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When Nigel Beasley approached me to write on my experience of clinical management, I was a little surprised. I see myself as primarily a clinician, but have had increasing involvement with clinical management within my Trust.

I am now in my eighth year of consultant practice, working as an implantation otologist and paediatric ENT surgeon in Nottingham University Hospital. My clinical duties are rewarding, stimulating and at times challenging. During my training I was involved with various organisational roles within the departments in which I worked. In practical terms this meant ensuring adequate junior doctor cover, resolving on-call cover clashes, and dealing with induction and organisation of the ward based trainees. This gave me the opportunity to sit on departmental meetings to gain some insight into the interactions between the consultant team and the administration / management team at departmental level.

During my first few years as a consultant I concentrated on developing my clinical practice and establishing good working relationships with other relevant departments within the Trust and clinical colleagues outside of the Trust. I had a role in the management structure of our Nottingham Auditory Implant Programme (NAIP), and was appointed by the department to oversee the core trainees and Foundation Year 2 (FY2s) on our service.

Three years ago, the opportunity arose to apply for the position of Head of Service (HOS) in ENT. After some thought, and a lack of other willing applicants, I put myself forward and following an interview process was appointed. This role came with a 1 programmed activity (PA) allocation. It was largely an operational role, working with the assistant general manager of the specialty and the directorate management team (DMT). By way of explanation, in our Trust each specialty has an HOS, and specialties are grouped together into clinical directorates, managed by the DMT.

“It is important to be fair and consistent in your approach to colleagues. This will mean setting clear boundaries and being transparent in how you work.”

The DMT comprises of a business manager, a clinical lead and a clinical director (CD) who is a consultant clinician. The DMT is supported by a human resources representative and a directorate accountant. ENT falls within the head and neck directorate, which also includes maxillo-facial surgery and ophthalmology.

As HOS I was responsible for the overall performance of ENT and audiology including NAIP. I saw myself as a link between the management team and the consultant clinical staff. I felt my role was to help the consultant staff deliver the best possible clinical service and develop the department in the direction desired. I aimed to do this within the framework outlined by the Trust’s procedures and guidelines. There was also a strategic component to the role, developing a five-year development plan for the department and presenting this to the Trust board. I had regular meetings with the DMT to discuss performance issues, and increasingly to discuss the delivery of our financial efficiency programme (FEP).

During my time as HOS I was delighted to make the business case to expand our consultant staff, and to re-design our theatre and clinical timetable to accommodate the increase.

Approximately 18 months ago it became clear that our current CD wished to stand down from the post and so the Trust looked to appoint a successor. I was approached by the chief executive officer (CEO) to discuss whether I would consider applying. I raised concerns at the time that I was still relatively early into my consultant career, and relatively inexperienced at medical management. My other major concern was how I would accommodate the extra work of being a CD whilst being a full time clinician. The CEO understood these reservations, but assured me there would be adequate time made available to fulfill the role and that guidance and mentorship would be made available. After some reflection and discussion at home and with colleagues I did apply for the position, and was successfully interviewed and appointed.

Before applying, I was able to propose an alteration to my job plan that meant I would be released from two clinical sessions, in order to free up sufficient management time. I was also able to use the funds released by this to back fill these sessions with a locum colleague, so that there was no impact on clinical care. We have now taken this further and appointed a substantive colleague to develop the paediatric service, which I see as a big step forward for the department.

My current role as a CD involves a weekly directors’ group meeting with the chief executive’s team, CDs and pathway clinical leads. This is regarded as the senior clinical management group within the hospital and advises the Trust board. The meetings have a theme of strategic / investment, quality and performance depending on where they fall within the month. This is an opportunity to input into the strategic direction of the Trust, and impact on the quality issues that mean so much for our patients and colleagues. It is a forum to enable directorates to work together and learn from each other’s experiences.

In addition to regular meetings, I sit on working parties within the Trust and chair a sub-group. I have been involved in strategic work with our local clinical commissioning groups. I have sat on a number of consultant interviews for many different specialties. I have also been involved in potential disciplinary matters within the Trust advising on adherence to the Trust’s values and behaviours policy.

I continue to work closely with the HOS for the specialties within our directorate and the business teams that support them.

I would not suggest that I have got everything right over the last three years, or that I have achieved all that I want to achieve in my current role, far from it. I have learnt some valuable lessons and would like to share some thoughts from my experience to date.

In order to be effective in clinical management, you need to make time for the role. Not only so that you have time to develop and implement ideas, prepare sufficiently for meetings, but also so that you are available. Colleagues will invariably come to you with issues, often just dropping into your office.

It is important to take time to listen to your colleagues and respect their opinions. You might not be able to deal with their issues right away, but they will appreciate someone giving them time to discuss matters. It is important to be fair and consistent in your approach to colleagues. This will mean setting clear boundaries and being transparent in how you work. This may lead to difficult conversations and may take time to develop this approach.

You must use the Trust guidance and policies to ensure your approach is consistent with your colleagues across your Trust. You must use the support team you have. Delegation can be difficult, but is necessary to manage the work that will come to you. Taking advice is important, as you will not know the answers to all the enquiries that come your way, but you should know someone who can help. You will have an experienced team around you who have the time and skills under your direction to deliver.

“Personally, I have found time discussing issues with trusted colleagues the most useful way of developing as a clinical manager.”

If possible, try to meet with people rather than engaging in prolonged email discussion. It is much easier to understand and resolve issues with a chat, rather than days of drawn out email conversations, often with unnecessary recipients being copied in. You will find that your inbox rapidly fills up, so effective email management becomes a must.

You should discuss problems you are having with your colleagues or find a trusted mentor who has held the position you occupy to talk through issues. The challenges you encounter are rarely new ones, so others will have faced these in the past. It is useful to share their experience, so you can learn from their good practice whilst hopefully, avoiding their mistakes.

Remember you are primarily a clinician. Your patients must come first. You will not be in your management role forever. Hopefully by applying the fair and consistent approach outlined above, your colleagues will appreciate the time you have given to the role and welcome you back as a clinical colleague.

Personally, I have found time discussing issues with trusted colleagues the most useful way of developing as a clinical manager. There are many management training programmes available but often at significant cost, both financial and time related. I have found the King’s Fund has a variety of seminars, short courses or longer courses that can be of interest [1].

I would encourage those who are interested to become involved in medical management. It is inevitable in the current climate that our services will change in the next few years. The constant financial pressures and drive towards seven day working will define the service we provide to our patients. In my experience, it is better to be involved in driving the change, rather than having change thrust upon you.



1. King’s Fund.
Last accessed July 2014.


Declaration of competing interests: None declared.

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Andrew Marshall

BSC, MBBS, FRCS, sits on the council of the section of Otology at the Royal Society of Medicine; past treasurer of the British Cochlear Implant Group; sits on the Clinical Reference Group for Specialised Ear Surgery and Ophthalmology.

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