Anaesthesia Clinical Directors in the United ... - Wiley Online Library

Anaesthesia, 1999, 54, pages 753–760 ................................................................................................................................................................................................................................................

Anaesthesia Clinical Directors in the United Kingdom: organisation, objectives and support needs G. M. M. Thoms,1 G. A. McHugh,2 B. J. Pollard3 and J. Moore4 1 Senior Research Fellow in Anaesthesia and Public Health Medicine, 2 Research Associate, and 3 Professor of Anaesthesia, University Department of Anaesthesia, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK 4 Consultant Anaesthetist, Department of Anaesthesia, Wirral Hospitals NHS Trust, Arrowe Park Hospital, Arrowe Park Road, Upton, Wirral, Merseyside L49 5PE, UK Summary

A postal survey of all 269 acute hospital trusts identified in the United Kingdom was carried out to study the work of Clinical Directors of anaesthesia. Initial responses from 163 Clinical Directors and 129 completed questionnaires were analysed. Four main areas of concern revealed by the survey were contracts and objectives, funding of managerial sessions, access to information and perceived need for support. Most Clinical Directors had no job description and most had no formal written objectives, despite a substantial body of advice that these should be provided. There was generally substantial underfunding of managerial hours compared with those actually worked and approximately 20% of Clinical Directors surveyed had no funding for managerial duties. Clinical Directors’ ratings of the information available to assist their decision making were also a cause of concern. Clinical Directors perceived that they need better networking, more training particularly on human resource management and improved management information. Keywords Management; clinical directorates. ...................................................................................... Correspondence to: Dr G. M. M. Thoms Accepted: 9 March 1999

The health reforms of the early 1990s divided the business of hospitals in the UK into Clinical Directorates, with the intention that management tasks and processes would be delegated down the organisation to be dealt with at directorate level. Most directorates were headed by medically qualified Clinical Directors and, almost overnight, doctors started to become far more involved in management. There is a growing medical management literature, including important guidance for Clinical Directors on how to do the job [1–18], some of which is directly aimed at anaesthesia Clinical Directors [7, 8, 16]. Despite these changes, little has been written about what is actually happening in anaesthesia services and operating theatres based on investigations of the work of Clinical Directors. Two exceptions are the 1993 British Association of Medical Managers (BAMM) survey of Clinical Directors (including 66 anaesthetists) [19, 20], and a study of 13 surgical Clinical Directors in 1995 [21]. Taken together, these studies showed that Clinical Directors’ objectives were frequently unclear, that the process of setting objectives was also often unclear, that actual time spent on management Q 1999 Blackwell Science Ltd

tasks outweighed contracted time by a factor of two, and that there were unmet needs for a national support structure and for more management training. Better information on the work that anaesthesia Clinical Directors actually do each day is important. First, it is needed to underpin measures to support managers and improve their effectiveness. In his classic study a quartercentury ago, ‘The Nature of Managerial Work’ [22, 23] Henry Mintzberg pointed out how essential it is to have a detailed understanding of managers’ use of time. He shadowed senior managers, building up a picture of the countless day to day transactions, roles and duties involved in a manager’s working day, and showed that without such information, attempts to design support systems, improve information flow, or provide training for senior managers might miss the target. Second, understanding the work of anaesthesia Clinical Directors is important because they are becoming increasingly exposed and their performance ever more conspicuous. The Audit Commission’s ‘Anaesthesia under Examination’ [24] puts them in the spotlight, and the 753

G. M. M. Thoms et al. • Anaesthesia Clinical Directors in the UK Anaesthesia, 1999, 54, pages 753–760 ................................................................................................................................................................................................................................................

accompanying guidance note for hospital trust board directors [25] prompts them to scrutinise the role, objectives and support structures of anaesthesia Clinical Directors. Furthermore, right across the medical profession there are pressures to improve quality of care [26] and restore public confidence [27]. The drive by the UK Department of Health to implement clinical governance [26] explicitly adds a new layer of responsibilities for anaesthesia Clinical Directors. They are now effectively responsible for leading clinical quality [28] within their service. Such quality improvement systems include: X mechanisms to assure and improve clinical performance X acting on clinical audit X accreditation X audit of consumer feedback X implementing evidence-based practice X developing leadership skills X action to reduce clinical risk X rapid detection of and response to adverse events. The two main national professional bodies, the Royal College of Anaesthetists and the Association of Anaesthetists, have together responded by launching their Good Practice Guide [29]. The General Medical Council has announced an intention to publish guidance in May 1999 which will place further duties on Clinical Directors. These will include taking action on reports of poor performance and more intensive monitoring of quality [30]. Clinical Directors will be at the cutting edge of implementing these national programmes to improve standards. The present study, concentrating on Clinical Directors of anaesthesia and operating theatres, was therefore carried out to supply basic, timely information on this important group, in the light of the apparent growing demands upon them. Methods

Following piloting in April 1998, which included confirmation of the issues that anaesthesia Clinical Directors themselves see as most important, preliminary information forms and questionnaires were sent (in June 1998) to all 269 acute hospital trusts in the United Kingdom that could be identified as having an anaesthesia service in Binley’s Directory of NHS Management [31]. A second questionnaire was sent to nonresponders. Data sought in the survey included: X directorate functions, budget and staffing details X objectives, personal and organisational X existence of job descriptions X managerial hours, worked and paid for X proportion of time spent on strategic tasks and on operational tasks X perceived levels of support locally, from within and outside the directorate 754

adequacy of information available perceived need for support from sources outside the hospital. We defined an ‘Anaesthesia Service Directorate’ as one that included the main anaesthesia service and this directorate became the unit of sampling. Several implications arise from this necessary simplification: X Clinical Directors whose own specialty was other than anaesthesia were included. X In eight hospitals, all made up of a small number of very large directorates, anaesthesia Clinical Directors were essentially present but known by another name, such as Lead Clinician, Clinical Coordinator or Chairman of Anaesthesia, and it was these individuals who provided responses. X Hospital trusts with no Clinical Director in post, no directorate structure, or a directorate structure reported to be disputed or seriously dysfunctional were excluded. X When there was more than one relevant directorate in a hospital trust, only the directorate including the main anaesthesia service was counted, and therefore some anaesthesia Clinical Directors (for example in separate directorates of pain services, intensive care or day case) are excluded. Before closing the study in October 1998, and in an effort to learn about nonresponders (to the second mailing of the main survey pack), all 106 nonresponders were mailed a one-page questionnaire (with a personal letter and prepaid return envelope to encourage participation). Aims were three-fold: X to ascertain accuracy of contact details on the database, and to confirm appropriateness of inclusion X to learn reasons for nonresponse X to understand attitudes to the main survey and its objectives. X X

Results

Response rates Of the 269 possible sites, 21 had no functioning directorate structure and were excluded from analysis, leaving 248 eligible for study. There were initial responses from 163 sites supplying basic contact information; and 129 of these then provided completed survey questionnaires, a final response rate of 52% of the 248 eligible trusts. From the 106 sites that made no initial response, 52 respondents completed ‘nonresponder’ questionnaires. The overall number of trusts that contributed information of some kind, at either initial contact, main survey or nonresponder follow-up stages, was therefore 215 (80% of 269). Clinical Directors Clinical Directors themselves were predominantly male (82% male: 18% female), ranged in age from 29 to 60 years Q 1999 Blackwell Science Ltd

Anaesthesia, 1999, 54, pages 753–760 G. M. M. Thoms et al. • Anaesthesia Clinical Directors in the UK ................................................................................................................................................................................................................................................

Table 1 Composition of Anaesthesia Service Directorates. Areas of managerial responsibility

Frequency (out of 129)

Percentage

Acute pain Chronic pain Obstetric anaesthesia Intensive Care Unit Operating theatres Day surgery High Dependency Unit Sterile supplies Pre-op. assessment unit Endoscopy unit Medical equipment Surgery Medical electronics Orthopaedics/Trauma Accident and Emergency Palliative care

119 112 105 100 90 77 53 41 34 28 27 10 10 7 7 6

92 87 81 78 70 60 41 32 26 22 21 8 8 5 5 5

with means of 47 years (male) and 50 years (female). Medical graduates outnumbered nonmedical substantially (98%: 2%). The mean time already spent in the Clinical Director role was 3 years (range 1–10 years). The reporting relationship described was: to Chief Executive (44%); to Medical Director (23%); to both (17%); other arrangements (16%). Functions within directorates The most frequent responsibilities found in anaesthesia Clinical Directorates were pain services, obstetric anaesthesia, intensive care units, operating theatre management, day surgery and high dependency units (see Table 1). A total of 44 separate functions, many of which may be distinct departments, were reported as falling within the remit of anaesthesia Clinical Directors. The largest single count of functional responsibilities was 20 and the smallest was two (median eight). Staffing and budgets Staff numbers varied markedly in the 109 sites providing data. Twenty sites did not have data for staff numbers. Total staff strength ranged from 10 to 672 whole time equivalents (median 134). Nonmedical staff showed the greatest variation (range 1–558 whole time equivalents, median 120). Medical consultant strength ranged from 6 to 58 whole time equivalents (median 17). Directorate annual budgets ranged from £0 to 22.5 million (median £5.5 million) and hospital annual budgets ranged from £16 to 350 million (median £69 million). Studies of patterns in an attempt to find clear relationships between function and dimensions were largely unproductive. For example, there was no clear association between Q 1999 Blackwell Science Ltd

hospital budget and directorate budget, with the largest directorates being encountered about as frequently in large and in small hospitals. However, there was an apparent distinction between directorates with and without operating theatre management: those 39 directorates that were not responsible for operating theatres had smaller median directorate budget (£3 million) and total staff strength (52), than the 90 directorates that did include theatres (medians: budget £6.5 million; staff strength 155). Objectives for Clinical Directors Analysis of formal job descriptions and written formal objectives showed that most Clinical Directors had no job description (57%). Most had no formal written objectives (53%), and 36% had neither. We distinguished formal objectives, set for a Clinical Director by their manager, from personal objectives that respondents were aspiring to. An overview (Table 2) shows an analysis of the most commonly reported objectives, based on a total of 541 personal objectives (from 122 sites supplying data). Personal ‘aspired to’ objectives were used since all respondents had these, and nearly all respondents were working to them; whereas many lacked formal objectives set by their organisation. The match (or mismatch) between personal ‘aspired to’ objectives and organisationally set objectives was reported on by 57 respondents. Five (9%) stated that there was a ‘clash’ between personal and organisational objectives. The remaining 52 respondents were evenly split between having ‘some overlap’ and ‘a close match’ between own and organisational objectives. Funding for managerial time Clinical Directors’ weekly time spent on managerial work ranged from 3.5 to 30 h (median 11), and there were two full-timers (Fig. 1). There was generally substantial underfunding of managerial hours, with 20% having no funded managerial time. Nature of managerial tasks and duties Managerial activity was broken down as shown in Table 3, respondents having been asked to estimate the average managerial time spent in the three categories shown, which were defined according to responses received at the pilot stage. The range was substantial: operational work time occupied from 5 to 95% of managerial time (median 50%), clinical leadership ranged from 0 to 70% (median 30%) and strategic work from 5 to 70% of managerial time (median 20%). A subgroup of 27 directorates that had the most strategic work (40% of managerial time or more) was compared with a subgroup of 23 directorates with the most operational work (70% of managerial time or more). 755


Table 2 Most commonly reported personal Strategy and planning – 138 objectives X Examine and report on the future direction of all services within the directorate X Lead the business planning process within the directorate X Develop robust service plans, priorities and objectives for each specialty in the directorate X Ensure alignment of directorate objectives with hospital objectives

objectives (distillation of 541 objectives in 122 sites).

Human Resources – 111 objectives X Manage the staff resource, having regard to all employment policies and procedures X Lead the recruitment of staff; maximise retention of staff X Undertake staff performance review X Ensure medical and nursing staff education and development to the appropriate standard Efficiency and theatre capacity – 101 objectives X Ensure efficient use of staffed time in theatres X Optimise scheduling of cases in theatres X Monitor actual activity against contracted performance level X Improve emergency throughput in theatres Quality, risk, safety and standards – 61 objectives X Ensure delivery of surgical services within patient charter standards X Develop and implement clinical guidelines for patient care X Ensure quality of services through clinical audit and risk management X Ensure maintenance of anaesthetic and monitoring equipment to current standards Specific service developments – 59 objectives X Develop an acute pain control team X Develop chronic pain services X Establish a high dependency unit X Improve pre-operative assessment services X Merge two anaesthetic departments Budgetary control and financial performance – 41 objectives X Plan and account for overall resource use within the directorate X Operate within agreed financial limits X Negotiate additional funding for essential developments Information management and technology – 12 objectives X Improve information systems X Establish a working IT system in theatres X Develop project management competencies in the directorate Communication – 11 objectives X Develop a partnership relationship with a nearby trust X Improve communications throughout the directorate X Improve communications with external agencies especially primary care and purchasers Research capability – 7 objectives X Build capability for research through education and example X Seek funding for appropriate research X Ensure that relevant research findings are disseminated locally, and that they inform clinical practice

Figure 1 Managerial hours: contracted and

actual. 756

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Table 3 Classification of managerial work,

based on responses at pilot stage.

In the pilot study many types of managerial activity were described. These appear to group together into three broad classes of managerial work. In the main survey, respondents estimated the percentage of managerial time spent on each class of managerial activity. These classes were as follows: Operational Examples are real time scheduling issues, resolving conflicts, monitoring cancelled operations, firefighting. Timescales are mostly hour to hour or day to day. Clinical leadership Examples are work on quality processes and standards, achieving negotiated contractual targets, agreeing and working to budgets. Timescales are mostly week to week or month to month. Strategic Examples are work on major change, developing strategy for the directorate or the whole organisation, service re-configuration planning, forward manpower planning. Timescales are mostly long term.

Respondents in the ‘most strategic’ group had larger mean budgets (£6.6 million vs. £5.0 million), larger staff numbers and a slightly higher level of contentedness with their support staff.

information, theatre activity information and theatre/ anaesthesia cost information as being ‘poor’ or ‘very poor’; and 49% rated theatre efficiency information as being ‘poor’ or ‘very poor’ (Fig. 3).

Levels of support within the hospital Most Clinical Directors felt adequately supported by key staff within the directorate (Fig. 2). However, support from secretarial staff was reported to be ‘poor’ or ‘very poor’ in 12% of sites, and support from information staff was rated ‘poor’ or ‘very poor’ in 33% of sites. Most directors were also content with the level of support from above in the hospital hierarchy. Only a handful of Clinical Directors reported ‘poor’ or ‘very poor’ support from both Chief Executives and Medical Directors. Clinical colleagues from outside the directorate were seen as far less supportive than those from within. Perceived levels of support from trust board members and from purchasers were rated as ‘poor’ or ‘very poor’ in 26% and 64% of sites, respectively. Clinical Directors rated the adequacy of information at their disposal. Over one-third rated anaesthesia activity

External needs for training and support Free text comments on perceived needs for education, training and support external to the hospital were supplied by 90 Clinical Directors. The commonest need (24%, n ¼ 22) was for more ‘basic education for the Clinical Director role’, especially in respect of managing staff, personnel and employment regulations. Networking with other Clinical Directors was sought by 21% (n ¼ 19) and more education on monitoring performance and information management by 14% (n ¼ 13). Barriers to training and external support were mentioned; 11% (n ¼ 10) reported insufficient time and 12% (n ¼ 11) a lack of local support for necessary training and education. Nonresponder survey We received information from 52 respondents, providing 70 reasons for nonresponse and 32 sets of attitudes to the

Figure 2 Support from within the

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Figure 3 Adequacy of information.

survey. Principal reasons for nonresponse were: too busy and could not give the survey priority, 18 (26%); papers lost after receipt, 10 (14%); never complete questionnaires, 9 (13%); papers never received, 8 (11%); key information not available, 8 (11%); other, 2 (2%). Principal attitudinal results were: support aims of study, 24 (75%); could not remember aims of study, 6 (19%); thought survey was unimportant, could not see the point, 2 (6%). Discussion

The anaesthesia Clinical Directorates that are the focus of this study do not appear to have been investigated in such depth before. The variety of these organisations and complexity of some of them is striking, as evidenced by a wide range of functions, of size in terms of staff numbers and of budgets. There is a 67-fold difference in numbers of staff managed between the top and bottom of the range, for example, and some Clinical Directors are managing directorates spanning 20 service functions or departments. The study adds to knowledge about anaesthesia Clinical Directors in four broad areas: objectives and priorities; remuneration for managerial work; support from inside the hospital; and perceived needs of Clinical Directors for support and education. Much authoritative writing, including the recently produced ‘Good Practice’ guide for Departments of Anaesthesia, recommends that Clinical Directors should have a separate contract, an agreed job description and adequate sessional time for their managerial duties [29]. We did not ask about separate contracts for the Clinical Director role but we did ask about job descriptions and formal written objectives. Fewer than 50% of anaesthesia Clinical Directors had a formal job description and fewer than 50% had clear written objectives, suggesting some lack of engagement in the mainstream of hospital management, which may operate to the detriment of the specialty. We sought information on any reported mismatch 758

between personal and organisational objectives. The proportion reporting a major mismatch was 9%. Assuming that the sample for this finding was truly representative, an extrapolation to the entire population of hospitals would suggest that around 24 Clinical Directors are in the unenviable position of taking forward objectives to which they do not personally aspire. This group may be in particular difficulty and need assistance. Our study confirmed previous findings [19–21] of a general pattern of under-funding of the managerial component of the work. However, we did not ask about clinical sessions from which the director has been relieved of duties, and it is possible therefore that our findings may overstate the problem. The time required to carry out managerial duties was reported as being substantially greater than the time allocated. In some cases (19%), Clinical Directors received no additional funding for time spent carrying out management work. Many Clinical Directors reported insufficient time allocated to carry out their managerial role properly. Although relationships with key personnel from within the hospital were generally reported as satisfactory, 18% reported being inadequately supported by either their Chief Executive or their Medical Director. Assuming that the sample for this finding was truly representative, an extrapolation to the entire population of hospitals would suggest that around 48 Clinical Directors lack one of these vital high-level supports. This group may be in particular difficulty and need extra assistance. A sizeable minority (26%) reported dissatisfaction with the support received from Trust Board level, and there is even less satisfaction (64% ‘poor/very poor’) with reported support from commissioning organisation level. Support provided to Clinical Directors from within the directorate was far more frequently rated as adequate for administration and finance functions than for information or training functions. The 7% minority with inadequate business manager support (signifying a group numbering Q 1999 Blackwell Science Ltd


about 17 Clinical Directors across the UK if our sample is representative) may be in particular difficulty. Information appears to be a widespread concern. Both the adequacy of information and the levels of support from information staff were frequently seen as inadequate. Clinical Directors as a group might significantly improve the position on information by agreeing a core dataset for management of anaesthesia services and operating theatres and by drawing attention both locally and nationally to any impact that deficient information may have on effective decision making. Theatre efficiency data are reported as being particularly inadequate; this appears to run counter to the success of waiting list initiatives, given the vital part that efficient operating theatre utilisation has to contribute to these. Clinical Directors’ perceptions of the support needed covered two main areas. First, there is a general concern about isolation and a widespread belief that closer networking of anaesthesia Clinical Directors would be valuable. The Royal College of Anaesthetists, the Association of Anaesthetists and the British Association of Medical Managers all have the potential to respond, independently or jointly, to this need. Second, there are some major personal training needs to be addressed, particularly relating to human resource management and monitoring performance. In the past there have been a number of good examples of training schemes at the local level, such as shadowing existing Clinical Directors and in-trust management courses. At the national level, the Association of Anaesthetists has run a seminar series specifically for anaesthesia Clinical Directors, although this provides only for small numbers at any one time. Since the organisations that anaesthesia Clinical Directors manage show so much variation, their support needs may vary too. More detailed work appears to be needed to identify Clinical Directors’ detailed training needs. Issues to consider include how these vary according to own level of personal development (which we did not study in this survey), how they relate to the different types, sizes and styles of organisation being managed, and the need for training that is reactive to new initiatives, such as the clinical governance agenda. Since so many Clinical Directors spend so much time on operational issues, some may wish to be offered training in aspects of service operations management, such as facilities management, scheduling, optimisation, and industrial approaches to quality assurance and performance monitoring. Acknowledgments

Clinical Directors of anaesthesia across the United Kingdom, who participated in the survey; Ms Lynn Smith (database design); Mr Tim Scott of BAMM Q 1999 Blackwell Science Ltd

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