1. All practising doctors are responsible for the use of resources; many will also lead teams or be involved in the supervision of colleagues;2 and most will work in managed systems, whether in the NHS or in the independent , military, prison or other sectors. Doctors have responsibilities to their patients, employers and those who contract their services. This means that doctors are both managers and are managed. This booklet will be particularly relevant if you have a management role, but should be helpful for all doctors.
2. For the purposes of this booklet, management is defined as:
Getting things done well through and with people, creating an environment in which people can perform as individuals and yet co-operate towards achieving group goals, and removing obstacles to such performance.3
3. Doctors' management roles often involve responsibility for teams, people and the resources they use. If you manage resources other than people, or develop policies, set standards or audit others, you should follow the guidance in this booklet as far as it is relevant to your role.
4. You continue to have a duty of care for the safety and well-being of patients when you work as a manager. You remain accountable to the GMC for your decisions and actions even when a non-doctor could perform your management role.4
5. Good Medical Practice sets out the fundamental principles that should underpin the practice of all doctors, and those principles are not repeated here. It is essential therefore that you have a detailed working knowledge of the principles set out in Good Medical Practice and in the other booklets that make up our Duties of a Doctor pack, and that you apply them in all aspects of your work.
6. We recognise that doctors in an assortment of roles take on management responsibilities to varying degrees: you may be a single-handed general practitioner or lead a small clinical team; or you may be a clinical or medical director or a chief executive. We also recognise that your ability to put into effect parts of the guidance in this booklet will depend on the authority your position gives you as well as the resources made available to you.
7. With this in mind, you must make every effort to follow the guidance in this booklet, where it is your responsibility and within your power to do so. Where it is not, you should do what you can to raise awareness of any problems with those who are in a position to make change. The extent to which you will be held accountable will inevitably depend on the circumstances: your position, the resources available to you and the nature of the problem will all play a part in evaluating the extent and nature of your accountability.
8. The Committee on Standards in Public Life5(the Nolan Committee) set out seven principles for the conduct of holders of public office. The principles have been widely accepted as applicable in areas far wider than those for which they were initially drawn up, and they offer a useful set of principles for doctors who manage.
9. The seven principles are:
10. All practising doctors use resources and play a role in setting priorities, developing policies and making other management decisions. All doctors have an obligation therefore to work with both medical and non-medical managers in a productive way for the benefit of patients and the public.
11. This booklet is concerned with principles of good practice and is not intended as a general management handbook, although we intend to publish more detailed guidance to supplement these principles. The principles and ethical standards set by the British Association of Medical Managers, the Institute of Healthcare Management and the Department of Health's Code of Conduct for NHS Managers are consistent with those described in this guidance.
Good Management Practice
Providing a good standard of management practice
12. It is not possible to set out all the roles doctors take on as managers. If your role involves responsibilities covered in this booklet, you should do your best to make sure that:
systems are in place to enable high quality medical services to be provided
care is provided and supervised only by staff who have the appropriate skills (including communication skills), experience, training and qualifications
significant risks to patients, staff and the health of the wider community are identified, assessed and addressed to minimise risk, and that they are reported in line with local and national procedures
the people you manage (both doctors and other professionals) are aware of and follow the guidance issued by relevant professional and regulatory bodies, and that they are able to fulfil their professional duties so that standards of practice and care are maintained and improved
systems are in place to identify the educational and training needs of students and staff, including locums, so that the best use is made of the time and resources available for keeping knowledge and skills up to date
all decisions, working practices and the working environment are lawful, with particular regard to the law on employment, equal opportunities and health and safety
information and policies on clinical effectiveness and clinical governance 6 are publicised and implemented effectively.
13. It is crucial that clinical performance is managed at the local level. This is an essential feature of a GMC-approved working environment. You must make sure that effective systems are in place to give early warning of any failure, or potential failure, in clinical performance, and that such failures are addressed quickly and effectively.
14. You should make sure that the people you manage have appropriate supervision, whether through close personal supervision (for junior doctors, for example) or through a managed system with clear reporting structures.
15. You should make sure that adequate systems are in place for investigating complaints promptly, fairly and thoroughly and that all staff, regardless of grade or seniority, are aware of reporting and complaints procedures and can seek advice, report an incident or make a complaint when necessary.
16. You should make sure that appraisals are completed fully and on time for the staff you manage. You should enable your staff to complete activities identified by appraisal.7
Competencies and standards that define a good manager8
17. As an effective manager, you should be able to:
lead a team effectively
identify and set objectives
manage resources and plan work to achieve maximum benefits, both day to day and in the longer term
make sound decisions in difficult situations
know when to seek help and do so when appropriate
offer help to those you manage, when they need it
demonstrate leadership qualities through your own example
delegate appropriately - to empower others, to improve services and to develop the skills of the people you manage - without giving up your own responsibilities
consider and act upon constructive feedback from colleagues.
18. As an effective manager, you need a sound working knowledge of the:
main clinical and other issues relevant to those you manage
key skills and contributions of other health professionals
roles and policies of local agencies involved in healthcare
use and application of information and information technology
nature of clinical and other risks
limits of what is affordable and achievable
principles of change management
culture of the organisations in which you work
structure and lines of accountability in the organisation in which you work
principles of good employment practice and effective people management.
Responsibilities, conflict and accountability
19. You should establish clearly with your employer the scope of your role and the responsibilities it involves. You should raise any issues of ambiguity or uncertainty about responsibilities in multi-disciplinary teams in order to clarify:
lines of accountability for the care provided to individual patients
who should take on leadership roles or line management responsibilities
where responsibility lies for the quality and standard of care provided by the team.
20. Whether you have a management role or not, your primary duty is to your patients. Their care and safety must be your first concern. You also have a duty to the health of the wider community, your profession, your colleagues, and the organisation in which you work.
21. Management involves making judgements about competing demands on available resources. If managerial concerns conflict with your primary duty to the extent that you are concerned for the safety or well-being of your patients, you should declare the conflict, seek colleagues' advice, and raise your concerns formally with senior management and external professional bodies as appropriate.
22. At times you may not have the resources to provide the best treatment or care that all your patients need. At such times your decisions should be based on sound research information on efficiency and efficacy, and in line with your duties to protect life and health, to respect patients' autonomy and to treat justly.
23. You should take into account the priorities set by government and the NHS or your employing or funding body. You should discuss the issues within the healthcare team, with senior management and, when appropriate, with patients.
24. You are accountable to the GMC for your own conduct and for any medical advice you give, including while you serve on a hospital board or other corporate body. If you are concerned that a board decision would put patients or the health of the wider community at risk of serious harm, you must ask for your objections to be formally recorded and you should consider taking further action.
25. If you have good grounds to believe that patients or the health of the wider community might be at risk of serious harm, and you have done all you can to resolve the problem by raising your concerns within the organisation in which you work, you may consider making them public,10 provided that patient confidentiality is not breached. You should consult a defence body or professional association before taking a decision of this kind.11
26. As well as keeping patients' clinical records, about which Good Medical Practice gives advice, you must keep financial, employment, research and other records for which you are responsible in good order. Good records are part of good management: you should keep paper or electronic audit trails to demonstrate good management decision-making. This is particularly important if you manage a healthcare business.
27. You should keep clear, accurate and legible management records of relevant decisions and transactions in line with the law, local procedures and good practice. These records should be made at the same time, or soon afterwards. These records must be compiled and stored securely and used honestly, with proper regard for patient and staff confidentiality, and made available to anyone authorised to see them. When disposing of records, you must do so with similar care and in line with relevant guidelines. You should take professional advice as necessary.12
29. If you work as one of a group of independently contracted GPs, you have an individual responsibility to make sure that the practice has appropriate systems in place to deal supportively with problems in your own or your partners' conduct, performance and health.
Maintaining good management practice
30. As a manager, you must work within the limits of your competence. You must keep up to date with and observe laws and statutory codes of conduct relevant to your particular responsibilities and location,13 seeking expert advice when you need it.
31. You should make sure that you keep up to date with and use guidance on the knowledge, skills and attitudes necessary to carry out your management responsibilities. The British Association of Medical Managers, the Institute of Healthcare Management, the NHS Confederation and the NHS Institute all offer guidance in this area.
32. You should take part in professional development and educational activities appropriate to your management responsibilities. You should also take part in annual appraisal and revalidation,14 both of which should involve someone who knows about management (who might not be your clinical appraiser) looking at your performance as a manager. You should also consider using medical and management support systems, such as mentoring, coaching and action learning.
33. You should review your own performance as a manager and take part in regular audit and reviews.
34. You need to be clear about your role and the roles of your staff when accepting jobs and drafting job descriptions, making use of human resources expertise when appropriate. You should also consider the resource, development and training needs involved in jobs that you apply for or offer to others.
Teaching and training, appraising and assessing
35. You must make sure that only people with the appropriate knowledge, skills and attitudes conduct teaching and training for which you are responsible.
36. You must make sure that adequate systems are in place to advise patients of their rights to know if any trainee doctors are involved in their care and to choose not to participate in teaching or research. You must make sure that patients' wishes are followed and that their care is not adversely affected if they choose not to participate.
37. You should keep up to date and develop your skills in line with your professional obligations. You should make sure that the people you manage have opportunities to do the same.
38. You should make sure that you and anyone to whom you delegate responsibility for appraising and assessing receives appropriate training and regular feedback.
39. You must be honest and objective when appraising or assessing colleagues' performance and when providing references. The safety of patients and the public could be put at risk if you make false, exaggerated or incomplete comments about another professional's competence or experience.
Relating to patients
Confidentiality and access to information
40. Your work might involve patients both directly and indirectly in a variety of settings. Whatever the context, you and those you manage should follow GMC guidance on consent and confidentiality.16
41. If you have wider responsibilities for consent and confidentiality issues within your organisation you should keep up to date with and observe the legal and ethical guidelines on handling confidential information, with particular reference to the Data Protection and Freedom of Information Acts.
42. You should ensure that systems are in place to:
store, use and disclose confidential information in line with the law and professional guidance
regularly review consent forms and patient information leaflets and make sure that they comply with professional guidance, including guidance from the GMC
provide data protection and records managers17 with the training and support they need to carry out their responsibilities
provide other staff who have access to patient records and other personal information with appropriate training on confidentiality and good record keeping
include in relevant staff contracts a clear statement that staff must respect and maintain patient confidentiality.
Communicating with patients
43. You should make sure that you and those you manage:
listen to patients and show respect for their views about their health
always take seriously patients' descriptions of events
provide information which patients or others need or want to know in a way they can understand
respond to questions or inquiries honestly and fully, without compromising your duty of confidentiality.
Responding to incidents and complaints
44. Concerns about patient safety or the conduct, health or performance of staff can come from a number of sources, such as patients' complaints, colleagues' concerns, critical incident reports and clinical audit. If you receive such information you have a duty to act on it promptly and professionally. You can do this by investigating and resolving concerns locally or by referring serious or repeated incidents or complaints to senior management or regulatory authorities.
45. If you are responsible for investigating incidents or complaints you should make sure that:
appropriate adverse event and critical incident reports are made within the organization and to other bodies, such as the National Patient Safety Agency
you have a working knowledge of the relevant law and procedures under which investigations and related proceedings are conducted
patients who make a complaint receive a prompt, open, constructive and honest response
clinical staff understand their duty to be open and honest about such events with both patients and managers
all other staff are encouraged to raise genuine concerns they have about the safety of patients, including any risks that may be posed by colleagues
staff members who raise concerns are protected from unwarranted criticism or actions
systems are in place to ensure that incidents, concerns and complaints are investigated promptly and fully
the person or people being investigated are treated fairly
patients who suffer harm receive an explanation and, where appropriate, an apology18
recommendations that arise from investigations are implemented or referred to senior management.
Working with colleagues
46. It is essential to good patient care that you work effectively with colleagues from a variety of disciplines, both within teams and within and between organisations . You should be alive to the benefits of consulting with staff, who are often the first to identify problems and areas where improvement is needed.
Treating colleagues fairly
47. All doctors must treat their colleagues fairly. You must tackle discrimination where it arises, actively promote equality and diversity and encourage your colleagues to do the same. You should have a working knowledge of the relevant law and your organisation's policies and know where to get expert advice.
48. You should be prepared to discuss constructively and sympathetically any work problems the people you manage may have.
49. Healthcare is increasingly provided by multi-disciplinary teams. Such teamwork can bring benefits to patient care, but problems can arise when communication is poor or responsibilities are unclear. If you manage a team, you will need to recognise when it is not functioning well and know where to go for help.19
50. When leading a team you should:
respect the skills and contributions of your colleagues; you must not make unfounded criticisms of colleagues, which can undermine patients' trust in the care provided
make sure that colleagues understand the professional status and specialty of all team members, their roles and responsibilities in the team, and who is responsible for each aspect of patient care
make sure that staff are clear about their individual and team objectives, their personal and collective responsibilities for patient and public safety, and for openly and honestly recording and discussing problems
communicate effectively with colleagues within and outside the team; you should make sure that arrangements are in place for relevant information to be passed on to the team promptly
make sure that all team members have an opportunity to contribute to discussions and that they understand and accept the decisions taken
encourage team members to co-operate and communicate effectively with each other
make sure that each patient's care is properly co-ordinated and managed, and that patients are given information about whom to contact if they have questions or concerns; this is particularly important when patient care is shared between teams
set up and maintain systems to identify and manage risks in the team's area of responsibility
monitor and regularly review the team's performance and take steps to correct deficiencies and improve quality
deal openly and supportively with problems in the conduct, performance or health of team members through effective and well- publicised procedures
make sure that your team and the organisation have the opportunity to learn from mistakes.
Communicating with colleagues
51. Effective communication with colleagues and others is essential for good healthcare. You must make sure that those you manage have the information they need when they need it. You should also pass on any relevant information to senior management.
52. You must be satisfied that suitable arrangements are in place for patient care when staff you manage are off duty, and that effective handover procedures are followed.
53. When you delegate your managerial responsibilities you must be sure that the person to whom you delegate is competent to do what is asked of them and has the necessary information, authority and resources. You will still be responsible for the overall management of the tasks you have delegated.
Financial and commercial dealings
54. You must be open and honest in any financial and commercial dealings you are responsible for. You must make sure that you and those you manage are competent and have the necessary training or advice for any financial work you take on.
55. You must declare any interests you have that could influence or be seen to influence your judgement in any financial or commercial dealings you are responsible for. In particular, you must not allow your interests to influence:
the treatment of patients
purchases from funds for which you are responsible
the terms or awarding of contracts
the conduct of research.
56. You should make sure there are adequate systems in place to monitor financial and management information and that you and those you manage make full use of them. This includes awarding contracts and managing waiting lists and service plans.
57. You must make sure that the funds you manage are used for the purposes they were intended for and are clearly and properly accounted for. You should also make sure that appropriate professional services, including audit, are commissioned when necessary.20
58. You should follow the advice in Good Medical Practice in relation to your own health. You should also:
protect those you manage from risks to their health
protect patients from risks arising from your own or your colleagues' health21
respond constructively to signs that colleagues have health problems; in particular you
should be alive to mental health problems, depression, and alcohol and drug dependence
help and support colleagues who have health problems.
59. If you are an occupational health manager you might have contractual obligations to employers, as well as professional obligations to their employees. You should consider the advice in Confidentiality: Protecting and Providing Information. Further advice is available from the Faculty of Occupational Medicine.