Skin in the Game

DO DOCTORS AND NHS MANAGERS HAVE ENOUGH SKIN IN THE GAME?

Skin in the game is a term mainly used in the financial world where it is thought that those persons who are playing the game (e.g. fund managers) should have their own money and reputation involved so that they are as rewarded or as damaged as the people on whose behalf they play the game (i.e. their customers, investors). Philosopher and author Taleb has ignited a debate on the importance of this, he points to a Hammurabic code where if a house were to collapse and kill the owner of the house then the builder will be given the death penalty - now that is some real skin. This blog has already written on how Warren Buffet would not take a fee unless he crossed a certain level of achievement for his investors (http://successinhealthcare.blogspot.co.uk/2012/01/getting-paid-for-performance-buffet.html); apparently Buffet also has his own money invested along with his investors - he has enough skin in the game.

This got me thinking on what kind of 'skin in the game' we have in the NHS. Of course that is a large one to put out in a short blog. Lets try a limited short version.

In the past when doctors were employed as consultants in the NHS there was a requirement to live within a defined distance of their hospital so that they can respond to urgent and emergency calls when they are on duty and also help their colleagues when necessary even if they were not on duty. In the past consultants had an obligation to let the hospital know if they will be out of the area (even if they were not on call or on annual leave). Doctors were paid some money as relocation expenses to facilitate the same.

This obviously meant that the doctors working in a hospital lived within the catchment area of the hospital. In the event of an urgent need for healthcare for the doctor or for their families, they are highly likely to attend the hospital where they work. The success and failure of the hospital had the potential to directly affect them. In the last decade or so, the obligation to live within the local area seems to have disappeared due to a combination of societal changes of both spouses working and the officialdom seeming to demand that the doctor be available only when rostered to do so. However a large number of permanent senior doctors still live in the catchment area of their local hospitals. By definition there is skin in the game - if your hospital mortality or morbidity or general services were bad you and your family were likely to be affected by it.

The other aspect for consultants in the NHS is many consultants expected to work for many decades in one hospital, they do not expect to move. This has seen a slight change recently but it is substantially true that you would generally not find NHS substantive consultant post holders move very often. They develop, grow skin into the game. There is of course the issue of excess skin in the game where people with too much stake take too much risk, perhaps in the case of NHS consultants it may be a case where due to their superior knowledge of local and national situation they learn to avoid personal risk while all the risks remain for their patients. The doctors have a reputation risk - this is really serious - so serious that a doctor can be struck of for damaging the risk of their profession; at a personal level the reputation is equally serious;  due to peer pressure and long service reputational damage can be devastating.

I am unable to find a historic or current requirement that states that executive directors of NHS hospitals were/are obliged to live in the catchment area of their hospitals. I know of many hospital directors who do not live in the geography covered by their local hospital. This means in reality they have not much skin the game. In contrast to NHS consultants, board directors stay in post only for a fraction of the time that a consultant stays in post - compared to consultant appointments, executive director appointments are practically musical chairs or passing the parcel. Again there is not much skin the game. Of course there is a reputational issue but with performance measurement in the NHS for managers not being so accurate as say for a financial fund manager a large gooey fudge substitutes for reputation.

I don't know how practically applicable the above thoughts are. I have already written about the fact that NHS board director contracts have no reward or punishment for anything other than financial performance (Whose job is it to reduce mortality? http://successinhealthcare.blogspot.co.uk/2013/06/whose-job-is-it-in-nhs-to-reduce-deaths.html) Modern life and employment conditions may mean that we may not be able to demand that people live where they work. However we do need to find a way to ensure the skin in the game for NHS managers and directors; increase skin in the game for doctors.

Perhaps a starting point might be to publicly declare if they live within the area of the hospital where they work and how long have they lived within the area (not asking for private addresses, just for HR to declare if they live within the area). Perhaps remuneration and penalties should be linked to quality of performance (when we get around to understanding how we can measure quality meaningfully). We must think of other ways that suit the modern world to increase skin in the game. Healthcare is person to person business, very important for healthcare professionals to remember - no skin means poor game.

©M HEMADRI 

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Clinical Leadership 'Development' - have we got it right?

Development has two components; in order, first is technical skills (hard) and second is personal (so called soft).

Technical skills in my view has two steps core professional skills (how to do the best) and core generic skills (how to do the best for everyone, every time, everyday). Many of us are good at our core professional technical skills (eg surgery, finance, radiology, facilities, HR, cardiology, etc) but it is very well known that in healthcare many of us are unaware of core generic technical skills (evidence, shared baselines, operational data analysis and data tracking, data based decision making).

The NHS is and has been focused for a while on 'leadership', 'social movements', 'change' and such similar things.

My problem with this is profound. I believe that core generic technical development should precede personal development. Personal development methodology is very profound and is designed to promote self-awareness and self-belief. The risk is when the personal development comes before the technical development, people become so convinced about themselves and what they are doing that they feel that technical development is a non-essential trivial distraction.

What is also interesting is the technical skills are easier to teach/learn, assess and practice though most people would think it is difficult and personal development is far more difficult to achieve and demonstrate though most people would think that they have 'got it' after a few sessions.

I have huge concerns that at a local level the deaneries and SHAs do not do this and at a national level personal development happens at a fantastic level to NHS persons who mostly do not have the technical development. 

The fundamental message here is, one must know what/how to do it before they begin to believe they can do it.

Clinical Leadership

One of the weirdest ideas of leadership and leaders is about being a 'senior', board member, top management, etc. Please let me explain. Leaders by default definition have followers; no followers - no leaders. Leaders become and remain leaders because followers allow them to do so. This does two things - the leaders begin to believe that they belong where they are (in leadership positions) due their 'own' and followers become passive because they put the leaders in there in the first place and do not want to admit wrong judgement. Further factors are mathematical politics, allowing time and running on reputation. There are glaring examples in politics that many of us would be aware of.

Once this happens, leaders begin to believe a bit too much in their own credentials. They forget that the fundamental source of all leaders and leadership is followers. The leaders who are by this time out of touch, deluded and completely in their own world begin to substitute the power of followers by the power of rules, law, agenda, reward, punishment and so on. Interestingly and correctly these are the tools of managers/administrators. The tension starts building, leaders become ineffective, leaders and followers become frustrated, external pressures build on what is perceived as 'failing' leaders, leaders use even more top down management methods because this is seen as going 'forwards' rather than stopping and getting back in touch with what put them there.

So the perpetual confusion between the roles of leaders and senior managers results in the unwillingness to recognise that all managers are NOT leaders and not all leaders will have good managerial skills (try telling that to any of your board members, medical directors, clinical directors or similar, that they are a 'director' or 'senior management' but not a leader). Some are blessed with both, both need some of the other's skills; what is crucial to understand is that leadership and management are fundamentally different. The sources of power of the managers are authority, position and mandates; the drivers are policy, guidelines, targets and the deliverables are the successful completion of what they are required to do. For managers failure is something to avoid.

The sources of power of leaders are first and foremost their followers; the background is usually due to knowledge, expertise, passion, and deliverable for leaders is their ability to bring people together for a cause if possible with success. Failure of a task is a learning experience for leaders and a true leader will rejoice the coming together of their followers irrespective of the eventual outcome.

In this context I would suggest that doctors are in a unique position. Doctors would and should quite simply be able to differentiate between managerial role and leadership role. Doctors due to their power of knowledge and skills in their chosen field need to aim to deliver the best care in the pursuit of clinical excellence that will actually be their 'management' role. Doctors as managers as currently taught in deanery 'management' courses completely miss this point. Doctors need to manage their time and resources to provide clinically superior care, that is the success of a doctors real management role; the management of their own clinical care delivery. That is the role of every doctor including the clinical director and the medical director. I could argue that for doctors good clinical management is the only management that is relevant.

We have to understand that most of us will not be leaders and we have to develop good followership traits along with management skills. Even those who are leaders must support other leaders whole-heartedly. Some doctors would demonstrate leadership. In my view the leadership is not really linked to any title or position in their place or work. These leaders should be recognised and supported. This would usually but not all the time be based on good clinical management but not necessarily related to it.

One of the first things to do therefore is to de-link managerial hierarchy from leadership situations. That does not mean that some managers would be good leaders or some leaders would be good managers; it simply means that there is no formal link or requirement for managers to be leaders or vice versa. The next step is to recognise that leaders could be anywhere in the hierarchy and create an obligation on managers to recognise and enable these persons to be effective.

These would result in Successful Healthcare.