Tanveer Ahmed: Born to rule

THE relationship between administrators and clinicians in health care has much in common with the biblical quote underpinning the separation of church and state: Render therefore unto Caesar the things that are Caesar’s; and unto God the things that are God’s.

In the case of health care, doctors most likely consider themselves as God and administrators as the more fallible Roman emperor.

There is a common belief among corporate and hospital hierarchies that doctors make substandard bureaucrats or executives. Having trained for a decade and a half in a highly technical, clinical environment that is short on business, budget and management experience, doctors are seen as ill equipped for the entirely different skill set of management.

This is further entrenched by the negative attitudes many doctors have towards administrators, with doctors who do move into management roles seen as “going over to the dark side”.

But there is growing evidence from management firms, especially in American health care organisations, that the best run facilities with regards to cost management and clinical excellence have doctor–managers.

A recent joint London School of Economics and McKinsey report titled “When clinicians lead” found that hospitals with the greatest levels of clinician participation in management scored about 50% higher on important measures of performance, such as safety, cost and patient satisfaction, than those with the lowest levels.

Importantly, the authors found that doctors incorporated a sense of efficiency and accountability into their daily work.

Doctors are trained to focus squarely on treating disease. I was taught from day one of university to do everything in my power to cure, heal or advocate for the patient in front of me. But what about the patient who is not in front of me?

British health economist Roger Taylor  discusses this topic in his recent book God bless the NHS. He holds that doctors must better incorporate the “patient in the waiting room”, by which he means being mindful of the limited resources available to treat both the patient in front of you, as well as all other potential patients.

Much like the McKinsey report, Taylor notes that when doctors are more engaged with the financial management of the system, there can be a range of insights and improvements in incentives that may not be apparent to non-medical administrative staff.

While health policy took a back seat in the lead-up to the recent federal election, reining in the ballooning costs of health care in the face of ageing populations, costly new medical technologies and a demanding public will remain one of the greatest challenges for Western governments.

I spoke to Dr Emma McCahon, a Sydney paediatrician leading the way in bridging the gap between administrators and clinicians, about the doctor’s role in management. She is in charge of patient flow at Sydney Children’s Hospital and runs a leadership and management program for junior doctors through the NSW Department of Health.

“Doctors tend to hide behind patient care and not take too much interest in the management side”, she told me. “You just can’t implement programs in quality or safety without having people who can really negotiate with doctors on the ground — all the evidence overseas points to involving clinicians in the management side.”

However, Dr McCahon says most doctors “simply don’t see the whole range of players involved in the delivery of health care, from the nurse to the person folding out the linen. They also know nothing about cost”.

Mary Ditton, a senior academic in health management at the University of New England, told me administrators “are too undermined and poorly respected in the health care chain”. Sending a clear warning to the medical profession, she says the “industrial dominance of doctors in Australia is increasingly becoming an anomaly in the Western world”.

Dr McCahon says the essential cultural shift to more doctor involvement in management will take decades and believes it will happen from the bottom up. But she warns that doctors risk further whittling away of their authority if they, as a professional group, do not lead the community to rein in health costs.

This needs to occur in our discussions with patients and their treatment decisions as well as in our interactions with administrators.

Dr Tanveer Ahmed is a Sydney psychiatrist, author and local government councillor.

Dr Ahmed has given an assurance to MJA InSight that this is his original work.