Last week I stepped down from Edgecumbe Health after 20 years at the helm of this consulting practice. With some space and time on my hands at last, I can reflect back on the last 30 years of working closely with the medical profession, and the last 20 years of running a specialist consultancy in which I have focussed most of my attention on the medical profession. How have things changed in that time?
In the early days – that is, the late 1980s, I was greatly involved with GP vocational training, having studied for a DPhil in Psychology, with a research thesis on Patients’ Health Beliefs. Several GP practices in the Oxford Region – led by Dr John Hasler, GP Director at the time – allowed me to carry out my research on their patients to understand the specific health beliefs that influenced their attitude to the medical advice they were given, and their eventual decision to comply, or not. The notion that listening to or exploring what the patient believed was quite new. But others were introducing the idea that the patient was to be treated as an expert in the consultation, and the book by David Tuckett called “Meetings between Experts” was influential in my thinking, together with a framework called the Health Belief Model developed in the 1980s by Marshall Becker in the USA. Gradually, through a series of seminars and workshops with GP trainers and trainees, and working closely with David Pendleton (whom I later married!) who was developing the so –called Pendleton Rules with other Oxford colleagues (Peter Havelock, Peter Tate and Theo Schofield), we changed the approach to consulting so that GPs took time to explore patients’ ideas, concerns and expectations (later known as the ICE model) before working with the patient to agree the management of the problem they presented.
This led me further into the world of doctors and after a detour into management consultancy, where I learned the tools of the trade of an occupational psychologist, I decided to import those skills into the medical profession. Having learned about personality testing, interviewing skills and assessment for recruitment, I began to apply these to GP practices, GP educators, and educational supervisors. We developed an approach to appraising medical trainees that involved a much more in-depth exploration of their attitudes, values, behaviours and aspirations. We trained educational supervisors throughout the North West, in a partnership with Professor Jacky Hayden and her colleagues in the (then) Deanery that lasted 8 years. We extended it to Scotland, where the hospitality for visiting consultants like me was unmatched anywhere in the rest of the UK – I would invariably return home with a bottle of fine malt whisky and a doll in national Scottish dress for one of my daughters. Those were the days when I could phone my contacts and say “ I have an idea – how about running a programme on x” – and it would just happen. Procurement barely existed – if the idea was good and people were interested, we could just run with it. Wonderful relationships were forged around the country and by the time Edgecumbe Health was formed in 1997 we enjoyed a network of doctors all over the country who supported our work. It was a network that was to last for the best part of 20 years.
During that time, of course, things changed immeasurably in the NHS. Shipman’s crimes resulted in that classic declaration from Richard Smith, the editor of the BMJ: “All changed, changed utterly” – as, for the first time, doctors were expected to undergo revalidation to ensure they remained fit to practice. With this came medical appraisal – a big shock to a profession that had been used to self-regulation – and medical management, a further threat to a profession used to clinical freedom and a good deal of autonomy. Morale took a nose-dive and cynicism was rife. We spent several years in our travels around the country training doctors to be appraisers and to be appraised, enduring every kind of resistance in the book. But – as they say – it certainly developed our character and our resilience as consultants, and after a few years of this, there was no objection we had not encountered. Gradually, the more enlightened doctors saw the benefits that a good developmental appraisal could bring. But in the end, it wasn’t enough. It was clear that, if appraisal was to have any “teeth” and any real value in ensuring high quality medical practice, it would have to become more rigorous. So began a further round of training with yet more cynicism as appraisal took on a more assessment-focussed flavour. For a while it felt as though we were back where we were in 2000 when medical appraisal was first introduced and the same old cynical attitudes reared their head. But, as with most change, 15 years later it became standard practice. Every doctor had to complete at least one 360 degree feedback – something that would have been considered unthinkable 25 years ago even though in industry it was already standard practice.
Face to face training became combined with, and in some cases, replaced by, online training but this never really provided the same opportunities to practice the skills of appraisal and receive live feedback from a group of peers and a tutor. In the early years, we would videotape all those practice sessions and play back excerpts to the participants – still the most powerful form of feedback. With cuts to costs and pressures on time, training courses became curtailed and we fought to resist the pressure to pack as many delegates as possible on to the courses. Quality was our watchword and we maintained it rigorously, even if it meant losing business.
As the NHS became more and more stressful, we began to see the fall-out in respect of more difficult and dysfunctional team dynamics and individual doctors who struggled to cope and were often thrust too early into positions of leadership for which they were poorly prepared. Gradually, through the influence of the British Association of Medical Managers (BAMM) leadership programmes became the norm for doctors in medical management roles, but there remained a dearth of training for the ordinary consultant or GP who were somehow expected to have magically acquired leadership skills with no real formal tuition. When some inevitably failed they hit the buffers in various ways which did little for their dwindling morale and often caused long-term problems in their teams. The advent of the National Clinical Assessment Authority (later NCAS) in 2001 was the first time an organisation was set up specifically to support doctors whose performance had raised serious concerns. They were offered assessment in three forms – behavioural, clinical and health. We partnered with Professor Alastair Scotland and his colleagues at NCAS to develop the behavioural assessment which became a national standard and enabled doctors whose careers were in various stages of jeopardy to “get back on track”. We worked with appraisers to help them to recognise the early signs of difficulty so that a referral to NCAS would not be needed. There was a real appetite for this – the medical profession looks after its own and whilst this sometimes represented a closing of ranks, with the raft of medical scandals that beset the profession through the 1990s and beyond, greater intolerance for bad behaviour became evident. At the same time doctors who were genuinely in difficulty as opposed to being difficult were offered many more routes to support through, for example the Practitioners’ Health Programme and the BMA’s Doctors for Doctors. The Faculty of Medical Leadership and Management was established by an enlightened neurosurgeon, Peter Lees, making all matters to do with leadership and management accessible to doctors at every stage of their career. The climate was changing – there was support but also robust challenge – culminating in the hard hitting Francis report into the Mid Staffordshire scandal that was to prove another major turning point for healthcare. Values became the watchword – thus we became involved in values-based recruitment, devising selection processes designed to ensure that consultants recruited to hospitals were assessed for the values they demonstrated, as well as the clinical skills they brought. The braver organisations started to reject candidates, no matter how impressive their c.v. if it became clear during the recruitment process that their values and behaviour were at odds with the values of the organisation.
So at the end of my 20 years at the helm of Edgecumbe Health, I can look back over a truly fascinating, often challenging, and always rewarding series of encounters with doctors and those who lead and manage them. Under its new Practice Lead, Dr Megan Joffe – with whom I have worked closely for 11 years – Edgecumbe Health can look forward to further challenges in developing, supporting and remediating doctors who are struggling, and to improving the quality of the processes designed to recruit our future doctors.
Whatever has happened, doctors – for me – remain one of our most prized professions and I am immensely proud to have spent most of my career in their company.
by Dr. Jenny King