Patients are suffering because clinical decisions are being affected by managers and red tape, according to senior doctors in the NHS who express "strong dissatisfaction" at the impact.


Consultants believe the health service is one of the most effective in the world but also feel it is "creaking under the strain" of ever-rising demand.

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Research by Dundee and Glasgow universities found that consultants believe that when decisions are made in the NHS the "balance has tipped too far" towards managers and politicians.

Doctors feel that they are not listened to and are not sufficiently involved in decision-making, and they fear this could damage patient care.

The "stringent application" of waiting-time targets was frequently cited as resulting in consultants having less discretion over who should be treated and when.

The research, which was carried out for the British Medical Association's Scottish Consultants Committee, examined the changing experience of work among consultants in NHS Scotland.

Committee chair Dr Nikki Thompson said the report revealed the "hopelessness" consultants feel if they are unable to speak out on behalf of patients and an "over-riding sense of frustration" about the importance political or financial priorities have in the decision-making process.

A total of 68 consultants from different areas and specialities took part in in-depth interviews while 1,058 consultants completed an online survey

Professor Graeme Martin, of Dundee University, lead author of the report, said: "The consultants we spoke to complained that pressures in the system were causing significant problems for patient care.

"We also found evidence of strong dissatisfaction with the impact of non-clinical managers and bureaucracy in clinical matters."

The research suggested consultants believe there has been a "significant change" in what drives the decision-making process and "business-related rationale was seen to dominate decision-making rather than the rationale of medical professionalism, which consultants tended to equate with good patient care".

The report said: "While the NHS has always had to accommodate potentially conflicting rationales, consultants felt that the balance had 'tipped too far' towards business and financial decisions dominating how work was organised and evaluated, and that such a trend was inconsistent with effective and efficient patient care."

Doctors find the "increasing power" of non-clinical managers as an "especially worrying development", the research stated.

Despite these concerns, it also found the "majority of consultants regarded the NHS in a very positive light and identified strongly with the values of the NHS".

The report said: "Most of the interviews showed that consultants regarded the NHS as among the most effective systems in the world.

"However, it was also generally felt to be creaking under the strain of having to deal with year-on-year greater 'demand inflation' unmet by proportionate increases in resources."

Dr Thompson said: "This research shows that while consultants are overwhelmingly committed to the NHS and to our patients, there is a sense of hopelessness over how we can speak out and be heard on their behalf.

"It demonstrates the over-riding sense of frustration amongst consultants at the focus on political or financial priorities in the decision-making process.

"It is so important that the health service respects and responds to medical professional judgement, so that as consultants we are able to steer and develop the services we provide to meet the clinical needs of our patients."

Prof Martin carried out the research with colleagues Dr Brian Howieson and Dr Stacey Bushfield from Dundee University and Dr Sabina Siebert from Glasgow University.

"Consultants continued to play a vital role in holding together a healthcare system 'caught between a rock and a hard place'," Prof Martin said.

"On the one hand, the NHS is challenged by the demands of an ageing population and ever-increasing expectations among patients and politicians. On the other, it suffers from significant resource constraints.

"As researchers, we could not be other than impressed with the levels of engagement interviewees expressed about their jobs and clinical team colleagues.

"Nevertheless, we also detected a strong note of pessimism - indeed, sometimes fatalism - over how the healthcare system could be improved for the benefit of all stakeholders."

Prof Martin continued: "Whereas the NHS was once governed by medical professionals, who saw themselves as guardians of patient care, they now feel that the balance has tipped too far towards professional managers and politicians, who govern the service according to business and political logics.

"For example, the stringent application of waiting-time targets was frequently cited as evidence of the inappropriate reduction of consultants' discretion over who should be treated and when.

"Furthermore, as a result of the increasing demands placed on many consultants, their trust in the NHS as an employer has diminished rapidly.

"For this reason, you might expect their levels of engagement with their work also to be low but our data showed the opposite - their commitment to patients and clinical colleagues was remarkably high."

Health Secretary Shona Robison said: "Our NHS needs the right balance of strong managers, many of whom are clinicians, overseeing what is a complex system to ensure medical professionals are able to get on with the most important part of their job - caring for patients.
"We are determined to achieve that balance - and consultants numbers in our NHS are at a record high, with an increase of 4.8% over the last year to nearly 5,000 in total. At the same time, senior management posts in Scotland's NHS have reduced by 29.3% since 2010.
"Targets will always have a role to play in our NHS. They help ensure patients get timely treatment and have driven substantial improvements under this Government to what are historically low waiting times. On that basis it is no surprise that patient satisfaction in our NHS increased by over 20% since 2005.
"But again, this must always be balanced to ensure that clinicians are able to make decisions based on clinical need. Indeed, we promote that principle through the guidance we issue to NHS boards on performance management in our health service.
"The number of targets has reduced dramatically over the last decade. We now have 20 local delivery standards compared to over 200 under the previous performance assessment framework in 2004/5. However, we are happy to go on working with medical bodies like the BMA to ensure we continue to have the right targets in place to deliver the right outcomes for patients in Scotland.
"We will look closely at this report and we welcome the contribution of consultants, who are a crucial part of our NHS. It is hugely encouraging to see their commitment to our NHS and I hope we can work together to deliver further improvements."