Readers letters – 21 February 2014

Over the last several years it has become widely accepted that clinical leadership and clinical followership are essential components of successful NHS leadership and NHS change. Under the previous government, the Darzi NHS Next Stage Review stated that “clinical leadership is a topic central to the success of the health service”.

A recent report by the NHS Institute for Innovation and Improvement and the Academy of Medical Royal Colleges titled Engaging Doctors highlighted a review of the clinical leadership literature by Professor Chris Ham and Helen Dickinson and concluded: “Without doctors, attempts at radical large scale change were doomed to fail.”

This review also concluded that effective leaders require followers to implement change. The development of “followership” is therefore just as important as the development of leadership.

Clinical leadership is arguably now even more important considering the current reforms have supposedly put clinicians at the heart of the reforms.

The NHS Leadership website states: “Effective clinical leadership is critical if we are to achieve an NHS that genuinely has the quality of care at its heart… With the economic challenges facing the NHS it is imperative that frontline clinicians have the leadership skills to drive through radical service reform.”

The development of effective clinical leadership is dependent on clinical engagement, which in turn requires trust, shared values and a shared vision of the direction of NHS reform.

However, the last 25 years of NHS reform has seen all three main political parties in England support a market based vision for public service delivery. Labour MP and former cabinet minister John Denham summed this up well in an article in the Chartist.

He wrote: “All public services have to be based on a diversity of independent providers who compete for business in a market governed by consumer choice.

‘This pro-market vision is the antithesis of what medical professionalism is about’

“All across Whitehall any policy option now has to be dressed up as ‘choice’, ‘diversity’ and ‘contestablity’. These are the hallmarks of the ‘new model public service’.”

The Conservatives have now taken this much further with the Health and Social Care Act 2012 which legislates for a regulated external economic market with a much greater role for private provision of NHS care. Yet this pro-market vision is the antithesis of what medical professionalism is about.

Professor Eliot Friedson stated that medical professionalism was underpinned by an ideology that assigns a higher priority to needs based work rather than to economic rewards. It focuses on the quality and social benefits of work rather than its profitability. Thus medical work is “totally unsuited for control by the market or by government or business,” he said.

The obstacle of medical professionalism

Medical professionalism also presents an obstacle to market reforms because “medical sovereignty” exerts control over the market through cultural authority over patients. This represents the age old problem of information asymmetry as a cause of market failure.

In addition, doctors control access to the healthcare market and the allocation of resources.

A recent BMA and MORI poll confirmed that most doctors want to work collaboratively rather than in competition, and most GPs and patients want to use their local hospitals as long as they provide good care.

This all poses a huge problem for the Coalition’s pro-market reforms because the first guiding principle according to Andrew Lansley, the architect of the Health Act, is to “maximise competition… [it] is the primary objective”.

This type of collaborative working fundamentally undermines the functioning of a market system. I therefore subscribe to the view of Professor David Marquand, who stated that public service professionals “are in a profound sense not just non-market, but anti-market”.

This is almost certainly the reason why doctors have been excluded from the policy making process ever since Margaret Thatcher’s Working for Patients white paper in 1989 which introduced the internal market into the NHS.

This signalled the end of the “double bed” of policy making between the medical profession and the state which was so eloquently described by Professor Rudolph Klein at the time.

Another key issue surrounding markets and medical professionalism is public choice theory which rejects the idea of professionalism and the public service ethos, and views market competition as necessarily the route to greater efficiency in public service delivery. 

Julian Le Grand’s work in this area using the “knights, knaves, pawns and queens” metaphor has been particularly influential in favouring this approach in policy making.

Public choice theory underpinned the rise of new public management (managerialism) which favours narrow economic priorities and micromanagement practices – for example, audit, inspection, performance indicators, league tables, monitoring and centrally imposed targets – over professional judgment. Unsurprisingly this approach hasn’t been popular with clinicians.

The bottom line

Markets also undermine the social contract between doctors and patients and damage the doctor patient relationship because decision making becomes increasingly based on financial concerns rather than patient needs.

This was well summed up by David Coates from The Work Foundation.

He said: “Relationships between medical professionals and patients depend on trust rather than contractual obligations and attempting to reduce the provision of healthcare to economic transactions erodes the intrinsic motivations on which the doctor patient relationships depend.”

‘There is clear evidence that a shared vision is vital to effective clinical leadership’

It should therefore come as no surprise that the American medical profession lost public support faster than any other profession during the rapid commercialisation of the US healthcare system in the 1970 and 80s. This was also recognised by the Nobel prize winning economist Kenneth Arrow in a recent interview. He said: “One problem we have now, is an erosion of professional standards.”

This all poses a huge problem for the crucial issue of clinical leadership and its importance within the framework of NHS Leadership and the success of healthcare reform, because there is clear evidence that a shared vision is vital to the effective clinical leadership.

J. Silversin and M.J. Kornacki wrote: “Leadership is ineffective if doctors are not in agreement around a vision for the organisation, and physicians’ expectations of their practice life are incompatible with what change requires of them.”

Since market based reforms undermine medical professionalism and the very essence of what it means to be a doctor, this “shared vision” is impossible to achieve in the context of a market driven NHS, and also explains why there was such mass opposition to Lansley’s Bill from the medical and nursing professions.

I therefore believe that market reforms and market solutions for the NHS are indeed “doomed to fail”.

There will never be effective NHS clinical leadership and followership, and successful NHS reform until the failed market based policies of the last 25 years are abandoned and the medical and nursing professions are brought back into the policy making process.

I will finish with a quote from Arnold Relman, Emeritus Professor of Medicine at Harvard University and former editor of the New England Journal Medicine, which sums up the situation.

He said: “Medical professionalism cannot survive in the current commercialised healthcare market. The continued privatisation of healthcare and the continued prevalence and intrusion of market forces in the practice of medicine will not only bankrupt the healthcare system, but also will inevitably undermine the ethical foundations of medical practice and dissolve the moral precepts that have historically defined the medical profession.”

Dr Clive Peedell, co-leader of the National Health Action Party and co-chair of the NHS Consultants’ Association