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Dr Mahiben Maruthappu, a London-based junior doctor in acute medicine and Senior Fellow to NHS England’s Chief Executive, juggles the management theory with frontline service:
Recently there was a cardiac arrest call for an elderly patient our team had admitted.
While there are over 30,000 cardiac arrests a year in our country, statistics cannot capture the depth and intensity of such an event. Assessment, chest compressions, adrenaline, teamwork.
Despite our best efforts, the patient died.
Concurrently at NHS England, I’d been developing our innovation roadmap, and preparing for our major event Expo, where 5,000 people convene to discuss the future of the service and how we can harness technology across the system.
On the surface, the two worlds seem almost incomparable.
From August of this year I started to work part-time as a doctor on the wards, and part-time in the Chief Executive’s Office of NHS England, aiming to better understand the gap between front-line practice and national policy.
It’s taken time to adjust, moving from the rush of managing a patient with a heart attack to co-developing NHS England’s approach to combatting obesity and cardiovascular disease. Trying to balance the two has been as insightful as it has demanding.
Given the absence of precedent for such a pairing, expectations were murky. There are over 150,000 doctors in England; this is roughly four times the number of managers. Clinicians, managers and policymakers have had a tense relationship for decades. Serving as part of each has brought challenges, from uncompromising diary and rota managers to disagreements among clinical teams. While these settings are very different, threads of similarity join them:
First, the need to square consistency and personalisation: Across healthcare there exists a tension between abiding by evidence-based protocol and going off-piste, be it national policy to reduce sugar intake, or managing diabetic ketoacidosis.
The NHS has almost one million patient contacts a day, with over 835,000 people visiting their GP practice or practice nurse daily. We try to mitigate risk by basing all we do on robust evidence, but in some important spheres of care this simply does not exist, and instead, astute decision-making or rapid piloting is needed. Knowing when to abide by the evidence or drift from guidelines differentiates competence from excellence.
Healthcare – not just policy, management or medicine, but all three – blends art and science. A clinician must be aware of when to follow guidelines, and when to justifiably deviate – be it off-license use of a drug, or trialing a new minimally-invasive surgical procedure.
Likewise, research and data must drive policy, but this must be matched to the political landscape and feasibility, for example when building new models of care which require a mixture of local government, health and social care collaboration. There is perhaps more that connects the practice of medicine to the development of policy than most of us would like to believe – we aren’t that different.
Second, culture is king: A negative culture and one that lacks support results in poorer patient outcomes, errors and costs, as demonstrated by the Mid-Staffordshire inquiry. This is the same when handling a cardiac arrest as it is for establishing better integrated care.
We need a culture focused on innovation – concurrent improvements in safety, quality and efficiency, rather than any of these alone. With over 1.3 million staff, creating cohesion in the NHS is challenging to say the least, but it will dictate how far and fast we deliver.
I must admit, when thinking about culture, one key change concerns hierarchy. At NHS England, National Directors are known by their first name, juniors can approach seniors, respect is mutual. The wards, however, remain stifled rather than supported by hierarchy. Consultants, at times, offer limited acknowledgement to juniors making for dysfunctional and ineffective teams. There is perceivably more hierarchy on a ward-round between a handful of doctors, a nurse and a pharmacist, than amongst senior decision-making teams in policy.
Third, amidst growing demand, we need greater system alignment: Last winter alone 5,100 more people attended A&E everyday compared with 2010. Watching colleagues diagnose and treat a mounting number of patients arriving at A&E, or streamline programme management to its leanest in NHS history makes the pressures even clearer. But for us to be effective, we need stronger alignment. Healthcare is not just front and centre, local and national, clinicians and managers; it’s complex and it’s multidisciplinary. Appreciating this will be instrumental to whole-system working.
Practicing clinically while working in NHS England’s Chief Executive Office has been a privilege; but this should be the rule not the exception. Current events make it clear that greater alignment is needed from ward to board. I recently thought that offering front-line staff a seat at every national table could serve as a solution, from the Department of Health, to the Cabinet Office, to the emerging NHS Improvement, but the NHS needs a more robust approach.
Make or break, it is perhaps time to rethink and recalibrate the relationship between our staff and our system.
- This article has previously been posted by the HSJ.