Clinicians In Management Does It Make A Difference

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Executive Summary, This report adds to the evidence base to support the benefits of clinical leadership by focusing on the. strategic governance of NHS hospital trusts in England Using information provided on trust websites. a data base was constructed of the qualifications of board members over three years 2006 7 2008 9. distinguishing between clinical and non clinical backgrounds For the final year 2008 9 102 trusts were. represented Tests were then conducted to establish whether the mix of qualifications of board members. had any impact on performance outcomes The latter included Annual Health Check ratings published. annually for trusts by the Healthcare Commission now Care Quality Commission focusing on Quality of. services and Use of resources the hospital standardised mortality ratio published by Dr Foster and. patient satisfaction measures included in the national patient survey. Research highlights, 1 Clinical participation in board level management is low by international standards On average clinicians make up just over a quarter of all. board members 26 03 and doctors 14 in English NHS hospital trusts Numbers have however increased slowly between 2006 9. 2 More clinicians are likely to be on the boards of trusts where the CEO has a clinical background. 3 Increasing the number of doctors on boards significantly increases quality assessed in terms of Health Commission trust ratings lower. morbidity rates and increased patient satisfaction. 4 There is evidence of a positive but not clearly significant relationship between doctors on the board and financial ratings. 5 The number of board members with nursing and allied health professional backgrounds is less clearly associated with improved. performance outcomes,Introduction, In most countries there has been a trend to extend the 58 per cent compared to 74 per cent in the US and 93 per cent. participation of doctors and other clinical professionals in the in Sweden 5 Obstacles to persuading clinicians to take on. management of health services In the UK this has been an explicit management roles such as weak or non existent incentives a lack. policy goal since the publication of the Griffiths report in 1983 of training and administrative support also continue to be significant. Twenty years later the NHS Next Stage Review 1 commissioned. Until recently efforts to boost clinical leadership have also been. by Lord Darzi concluded Leadership has been the neglected. hampered by the lack of a strong evidence base In some quarters. element of the reforms of recent years That has to change. this has fuelled scepticism about the wisdom of having well trained. Accordingly there have been attempts to create a mixed economy. doctors take on management roles that might distract them away. of clinical and non clinical senior managers in the NHS with. from the core business of patient care However increasingly this. doctors on the shortlist for all future Chief Executive Officer CEO. view is hard to sustain A survey conducted by McKinsey co. appointments 2 The medical profession itself has also supported. and the London School of Economics of 1200 public and private. change requiring that all undergraduate and postgraduate courses. hospitals across seven countries UK US Germany France Italy. incorporate a new Medical Leadership Competency Framework. Canada and Sweden found that hospitals with the most effective. As one influential report published by the Royal College of. management practices tended to be those with higher proportions. Physicians put it the time has come to acknowledge the corporate. of medically qualified managers 5 A study by Goodall 6 of. responsibility of doctors and foster complementary skills of. the top 100 US hospitals in the US also finds a link between the. leadership and followership at all levels 3, medical qualifications of CEOs and the higher ranking of hospitals. Most recently pressure to deliver change has intensified with It would seem therefore that clinical leadership is not just about. moves to make doctors responsible for commissioning services controlling professionals and turning poachers into gamekeepers. through new Clinical Commissioning Groups A programme to It may also have real quantifiable benefits for those who use our. deliver 20bn of extra productivity by 2014 15 has also been set health services. in motion known as QIPP quality innovation productivity and. The aim of this report is to extend and deepen this evidence base. prevention This will involve significant changes in the work of. by exploring for the first time the impact that clinical professionals. doctors and much greater investments in clinical leadership at all. might have on strategic decision making Specifically we look. levels to make it happen 4, at whether it makes a difference if NHS trust hospitals involve a.
This enthusiasm for clinical leadership rests on the assumption greater number of nurses and doctors on their governing boards. that doctors and nurses will bring increased understanding Will this lead to greater performance and if so how much and in. and credibility and better communication 5 In terms of what areas. understanding clinical managers with expert knowledge of the. In what follows we firstly outline the main questions that guided. core business of health services and a deeper awareness of what. our study before describing the main data sources used The. patient care involves should make better informed decisions. report then reviews the findings and implications for policy As we. regarding service design and resource allocation These managers. shall see there is compelling evidence to show that increasing. are also likely to have greater legitimacy and the ability to leverage. the number of doctors on hospital trust boards does have marked. support for change, positive consequences for quality assessed in terms of Health Care. Notwithstanding these benefits of stronger clinical leadership Commission HC trust ratings the Dr Foster Intelligence hospital. progress has been slow The UK still has one of the lowest measure and the patient satisfaction data also provided by the HC. proportions of clinically qualified managers of any health system in collaboration with the Picker Institute. Questions informing the study Research design and methods. The study reported here draws inspiration from a wider literature To address these questions our study focused on the governance. on corporate governance in the private sector 7 This research of NHS hospital trusts in England In 2008 9 this sector consisted. highlights the importance of the membership and dynamics of 169 acute care trusts with a total budget including community. of executive and non executive boards for the performance of services of 51 5 billion approximately 64 of the total budget for. large firms In particular it is has been found that board directors all NHS front line services Because there is no central repository. contribute most when they have specialised experience and of information on hospital governance it was first necessary to. expertise relevant to the domain or sector Because technology construct our own unique dataset by manually working through the. regulations and structural changes are normally highly path websites and annual reports of individual trusts Where information. dependent prior knowledge of a given sector is of considerable was available we observed the composition of the board and for all. value in helping to quickly process information and solve complex members gathered information on their professional qualifications. problems 8 for example doctors nurses accountants etc and job titles Only. trusts which offered full information in terms of board membership. Such findings of course beg the question of whether similar. were included resulting in a final sample comprising 240. conclusions might be drawn about public organisations such as. observation points over three years 2006 7 to 2008 9 In the final. hospitals While hospitals in the UK continue to be publicly owned. year 2008 9 102 trusts were represented, many are now have boards on the corporate model with degrees of. autonomy and accountability to manage their own affairs 9 10 Over this period we also collected information on trust performance. But does this mean that board level decisions will have a similar and outcomes derived from three main sources. impact on performance outcomes such as service quality Might. n Annual Health Check ratings published annually for trusts by. one also expect the specialist expertise of board members will be. the Healthcare Commission now Care Quality Commission. significant especially of clinicians with their deep understanding of. between 2005 6 and 2008 9 focusing on Quality of services. the core business of health care,and Use of resources. Given these debates our primary research question was to focus. n Patient outcome data in the form of the hospital standardised. on how far if at all the presence of clinicians on the boards of. mortality ratio published by Dr Foster Intelligence. hospital trusts makes a difference to performance outcomes. As we noted earlier the belief that they will is strongly assumed n Patient satisfaction data from the annual national patient survey. in much recent policy thinking in the UK and elsewhere 11. As noted earlier our objective was to test whether or not there was. However clearly much will also depend on the skills and. any relationship between these output and outcome indicators and. motivations of clinicians who take on senior management roles. the presence of clinicians in strategic leadership roles To do this. and the extent to which they are able to make their voices heard. we first distinguished between directors with a clinical background. The latter is especially true in the NHS given what Edmonstone. and those with a non clinical qualification or expertise We then. 12 refers to as a unitary and command and control, further differentiated between the clinical backgrounds of directors. managerialist viewpoint which denies the legitimacy for clinical. segmenting the population in two categories doctors and nurses. leadership and emphasises instead a single source and locus. and other allied health professions Following this regression. of control general management, analysis was used to test whether any relationships existed that.
A further question regards which performance measures Will were statistically significant between these board member. stronger clinical leadership impact on performance understood qualifications and various outcome performance measures. broadly to include quality outcomes and financial efficiency or. To ensure our findings were robust we tried as far as possible to. just the former On the one hand it might be argued that clinical. rule out other factors that might influence performance outcomes. managers will contribute most to quality outcomes given their. such as hospital size status Teaching Foundation Trust number. particular motivations and expertise It has been suggested. of admissions length of stay percentage of bed occupancy. however that doctors and nurses in management roles may well. number of staff and the average age of patients by including these. contribute to meeting efficiency goals 5 especially in those. in the model Additional tests were also conducted to discount. contexts where there is extensive training and support see for. the possibility that high performance levels were explaining the. example the case of Finland 13, presence of clinicians on boards rather than the other way around. Lastly is the question of whether the positive outcomes of. In what follows we describe the results of this analysis looking. clinical leadership derive from the participation of all clinicians. first at the overall profile of the sample in terms of governance. in management including nurses and allied health professions. arrangements and then at the relationships between board. or only doctors The latter follows from much of the academic. membership and performance outcomes, literature which emphasises the dominance of medicine and. the key influence doctors have over the means and ends of. service provision In this respect while nurses and allied health. professions might help shape strategic decisions it is doctors. who will ultimately have most impact However against this. is the observation that nursing knowledge tends to be more. population focused systematized and team based as opposed. to individualistic 14 This fact may make nurses better suited. for management roles and more able to reconcile clinical with. organisational and financial priorities,The governance of UK hospital trusts. In terms of overall profile we find that the average size of trust Table 2 Clinical involvement in the boards of English NHS. boards was 12 45 directors in 2008 9 the largest having 17 trust hospitals 2006 7 to 2008 9. directors This is roughly the average size of corporate boards in. the private sector As we expected non executive directors made AVERAGE LOWEST HIGHEST. up around 51 of board membership while as Table 1 indicates of clinicians 26 03 6 25 60. the average percentage of female directors was 35 on the board. Table 1 General profile of NHS hospital trusts of doctors 13 84 0 50. 2006 7 to 2008 9 on the board,AVERAGE LOWEST HIGHEST of nurses 12 19 0 40. Clinicians In Management Does It Make A Difference Gianluca Veronesi Ian Kirkpatrick and Francesco Vallascas Executive Summary This report adds to the evidence base to support the benefits of clinical leadership by focusing on the strategic governance of NHS hospital trusts in England Using information provided on trust websites a data base was constructed of the qualifications of board

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