Annex A > Chapter 8 - Management and Culture of the UBH and the UBHT > The development of the clinical directorate structure > The role of clinical director
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The role of clinical director
99 Dr Roylance told the Inquiry that:
`... the Clinical Director was responsible for everything that happened in his directorate. He had a substantial amount of support, but in terms of accountability, he or she was accountable to me for the proper conduct of affairs within the directorate. So the accountability line was quite clear.' [119]
100 Professor Vann Jones was one of several clinicians to give evidence of the burden which being a clinical director placed on a consultant. He said:
`... I still had to take care of my heavy clinical load, both in cardiology and in general medicine, as well as maintaining my research and teaching commitments. No help was forthcoming from the Trust for the additional load of Clinical Director.' [120]
101 Mr Baird, who was at one time Clinical Director for Surgery, was also asked about the responsibilities that came with being a clinical director:
`Q. Clinical Directors had relief, did they, from their clinical duties in terms of not having to do sessions per week - some sessions?
`A. Well, most of them did what they did before and just worked a bit harder. I mean, some of them gave up something ...
`Q. So in 1989-90 the rule, rather than the exception, was for people such as yourself to work in effectively your own time and for nothing?
`A. I can only speak for myself, because I know that other people, even Associate Clinical Directors within my directorate, accepted extra sessions to do that work, but I chose not to and it did not bother me much ... Traditionally, we have, if the week is considered 11 half days, which is what it is in contract terms, perhaps about half of that is fixed and the other half is flexible for things like emergency duties, administration, teaching, research and so on. I used to fit my work as Clinical Director into that time. And even if I was, for example, as I was this morning, at a fixed clinical session, you can still pop in and keep things going in-between times. You can keep the kettle boiling, you know.
`Q. So what you are describing is a situation in which people, because they were working for the greater good, would carry out a full clinical load and do whatever work they may have had as Clinical Director on top?
`A. Yes.' [121]
102 However, Dr Roylance outlined measures designed to ease the burden on clinical directors. He said:
`There was a national agreement that doctors assuming such roles as Clinical Director could either be paid two additional sessions' salary in respect of the out-of-hours work, the extra work they were going to do, or that money could be used to employ a locum to do part of the incumbent's work. So the national agreement was that for a job like Clinical Director, across the week there were two additional sessions of work that could and would be funded. I do not remember about individuals, but I do know that some Clinical Directors accepted the additional pay and put in the additional hours; some used the money for a locum to take some of the burden from their shoulders, and some declined either and said they would take it all in their stride. But the choice was theirs.' [122]
103 The clinical directors met monthly as the `Management Board'. Its function was explained by Dr Roylance:
`It was not an Executive Committee that itself made decisions. In the general management philosophy, the General Manager or in this case the Clinical Director who was assuming the General Manager function had to retain personal responsibility for the decisions that were made and it was not possible to let them fudge it and say "Nothing to do with me, the Management Board made the decision".
`... doctors up to that stage actually made policy and we had to slowly develop the idea that it was the Trust Board that agreed policy, on the advice of the management, through the Management Board, and the professions through professional advisers, so that it was a properly made decision, but this was a communication function in which I made sure that at least once a month I would meet them all together and we would discuss issues and they would discuss issues from their point of view and, as I say, resolve issues which transcended the directorate structure.' [123]
104 Some of the clinicians chosen to be clinical directors or associate clinical directors had little in the way of managerial experience. One such person was Mr Janardan Dhasmana, consultant cardiac surgeon, who was the Associate Clinical Director of the Associate Directorate of Cardiac Services from January 1993 to September 1994. Both Mrs Ferris, the General Manager for Cardiac Services, and Mrs Fiona Thomas, the Clinical Nurse Manager for Cardiac Services, recalled his problems in chairing meetings. Mrs Fiona Thomas said:
`He was not quite sure when to stop people from talking and how to stop arguments.' [124]
`... found it difficult to chair meetings and to ensure that decisions got made. This was particularly so where there was open conflict or even hostility in meetings.' [125]
106 In her oral evidence to the Inquiry, Mrs Ferris said:
`My recollection is that Mr Dhasmana deferred on a number of occasions to Mr Wisheart. Mr Wisheart was very experienced at managing meetings; he was very good at managing meetings. He often allowed Mr Wisheart to do that, because he found it difficult.' [126]
107 Both Mrs Ferris and Mrs Fiona Thomas said Mr Wisheart would intervene at these moments and that Mr Dhasmana would defer to him. Mr Dhasmana explained that this was because he:
`... had no such earlier experience and had asked Mr Wisheart for his advice and help ... Mr Wisheart did not take over as a chairman but tried to play an elder statesman's role in order to resolve differing views after a prolonged discussion.' [127]
108 Mrs Ferris also felt that Mr Dhasmana did not fully comprehend all the issues facing her as a general manager. She said:
`I expected to be able to discuss with my Clinical Director, the strategy and planning issues and the decisions that needed to be made before meetings took place. I found that it was not possible to do this with Mr Dhasmana. I also felt that he found it difficult to understand some of the concepts with which I, as General Manager, had to work. This essentially involved working within the existing system for the benefit of the services that we were offering to patients. I needed to focus on what was required of us under contracts, targets and other budget matters, but Mr Dhasmana found these issues difficult to understand.' [128]
109 Mr Dhasmana, on his appointment to the post of Associate Clinical Director, attended a course on `Management skills for the newly appointed consultant'. He was not provided with a job description or written guidelines to assist him in carrying out his new managerial responsibilities. Mrs Ferris said she found it:
`... surprising he was not given any guidance in how he should be effective in the Associate Clinical Director role. The course he attended would not have given him anything like that, although I am aware that the role of the Associate Clinical Directors, and indeed the Clinical Directors, was still very much evolving and developing and in fact, the Clinical Director roles did differ from directorate to directorate, depending on the style of the directorate, the style of the clinicians ... but I would be concerned that he had not received any guidance.' [129]
110 Professor Vann Jones, although he had managerial experience as the Clinical Director for General Medicine from 1 October 1989 to 30 September 1993, was reluctant to serve when asked to become the Clinical Director for Cardiac Services. He said:
`During 1993 the Chief Executive of the new Trust (formed 1 April 1991) had started to discuss the possibility of creating disease based Directorates. The first two to be considered were cardiac services and gastroenterology. In the absence of an obvious alternative candidate I reluctantly agreed to become Clinical Director of Cardiac Services. Again, I was the first Clinical Director of a new Directorate. I started in mid October 1993 and continued until the spring of 1996.
`In its initial stages, the Directorate of Cardiac Services was little more than a concept ... I and my General Manager, Lesley Salmon, had to try to establish what form the new Directorate of Cardiac Services would take.' [130]
111 Mrs Ferris was also critical of the lack of guidance she was given when she became General Manager of the Directorate of Cardiac Services in 1994. She said:
`I took up the post of General Manager, Cardiac Services on 7 November 1994. When I had been appointed to previous posts, I had asked my immediate manager for an indication of the key priorities and issues for the new job. In this new post, I asked Mrs Maisey, Director of Operations, for advice about the immediate priorities for the Directorate. My recollection is that I was told that the most important thing was to get the paediatric cardiac surgical services transferred to the Children's Hospital. I understood this to mean that I would need to give priority to completing the enabling work for the physical transfer of the paediatric cardiac surgical service. Apart from this, I had little guidance from executive level about the forward strategy or objectives for the Directorate, or generally what was expected of me as the newly appointed General Manager for Cardiac Services.' [131]
112 When Dr Roylance was asked about Mrs Ferris' feeling that there was a lack of guidance, he said that she may have felt this way because she was promoted before she was ready for that level of responsibility. He said:
`One could say that we may have been guilty of promoting her before she was ready ... If you read her account carefully you will see that she was counselled and advised by her predecessor ... and she had been in the Trust a long time and had been to management development meetings, she knew that her job by that time was to support and make effective her Clinical Director. If she was somebody who had a culture of wanting everything neat and tidy with a policy and a protocol all written and her authority all defined, you can see that appointing her to a directorate that did not exist, which had to be developed and so on, may be for a time, quite unsettling.' [132]
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Footnotes
[120] WIT 0115 0003 Professor Vann Jones
[124] WIT 0114 0008 Fiona Thomas
[125] WIT 0089 0017 Mrs Ferris
[127] WIT 0114 0043 Mr Dhasmana
[128] WIT 0089 0018 Mrs Ferris
[130] WIT 0115 0002 Professor Vann Jones
[131] WIT 0089 0004 Mrs Ferris