our Directorate and knows exactly what we deliver on. A request for information on what clinical activity we're undertaking is purely a tick box exercise to evidence a target's been met. Staff take time to record the activity explicitly for no additional benefits, no change in patient care, but it's done for the direct benefit of managers.

How much clinician time can be eroded in such a way? How many audits, data capture, clinical review, risk management proforma, benchmarking, key performance indicator outcomes, quality metric data and target data can clinicians be asked to complete, on every patient, before really it's compromising their work as clinicians and really should be work a data analyst or clinical governance staff or clinical effectiveness staff or a service manager should be undertaking?

But through habit and good will, clinical staff keep filling in the forms. If their boss tells them to, it's hard to say no.

Hardly the best way to inspire clinicians, to engender "clinical engagement" and improve quality, though.

A clever man shared a moment of insight with me, recently. He was of the opinion that staff motivation and drawing on the good will and expertise of clinical staff is a tricky job for managers because loyalties are divided and diffuse. His thought was that most clinical staff feel principal loyalty to their professional group, identifying themselves primarily in this way. "I'm a doctor. I'm a nurse. I'm an occupational therapist." At work, what I am is defined by my profession. This can be a modest factor or a very strong factor, as animated discourse on Dr Crippen's blog and Mental Nurse have evidenced.

After the professional role comes the discpline. "I'm a surgeon. I'm a GP. I'm an RMN. I'm a forensic psychologist." We identify ourselves by our discpline. I'm a psychiatrist.

Next, we identify ourselves with our service or our team. "I work as a cardiac surgeon within the Aceness on a Stick Unit. I'm a rehab OT in the orthopaedic ward for smashed up motorbike people. I'm a diabetes nurse working within the prison in-reach services." We think of ourselves as in-patient paediatric staff or as ITU staff or as community mental health workers in the CMHT or as palliative care staff in the hospice or whatever.

Then we've affilliation to the place, "I work for the Royal Magnificent Hospital. I work at the Wondrous Care Practice." We identify ourselves with the place and locality we work within.

We've then some understanding of the organisation. "I work for the Best Care Ever NHS Foundation Trust." The organisation tells us how we work, what we do, pays our wage so figures somewhere in our thinking, but is too abstract to be in the fore of our thoughts or loyalties.

Lastly it was suggested we've loyalty, "scattered like magical dust throughout this," to the NHS.

You could tell it was a senior and experienced clinician who'd suggested this, 'cause he's right on the money. When with a patient, our loyalty is to our patient. When thinking more abstractly, our loyalty tends to be to profession, discpline, team, hospital, then organisation.

Our Trust needs to do a lot of work in wooing and rewarding staff if clinicians are to be enamoured with the Trust agenda and do yet ever more for them . . .

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