82
in 59 patients without evidence of thrombosis.13 Patients with thrombosis also have a different distribution pattern of degradation products : using fibrinogen chromatography Fletcher and othersl6 classified 72 surgical patients correctly, as
400
ug/1
was
found
only
once
judged by leg scanning, although there were discrepancies in a further 29 patients. Unfortunately the technique is unsuitable for clinical use, but the principle of the method did suggest that measuring more than one breakdown product might give increased diagnostic accuracy. Certainly normal levels of both F.D.P. and fibrin monomer nearly always rule out important venous thrombosis but raised levels are still not diagnostic.17 Bynum and othersl8 have followed 52 patients for ten days after proven pulmonary embolism. 8 of these patients sustained a second embolus and this group had higher initial levels of F.D.P. and fibrin monomer than the non-recurrent group. Although the levels then reverted towards normal there was a second increase at the time of recurrent embolism. Unfortunately the mean values in the non-recurrent group were never grossly raised, which suggests that the discrimination of these tests may not be so good as was found in an earlier study.19 These older tests are insensitive; let us hope the newer more sensitive assays will enable us to identify abnormal fibrin production rapidly and accurately. WANTED: MEDICAL MANAGERS
takes responsihis own time and bility managing determining his own priorities. It can be argued that a clinical medical student becomes a manager the moment that he asks a nurse to help him to take his first sample of blood from a patient. The first time that the nurse refuses and he has to find some other method of venepuncture is when he first experiences the true difficulties of management. Since the reorganisation of the National Health Service in 1974, there has been a renewed and indecisive debate about what is wrong with N.H.S. management and its managers. There seems to be consensus that, in the administrative structure from the Department of Health right up to the bedside, there is a tier too many. Not surprisingly, the career managers at district level believe that district should remain as the essential part of the administrative structure. No more surprisingly, the area team of officers believe that, whatever should disappear in any future reorganisation, it should not be the area. And, not unnaturally, the regional team of officers argue that, in a future redistribution of administrative power, the region should be sacrosanct. As a background to this debate, castigation of reorganisation and manager-bashing have become routine entertainments wherever doctors meet. Apart from the actual act of reorganisation on the appointed day, other forces of change have come into operation-units of medical time; district consultative committees; community health councils; and unforeseen financial difficulties. Need has therefore arisen for a new type of administrator. Administration is now not merely a matter for somebody called The AdminisIN
a
sense, everyone is a manager who
for
16.
A. P., Alkjaersig, N., O’Brien, J. in Thromboembolism: and Treatment (edited by V. V. Kakkar and A. J. Jouhar); p.
Fletcher,
Diagnosis 25. Edin-
burgh, 1972. 17 Gurewich, V., Hume, M., Patrick, M. Chest, 1973, 64, 585. 18. Bynum, L. J., Parkey, R. W., Wilson, J. E. Archs intern. Med. 1977, 137, 1385. 19. Bynum, L. J., Crotty, C., Wilson, J. E. Am. Rev. resp. Dis. 1976, 114, 285.
trator ; it is in the hands of
multidisciplinary teams, of professional administrator, community physician, treasurer, and nursing officer. And at district-managementteam level the team is joined by general practitioner and hospital consultant. All these people must share equally and enthusiastically in consensus management (if consensus management be not a contradiction in terms). King Edward’s Hospital Fund for London can propose solutions to Health Service problems without being held accountable, as the Department of Health would be, if their proposals go awry. The Fund is therefore in a position to lead thought, and it has lately published a report on education and training of senior managers in the National Health Service.’ The report debates whether future managers in the Health Service should take something akin to the Armed Forces staff-college course; or should they embark on a training more geared to local-authority requirements? The present structure of the Health Service certainly demands top-class management. But if one decided that senior managers should have, say, an M.sc. in management, there are difficulties. Many people entering administration do not have degrees, so masterships are not to be had. As for the doctors who enter management, how will they find time to work for such a degree? Existing courses for trainee community physicians provide the necessary full-stops and commas of an academic background, but will they enable the trainee, when he reaches senior management level, to deal with pure managerial problems, such as negotiations with trade-unions and financial planning? The King’s Fund working-party think that troubles with the new organisational structure have obscured, in ministerial as well as in public eyes, the need for highly trained senior managers; in management leadership is vital, and it must come in part from Government ministers. For a start, the working-party proposes that health authorities should form a consortium for the provision of training in high-level management. There is no single or homogeneous activity called management; and the training needs of managers are also diverse, because of differences in employment sectors, regions, and previous training and experience (and so in levels of seniority). There is thus a case for both common service-wide courses and more specialised or local courses. Managers are decision-makers and planners, controllers, organisers, and motivators, and they are expected to have some understanding of personnel management and financial administration and a knowledge of the handling of information. The Health Service at the moment is being run by people prepared to do the best of which they are capable within existing confines. For the long term, however, we must be looking at the post-entrance training of the high-calibre individuals the service seeks to recruit. Nowadays in senior management the doctor, generally the community physician, has an important part to play. It has never been good enough merely to criticise "them", the managers. It is and always has been necessary to recognise that "we", the doctors, are involved in this management process.2 We must now find young and able doctors who are prepared to undergo training towards senior management. Training of Senior Managers in the National Health SerKing Edward’s Hospital Fund for London, 1977. £6. 2. Doctor as Manager. See Lancet, 1967, ii, 1193, 1246, 1248, 1295. 1. The Education and vice.
in 59 patients without evidence of thrombosis.13 Patients with thrombosis also have a different distribution pattern of degradation products : using fibrinogen chromatography Fletcher and othersl6 classified 72 surgical patients correctly, as
400
ug/1
was
found
only
once
judged by leg scanning, although there were discrepancies in a further 29 patients. Unfortunately the technique is unsuitable for clinical use, but the principle of the method did suggest that measuring more than one breakdown product might give increased diagnostic accuracy. Certainly normal levels of both F.D.P. and fibrin monomer nearly always rule out important venous thrombosis but raised levels are still not diagnostic.17 Bynum and othersl8 have followed 52 patients for ten days after proven pulmonary embolism. 8 of these patients sustained a second embolus and this group had higher initial levels of F.D.P. and fibrin monomer than the non-recurrent group. Although the levels then reverted towards normal there was a second increase at the time of recurrent embolism. Unfortunately the mean values in the non-recurrent group were never grossly raised, which suggests that the discrimination of these tests may not be so good as was found in an earlier study.19 These older tests are insensitive; let us hope the newer more sensitive assays will enable us to identify abnormal fibrin production rapidly and accurately. WANTED: MEDICAL MANAGERS
takes responsihis own time and bility managing determining his own priorities. It can be argued that a clinical medical student becomes a manager the moment that he asks a nurse to help him to take his first sample of blood from a patient. The first time that the nurse refuses and he has to find some other method of venepuncture is when he first experiences the true difficulties of management. Since the reorganisation of the National Health Service in 1974, there has been a renewed and indecisive debate about what is wrong with N.H.S. management and its managers. There seems to be consensus that, in the administrative structure from the Department of Health right up to the bedside, there is a tier too many. Not surprisingly, the career managers at district level believe that district should remain as the essential part of the administrative structure. No more surprisingly, the area team of officers believe that, whatever should disappear in any future reorganisation, it should not be the area. And, not unnaturally, the regional team of officers argue that, in a future redistribution of administrative power, the region should be sacrosanct. As a background to this debate, castigation of reorganisation and manager-bashing have become routine entertainments wherever doctors meet. Apart from the actual act of reorganisation on the appointed day, other forces of change have come into operation-units of medical time; district consultative committees; community health councils; and unforeseen financial difficulties. Need has therefore arisen for a new type of administrator. Administration is now not merely a matter for somebody called The AdminisIN
a
sense, everyone is a manager who
for
16.
A. P., Alkjaersig, N., O’Brien, J. in Thromboembolism: and Treatment (edited by V. V. Kakkar and A. J. Jouhar); p.
Fletcher,
Diagnosis 25. Edin-
burgh, 1972. 17 Gurewich, V., Hume, M., Patrick, M. Chest, 1973, 64, 585. 18. Bynum, L. J., Parkey, R. W., Wilson, J. E. Archs intern. Med. 1977, 137, 1385. 19. Bynum, L. J., Crotty, C., Wilson, J. E. Am. Rev. resp. Dis. 1976, 114, 285.
trator ; it is in the hands of
multidisciplinary teams, of professional administrator, community physician, treasurer, and nursing officer. And at district-managementteam level the team is joined by general practitioner and hospital consultant. All these people must share equally and enthusiastically in consensus management (if consensus management be not a contradiction in terms). King Edward’s Hospital Fund for London can propose solutions to Health Service problems without being held accountable, as the Department of Health would be, if their proposals go awry. The Fund is therefore in a position to lead thought, and it has lately published a report on education and training of senior managers in the National Health Service.’ The report debates whether future managers in the Health Service should take something akin to the Armed Forces staff-college course; or should they embark on a training more geared to local-authority requirements? The present structure of the Health Service certainly demands top-class management. But if one decided that senior managers should have, say, an M.sc. in management, there are difficulties. Many people entering administration do not have degrees, so masterships are not to be had. As for the doctors who enter management, how will they find time to work for such a degree? Existing courses for trainee community physicians provide the necessary full-stops and commas of an academic background, but will they enable the trainee, when he reaches senior management level, to deal with pure managerial problems, such as negotiations with trade-unions and financial planning? The King’s Fund working-party think that troubles with the new organisational structure have obscured, in ministerial as well as in public eyes, the need for highly trained senior managers; in management leadership is vital, and it must come in part from Government ministers. For a start, the working-party proposes that health authorities should form a consortium for the provision of training in high-level management. There is no single or homogeneous activity called management; and the training needs of managers are also diverse, because of differences in employment sectors, regions, and previous training and experience (and so in levels of seniority). There is thus a case for both common service-wide courses and more specialised or local courses. Managers are decision-makers and planners, controllers, organisers, and motivators, and they are expected to have some understanding of personnel management and financial administration and a knowledge of the handling of information. The Health Service at the moment is being run by people prepared to do the best of which they are capable within existing confines. For the long term, however, we must be looking at the post-entrance training of the high-calibre individuals the service seeks to recruit. Nowadays in senior management the doctor, generally the community physician, has an important part to play. It has never been good enough merely to criticise "them", the managers. It is and always has been necessary to recognise that "we", the doctors, are involved in this management process.2 We must now find young and able doctors who are prepared to undergo training towards senior management. Training of Senior Managers in the National Health SerKing Edward’s Hospital Fund for London, 1977. £6. 2. Doctor as Manager. See Lancet, 1967, ii, 1193, 1246, 1248, 1295. 1. The Education and vice.
