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Navigating the NHS
core issues for clinicians

Edited by

PETER LEES
Senior Lecturer in Neurosurgery
Director of Research and Development
Southampton University Hospitals NHS Trust

Foreword by

Sir Kenneth Caiman

Chief Medical Officer
Department of Health

MJM
THE BRITISH ASSOCIATION
OF MEDICAL MANAGERS

CRC Press
Taylor & Francis Group
Boca Raton London New York

CRC Press is an imprint of the

Taylor & Francis Group, an informa business
First published 1996 by Radcliffe Publishing
Published 2016 by CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 1996 Peter Lees
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
ISBN 13: 978-1-85775-106-2 (pbk)
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts
have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any
legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that
any views or opinions expressed in this book by individual editors, authors or contributors are personal to them
and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this
book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement
to the medical or other professional's own judgement, their knowledge of the patient's medical history, relevant
manufacturer's instructions and the appropriate best practice guidelines. Because of the rapid advances in medical
science, any information or advice on dosages, procedures or diagnoses should be independently verified. The
reader is strongly urged to consult the relevant national drug formulary and the drug companies' and device or
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devices or materials mentioned in this book. This book does not indicate whether a particular treatment is
appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional
to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and
publishers have also attempted to trace the copyright holders of all material reproduced in this publication and
apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material
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British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library.

Library of Congress Cataloging-in-Publication Data

Navigating the NHS: core issues for clinicians/edited by Peter Lees;

foreword by Kenneth Caiman.
p. cm.
Includes bibliographical references and index.
ISBN 1-85775-106-X
1. National Health Service (Great Britain). 2. Health care reform — Great Britain
I. Lees, Peter.
[DNLM: 1. National Health Service (Great Britain). 2. State Medicine — organization &C
administration — Great Britain. 3. Health Care Reform - history — Great Britain.
W 225 FA1 N3 1996]
RA395.G6N376 1996
362.1'0941-dc20
DNLM/DLC
for Library of Congress 96-13731
CIP
Typeset by Marksbury Multimedia Ltd, Midsomer Norton, Avon.
Contents

List of contributors v

Foreword vii

Preface viii

Acknowledgements ix

1 Introduction 1
Peter Grime

2 Where are we now? The NHS in the mid-1990s 7

Tim Scott

3 An introduction to priority setting in the NHS 17

Richards and Tony Lockett

4 What is NHS purchasing, and where is it going? 27

Tony Shaw and Murray Cochrane

5 Marketing in the NHS 39

Andrew Boon

6 Casemix, coding and contracting: a beginner's guide 51

Peter Lees and Paul Stafford

7 Shared care or integrated care? Managing clinical services for

chronic disease across the interfaces 63
Bob Young

8 Managing quality through outcome measurement and audit 73

Sue Lydeard and Steve George

9 Towards evidence-based practice: the role of research and

development, training and education 87
Stephen Holgate
 CONTENTS

10 Continuing medical education: a fundamental balancing act 101

Jenny Simpson

11 Management arrangements in NHS Trusts 109

Peter Beck

12 The medical director: corporate player, not representative role 119

Tim Scott

13 The clinical director: poacher turned gamekeeper? 129

Celia Cramp

14 The future 137

Tim Scott

Index 147
List of contributors

PETER BECK, Medical Director, Kotherham District General Hospital,

Moorgate Road, Oakwood, Kotherham, South Yorkshire S60 2UD
ANDREW BOON, Consultant Pathologist, Department of Cytopathology, St
James' University Hospital, Leeds LS9 7TF
MURRAY COCHRANE, Director of Developments, Cornwall and the Isles of
Scilly Health Authority, John Keay House, St Austell, Cornwall PL25
4NQ
CELIA CRAMP, Clinical Director, St Helens and Knowsley Hospitals, Whiston
Hospital, Warrington Road, Prescot, Merseyside L35 SDR
STEVE GEORGE, Lecturer in Public Health Medicine, Southampton University
Hospitals NHS Trust, Tremona Road, Southampton, Hants SO16 6 YD
PETER GRIME, Senior Registrar in Oral and Maxillo-facial Surgery, South-
ampton University Hospitals NHS Trust, Tremona Road, Southampton,
Hants SO16 6 YD
STEPHEN HOLGATE, MRC Clinical Professor of Immunopharmacology,
Southampton University Hospitals NHS Trust, Tremona Road, South-
ampton, Hants SO16 6YD
PETER LEES, Senior Lecturer, Honorary Consultant Neurosurgeon and
Director of Research and Development, Wessex Neurological Centre,
Southampton University Hospitals NHS Trust, Tremona Road, South-
ampton, Hants SO16 6YD
TONY LOCKETT, Associate Director, Corning Besselaar Ltd, 7 Roxborough
Way, Maidenhead, Berks SL6 3UD
SUE LYDEARD, Quality Development Manager, Southampton University
Hospitals NHS Trust, Tremona Road, Southampton, Hants SO16 6YD
JOHN RICHARDS, Head of Performance and Development, Southampton and
South West Hampshire Health Authority, Oakley Road, Southampton,
Hants SO9 4WQ
TIM SCOTT, Senior Fellow, BAMM, Barnes Hospital, Kingsway, Cheadle,
Cheshire SK8 2NY
 LIST OF CONTRIBUTORS

TONY SHAW, Chief Executive, Southampton and South West Hampshire

Health Authority, Oakley Road, Southampton, Hants SO16 4GX
JENNY SIMPSON, Chief Executive, BAMM, Barnes Hospital, Kingsway,
Cheadle, Cheshire SK8 2NY
PAUL STAFFORD, Director, Secta Management Consulting, Shelley Farm,
Shelley Lane, Ower, Hants SO51 6AS
BOB YOUNG, Consultant Physician, Department of Endocrinology, Salford
Royal Hospitals NHS Trust, Hope Hospital, Stott Lane, Salford M6 8HD
Foreword

The title of this book intrigued me. It conjured up nautical images of charts,
maps, shoals, rocks, wind, rain and storms. It suggested instruments to deter-
mine course and direction, compass and sextant. And of course it is a good
metaphor. Understanding the NHS is about knowing where you are going and
how to get there. The image of the course of a large tanker being changed by
many tugs also came to mind. The NHS does need to change, but it will only do
so if there are a number of willing and powerful forces at work.
But the image also begs several questions. The first and most obvious, is what
is the destination? This is a key question, and the answer to it sets the tone for the
chapters in the book. Is it about financial issues? Is it about career progression for
staff? Is it about managing the workforce? For me the answer relates to the
primary purpose of the NHS which is to meet the needs of patients and the
population, and to put them first. It means involving patients and the public
more in determining what is required and how best it can be achieved. It is first
and foremost about values. This is of course simplistic and such an objective has
within it a series of contraindications and conflicts. But at least it gives a sense of
purpose and direction to the organization.
But what do we need to get there? Again to stretch the nautical example, there
is a need for good management, teamwork and leadership. Without these the
ship will not function effectively and mutiny may even occur! Working together
in partnership is crucial, as is the recognition of the skills and expertise of all
members of the crew. In particular the captain needs to earn respect and ensure
that all members of the team are pulling in the same direction.
Then, there is the issue of instruments available to chart the course, monitor
performance, measure the distance travelled and identify problems ahead. The
radar function is important (intelligence) as is the need to continually improve
the methods available to control the direction (research). In addition the
members of the crew need to be regularly updated on these matters (education)
and be helped to do so.
This book sets out to chart some of these issues. It provides practical solutions
to problems, and gives examples for others to take up or reject.
Finally, it is perhaps important to stress that navigation and nautical
manoeuvres are not always easy. In doing so, particularly when the environment
is changing rapidly, the quality of life of the crew also needs to be considered.
The staff are our most important asset, we need to think of them too. This book
also gives some insights into how that might be done.
Sir Kenneth Caiman
March 1996
Preface

In just over a decade the NHS has undergone the most widespread changes
since its inception. Such has been the pace of change that unless you were at
the heart of the 'reforms' in the early 1980s you would be forgiven for
wondering where we came from and probably why. If proof of that
confusion were needed it can be found regularly among my senior registrar
colleagues when applying for consultant posts. Those clinicians perceived to
have a leaning towards 'medical management' seldom enjoy much interest
until that fateful time and will be very familiar with the oft-posed request,
'tell me something about management, I have an interview tomorrow'.
The stimulus for this book was to help medical trainees understand the
huge health care management 'industry' which has developed so rapidly and
which nowadays impacts upon us all, but such is the calibre of my co-
authors' contributions that this book has relevance to anyone trying to
negotiate their way around 'today's NHS'.
Using the history of the reforms as a backdrop, we have chosen discrete
topics (presented in broadly logical order) representing the major new
initiatives, with a bias towards the secondary care sector. The authors were
asked to make their chapters stand-alone, accessible for the uninitiated and
to imagine they were on the train en route to 'the interview' and had the
sudden urge to 'mug-up' on a pertinent topic quickly.
I conclude with an invitation. With the current pace of change, further
editions of this book are anticipated and ideas for inclusion next time would
be warmly welcomed.
Peter Lees
March 1996
Acknowledgements

This was not a solo effort and I am grateful for help and encouragement
from a number of people. All the authors are busy professionals but still kept
perfectly to deadlines. Sir Kenneth Caiman, the Chief Medical Officer, has
kindly written the Foreword and Dr Jenny Simpson and Tim Scott (of the
British Association of Medical Managers (BAMM)) have not only
contributed directly but have also given inestimable advice on the subject
areas and whom to approach as contributors. Peter Grime and Tim Lees,
trainees at the time, gave invaluable comment upon whether the objectives of
the book were being met. Gillian Nineham and her colleagues at Radcliffe
Medical Press have taught me a lot and with great patience. The speed that
Radcliffe turn such a tome into the printed book has impressed me
enormously. Those of you who, like me, are fortunate enough to work with
an outstanding secretary will appreciate the huge contribution of my
personal assistant, Clair Wilkinson.
To Doris and our daughter, Hannah, who was born during the final
preparation of the book
1 Introduction
Peter Grime

On the road to Damascus

Several years ago I made a decision to pursue a career in hospital medicine,

not as a physician (affectionately referred to in our unit as the 'clever
doctors') but as a simple surgeon. I made a list, as is my custom when I have
a decision to make: 'the advantages and disadvantages of achieving
consultant status'. I did not, indeed could not, at that time list any
disadvantages, but my list of advantages was long and positive: a consultant
post was for life, I would be my own boss, run my own department and be
free to run things as I decided. The financial rewards would be excellent:
good salary, good fringe benefits and good private practice potential.
Although it was going to take some considerable time with a lot of hard
work to get where I wanted to go, I have never been afraid of hard work and
knew that I had the talent to succeed. I could expect that, when I achieved
consultant status, my work intensity would decrease and the hours of 'hands
-on' work would diminish. There would be enough junior staff to do the
necessary routine work and that would free me to concentrate on 'higher
things'. The amount of 'boring' clinical work would go down, and I would
be free to choose the service that I provided. I viewed management in simple
terms. Hospital administrators (managers) would be there to facilitate the
success of my department and minimize any inconvenience to both myself
and my staff. I would make the decisions (manage) but have little to do with
the day-to-day implementation (administration).
A classical hospital medical or surgical training reinforces the belief that
you are correct, that you know best. This 'apprenticeship' is long and hard
and produces like-minded survivors: egotistical, arrogant, single minded,
determined, to name but a few of the 'surgical' personality traits that one
requires to succeed. One had, and still has, to be careful of the 'old boy'
network, which has great power to ensure either a smooth progression
through the 'ranks' of the 'King's Own Scalpels' or a rapid demobilization!
The ability to perform surgery and manage patients should be an advantage,
 NAVIGATING THE NHS

but one's main duty is to toe the party line, kiss the occasional frog, never get
romantically entangled with a consultant's daughter or wife and never, ever
do anything to interfere with the smooth running of the boss's private
practice! Taking all things into consideration, I could smell the sweetness of
success.
Unfortunately things did not go quite the way I wanted them to. I
managed to fall foul of 'the system'. For some inexplicable reason I began to
think independently or to be more honest. I began to speak and act more
independently and committed a heinous crime. I suffered 'opinions',
probably borne out of a frustrated development, and deviated from the
accepted path of behaviour. When the time came to move from registrar to
senior registrar, interviews came and went, and subsequently dried up! I was
facing a crisis in my personal and professional life. As a consequence I did
what I always do when difficult decisions have to be made; I reverted to self-
analysis and made my lists again. Analyse, conclude, act! What is wrong with
me? Why does nobody want me? I am good at my job, enthusiastic, hard
working, innovative; my curriculum vitae is excellent. How could anybody
not want me? The list contained personal good points, perceived bad points,
points for going on, points for career change. Do I really want to be a
consultant now? I revised my list of the advantages and disadvantages of
achieving consultant status in the health service. On this occasion I could not
list any advantages, yet the list of disadvantages was long and of consider-
able concern.
By this time the White Paper had arrived and the 'new-style' National
Health Service (NHS) management was born: proactive rather than reactive
(to the medical profession) management; passive administration; rolling
contracts with poor job security and a decreasing salary in real terms
(perhaps under the guise of performance-related pay); an increasing work
intensity because of an emphasis on work-load targets; the decreasing
number of junior staff with their limited hours 'on call' and fewer
consultants (probably redesignated more simply as 'specialists') than would
be needed to fill 'the gaps'; less clinical freedom and more market-oriented
practice; income generation; internal markets; management growth with an
unwelcome 'interference' in clinical matters; audit and information
technology (number crunching par excellence}-, the Patient's Charter; low
staff morale; attacks on private practice and associated media hype implying
poor consultant performance; a decrease in status, with consultants
perceived as 'just another employee - easily replaced!'
I began to view management in a different light, something that had been
taken away from, and turned against, the profession. The worm had turned!
The oppressed administrator, sick to death of arrogant, self-opinionated
 INTRODUCTION

doctors, grasped the opportunity to strike back under the guise of 'NHS
reform'.
It appeared that my potential job, if indeed there was to be one, was not
worth bothering about, an understandable attitude given rationalization of
thought for self-preservation.
Unfortunately I had reached the stage at which a career change was
impractical: not at my age and with a young family to support. I had to go on
and make the best of it! After a number of interviews, when I really felt that
the end was nigh and I was about to sink without trace, I finally convinced an
appointments committee to give me a chance and (gratefully) got on with it.
Once in the lifeboat I did not want to reach the point of applying for
consultant posts before revising my attitude, giving serious thought to future
practice and the role of a consultant in the 'new NHS'; after all I still needed
to reach dry land.
Looking back I could see two superficially different, yet deeply similar,
unproductive approaches to the consultant role (in both clinical practice and
management). My first deliberations were positive and rather self-focused. I
suspect, but cannot be sure, that I assumed an intention to play my part in
the NHS to the best of my ability. Surgical practice in the NHS would be
clinically and financially rewarding to me. I saw myself in a dominant, quasi-
managerial role, in control, making decisions for implementation by
someone else. My revised, later, list was extremely negative, although still
self-focused, and my attitude to the perceived loss of management control
was reactive, a somewhat paranoid view ('It is not fair, they are out to get
me. Resist all change, do not co-operate'), a view devoid of rational thought
for a supposedly intelligent, well-educated professional. 'What do they know
about health care and managing patients? I know best, and I should be
making the decisions'.
The NHS had changed for the worse because I was not going to get an
awful lot out of it! To be frank I am now appalled, as I hope you the reader
are appalled, at this negative behaviour. I have never considered myself to be
a negative person. I had not even recognized, until it was pointed out to me,
that both lists were devoid of one important sentiment. Not once had I ever
mentioned the 'patient' (the customer). I appeared to see everything in terms
of me and what I wanted and never in terms of what the patient needed or
wanted. What was I going to get out of it? I could see myself as part of the
problem rather than the solution.
Clinical education and training teaches us to listen, observe, examine,
investigate, conclude, act, review and change opinion if necessary. If we are
honest, the provision of health care in this country has been haphazard and
sometimes illogical, too often based on personal opinion rather than proven
 NAVIGATING THE NHS

value. The management of acute and emergency problems has generally been
first class, unlike the care in chronic disease, the management of which is all
too often less than desirable. Changes in management have to be both
clinical and administrative if we are to get the best value from available
resources.
I needed, indeed wanted, to review my attitude to health care and my role
in the provision of services. What would I do if I were managing (running)
my own business? How would I go about providing health care? I sat down
and produced the following list of questions: What do my patients
(customers) want? What do they need? Do I want to increase the range of
services I provide? Am I in a position to change and respond quickly, as
required? Can I provide the goods now? Do I have the appropriate skills? Do
I have the ability to develop skills, and even if I do, do I actually want or
need to develop them? Do I need to buy in skills? What facilities do I need?
What facilities do I have at the moment, and do I want or need to develop
those facilities accordingly? Can I afford to do that, and if I go ahead, will I
be able to meet the needs and the demands that those extra facilities will
generate? Can I increase my income without incurring extra costs (in other
words can I reduce unit cost and liberate income?) Could I generate income
from loans, get enough business to repay them and still provide myself with
enough personal income? Would I actually get more customers if I made
these changes, and where would they come from? What is the competition
doing that I am not? What could I provide that the competition is not?
Whether or not they need it, would my customers actually want it? What
would I charge? Would it be enough to cover my expenses, or would I price
myself out of the market? Do we have adequate representatives in the 'field',
and are we reaching all our potential customers?
Encouraged by my efforts I made another list of questions, assuming I
would be running the business for someone else: What do our customers
want and need now? What will our customers want and need in the future? Is
our organization geared up to providing those wants and needs at a
competitive price and acceptable quality? If it is not, what do we need to do
to correct the situation? Do we need more staff? Can we get better facilities?
Become more efficient? What can we do to help the business to succeed?
In order to make decisions (manage), I would need information. I could
not make decisions, nor answer the inevitable questions posed by customers,
without the relevant facts and figures. The customers would be expected to
enquire about 'results' and I would expect to produce evidence of my ability
to provide a 'quality' service. (Customers expect a reasonable service at a
competitive cost.) I would need to provide my customers with the goods they
wanted and to deal with them in a quiet and efficient manner, responding to
 INTRODUCTION

their comments and criticisms. The business would operate to a set of

reasonable standards, of which my customers would be made aware. That,
after all, is the business way.
What became very evident to me was that this 'business approach' differs
from the archetypal 'medical management' typified by the character of Sir
Lancelot Spratt in the 'Doctor' series by Richard Gordon and by my own
early aspirations. The traditional medical approach is almost exclusively self-
focused: 'I know best, you get what I provide and like it! I am the most
important person and deserve the biggest income'. The business way is
predominantly customer-focused, given that the questions asked should lead
to the provision of a service that the customer needs or wants rather than
that which the doctor wishes to provide. Salaries paid to all employees reflect
availability and maintenance of the work-force: employers will only pay
what is needed to keep staff and get the job done (without dropping to
unacceptable standards).
Looking at the questions posed I recognized an all too familiar scenario -
aspects of the NHS reforms - not in 'management' jargon but in 'plain
speak'. I recognised audit (what are we doing, how are we doing?); research
and development (what should we be doing, how do we improve on the
present?); marketing (what does the customer want?) or customer focusing
(providing for the needs of the customer); information technology
(computer-oriented gathering of vital facts and figures); quality control
(service to a satisfactory standard); resource management (getting the best
out of staff, equipment and facilities and keeping the costs down) or value
from resources; efficiency gains (reducing unit costs to release capital);
contracting (guarantees of work and control, therefore of income and, to
some extent, expenditure); The Patient's Charter (working to a set of
reasonable, published standards of business practice and a declaration of
intent to provide a satisfactory service).
Ask yourself the question, how would you run a business with an annual
turnover exceeding £70 million (the annual budget of an 'average' NHS
Trust)? It makes good business sense to budget for income and expenditure,
to cut the cloth according to the purse. Devolving budgets to individual
units, departments or directorates encourages self-reliance and promotes
inventiveness, providing that the degree of central control remains
unobtrusive. Changes in practice can lead to efficiency gains and liberation
of finances to spend on better, or more extensive, services. Without the
ability to generate true income, however (the 'pot' is a fixed size), there must
be a limit to what can be achieved. With 'winners' there will always be
'losers'; one directorate may grow as another contracts, one area may benefit
as another suffers. To that end not all the NHS reforms are desirable, and I
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