Different environments, cultures and skills

Good managers are more comfortable with thinking in terms of systems and they accept more readily the complexity of organisations and the need to work effectively in teams. They are more adept at using negotiation to deal equably with conflict, whereas doctors often perceive negotiation as a means to gain concessions from the other side. Managers are familiar with the world of economics, an area in which doctors are often uninterested, which usually places them at a considerable disadvantage in modern healthcare systems.

The occupational life of senior managers and senior clinicians tend to vary. It is unlikely that senior managers will stay in post longer than 5 years, but it is still the norm that senior clinical staff will stay in a job for over 10 years, and sometimes throughout their senior career. Over the years, most clinicians therefore have to deal with a succession of new managers in their departments, and in their working relationships with them they may see the same problems arising again and again. Consequently, the first task of a new manager often is to overcome the cynicism of clinical colleagues.

Management–clinician interaction takes place outside the clinical situation with the patient. The natural habitat is the committee, where different rules of engagement apply. Communication is often through the written word (paper or electronic), rather than the verbal or physical interchange with patients.

Committee culture requires considerable expertise and astute handling, whether one be the chair or a member. The language used by doctors and managers to argue and convince each other of the advantages of a proposal is not the same as that usually used between clinicians, particularly if more resources are at stake.

These differences are reflected in a survey by Reference Davies, Hodges and RundellDavies et al (2003), which found that chief executives were more optimistic than doctors about the state of the doctor–manager relationship. Interestingly, nurse-managers were even more supportive of the agenda of change in healthcare services than were general managers (Reference Degeling, Maxwell and KennedyDegeling et al, 2003).

Historical résumé

To understand the doctor–manager relationship we need to consider the nature of changes in the National Health Service (NHS). These have been charted by numerous researchers (e.g. Reference DopsonDopson, 1994; Reference Harrison and LimHarrison & Lim, 2003). Since its creation in 1948, the NHS has undergone radical structural shifts that have affected all NHS staff. The initial understanding (Reference Ham and AlbertiHam & Alberti, 2002) was based on the government's guarantee and funding of access to treatment for all citizens, with the medical profession taking responsibility for delivering care at an appropriate standard. This reflected an ethos of collective and corporate solutions to the welfare of all, in recognition of the enormous sacrifice made during the Second World War.

The infrastructure set up for the NHS at its inception remained largely intact until 1974. During this period, concerns about healthcare progressively increased both in government and in the community at large. Healthcare costs were escalating (3.5% of gross national product in 1950 to 6% in 1969), and the success of the NHS in dealing with acute conditions unmasked more chronic illness, which added to the rising costs. There was increasing awareness of local and regional inequalities in terms of allocation of funds, and a number of scandals occurred, leading to the publication in the late 1960s of Sans Everything (Reference RobbRobb, 1967). During the same decade, an inquiry into Ely Mental Hospital (Department of Health and Social Security, 1969) fuelled increasing concerns about the ‘Cinderella services’ (mental health, geriatric and community care services). In parallel with this, nascent pressure groups such as The Patients’ Association, the National Association of Mental Health (now named MIND) and Community Health Councils made the patients’ voice heard.

In the pre-1984 era, the manager could be thought of as a diplomat, attempting to find suitable compromise between clinicians and patients or carers when conflicts arose and demands were made. Between 1984 and 1991, the era of general management swept in. This gave managers a much greater say in the organisation and delivery of services. The introduction of the quasi-internal market in 1991 had a major impact on NHS culture. The managerial agenda no longer focused on the need to respond to internal organisational factors: it was required to meet central government agendas. This more assertive stance by government was fuelled by many circumstances, the most prominent of which was the need to reign in public expenditure. Throughout these changes, the relative influence of doctors and managers slowly shifted in radical but subtle ways. Initially, doctors were dominant, and they used their clinical experience to bolster their authority. Managers, at that time usually called administrators, simply gave what their title suggested – administrative support – without challenging the clinical view (Reference Davies and HarrisonDavies & Harrison, 2003). The arrival of general management, the internal market and, more recently, clinical governance, has put managers in the driving-seat, even in the face of physicians’ opposition.

The change in job title from administrator to manager is indicative of the changing culture within the NHS. Among the historical derivations of the word ‘administrator’ we find the concepts of giving service and rendering aid. ‘Manager’ has among its early meanings someone who conducts the course of affairs, causes people or animals to submit to their control, even causes something to happen by contrivance. This shift in language reflects the progressive move to more authoritarian and centralised control within the NHS. The role of the administrator as a diplomat working to solve localised problems and to maintain homoeostasis in an organisation has been replaced by that of the manager, whose function is to secure major change to deal with centrally decided edicts and guidelines.

A clear pattern can be determined from the changes that have taken place over the past 35 years. There has been a substantial erosion of the traditional professional medical dominance and autonomy, and this, not surprisingly, has led to increased unhappiness within the profession and to tensions in the doctor–manager relationship.

Perpetual motion

The constant changes in the NHS in recent years have been mirrored outside of the UK. No country appears to be satisfied with the current state of its healthcare system. Reforms are being contemplated, organised or implemented across the world, some in direct contradiction to others.

Reference Glouberman and MintzbergGlouberman & Mintzberg (2001a ,Reference Glouberman and Mintzberg b ) see structural divides in healthcare organisations. First, a horizontal cleavage separates clinicians, who work within the system and deal mostly with patients and their general practitioners, from managers, who primarily respond to outside organisations such as governments and funding agencies. Second, a vertical cleavage separates those irretrievably connected to the organisation (such as nurses and managers) from those involved with it but not so formally connected to it (the physicians and trustees). They contend that the lack of integration between these unreconciled worlds and mindsets is fundamental to an understanding of the difficulties in managing health services and one of the reasons for continuous processes of reorganisation. This inherent difficulty is independent of resource constraints but exacerbated by them. Such constraints remain a powerful and ubiquitous problem.

Different pressures are faced by doctors and managers in their day-to-day work. Doctors involved in the treatment of individual patients react to clinical demands. Patients do not frame these demands in terms of ICD–10, a taxonomy built on empirical and logical principles. Powerful and unconscious factors operate. Patients expect doctors, and hence the NHS, to relieve them of profound states of distress, of pain (mental and/or physical) and of fears of serious mental illness, chronic disability or death.

When we are unwell we place ourselves in the hands of doctors and nurses. This mobilises needs in us akin to those present in the child–parent relationship. Regressive forces express themselves in terms of a need for sustenance and reassurance that feeds into the expectation of what the health service should provide. Patients wish both consciously and unconsciously to have 24-h access to unconditional healthcare and the consequent reassurance that they can have respite from anxiety at all times. For patients, the National Health Service symbolises each individual's wish to have a nurturing parent constantly available – a National Breast Service – who also will sooth primordial fears.

Managers relate more to outside funding organisations responsibe for resourcing these conscious and unconscious needs without overburdening the taxpayer. The pressure on managers exerted by government comes from the electorate, who are, in fact, an agglomeration of all the individual patients, since we all visit a doctor at some time or other. What government and managers are faced with is an inherent contradiction: individuals demand a health service that meets all their needs, but the electorate (a collective of those very individuals) is reluctant to foot the bill. Governments are inherently vulnerable to such polarised interests because they constantly worry that any attempt to raise taxes jeopardises their electoral chances. This contradiction and anxiety is transmitted to managers, expressed as an unrealisable expectation to improve and extend the service within the existing resources.

Box 2 describes a recent dilemma that serves as an illustration of how the worlds of medicine and management can clash.

The clinical domain

Clinicians now feel that management has also entered into areas where before they themselves had general clinical autonomy (Reference Davies and HarrisonDavies & Harrison, 2003) (Box 3).

In the UK in the late 1990s, the switch from the internal market to centrally imposed diktat following a change of government made managers into government agents, following the political rather than the clinical agenda.

The international systematisation of medicine, with the introduction of case-mix measures, diagnosis-related groups and centrally agreed protocols and guidelines, makes medical care susceptible to management measures associated with income and remuneration. The imposition of national tariffs will become another step in this direction, leaving room for management to determine how clinical care is provided and how much is affordable. Incentives to doctors via remuneration under the new NHS employment contracts also place medical care under management control. Added to this, state regulation of medicine as a profession has introduced a system of inspection of standards (such as the Healthcare Commission), compulsory clinical audit, publication of league tables, clinical performance indicators, ‘star ratings’, gate-keeping arrangements between primary and secondary care, and so forth.

In the past, moral persuasion was relied on to encourage medical participation in effective and efficient systems of medical care and delivery, but failure by clinicians to regulate their own practice (evidenced by, for example, the Harold Shipman and Bristol Hospital inquiries) has invited governments to exercise a more regulatory approach.

A powerful element in this process of continuous change is the rise of regulation. Five new regulatory bodies were created in the NHS between 1998 and 2002, additions to an already crowded landscape. The self-directed (moral persuasion) model of regulation assumed that the NHS was fundamentally good hearted and had impeccable intentions. The current approach, however, is increasingly perceived by service providers to be a deterrence model which implicitly assumes that the NHS is amoral and that other, perhaps personal, motivations are put before the public good (Reference WalsheWalshe, 2002). Although couched in terms of laudable public health aims, the process is definitely dictatorial.

The overriding theme is therefore of lack of trust and an erosion of professional influence, power and autonomy. Reflective practice derived from individual expertise and professional consensus, based on expert opinion, is being replaced by critical appraisal and a benchmarking bureaucratic model.

These changes are a major source of the conflict undermining doctor–manager relations. Although there may be some advantages to these developments, they will be acheived at the cost of rigid formalisation of care and a corporate utilitarian approach rather than an emphasis on individualised attention.

Interdependence

In a complex health organisation such as an NHS trust, both doctors and managers are mutually interdependent (Box 4).

Box 4 Doctors and managers: who needs whom?

Doctors need managers	Managers need doctors
To resolve complexity of the working environment, which needs managing	Doctors are the vehicle of the ‘health delivery product’
To help them with unrealistic expectations	To ground them in the human and clinical reality of patient care
To mediate with the state	To translate government policy into clinical reality
To set boundaries of care	To recognise where boundaries are ineffective, unrealistic or inhumane
To act as repositories of negative comments from patients and to deal with complaints against the omnipotence of doctors	To contain their anxiety in certain situations
To have an overview of the needs of the whole service and not be influenced by parochial needs or those of the most powerful and influential	To inform them about the clinical realities in order to decide on apportionment of resources
To get the resources that are required to deliver the service	To use resources effectively and efficiently
To help them understand networking and committee skills	To communicate evidence-based clinical practice based on sound scientific principles

Clearly, managers and doctors have some things in common (Reference SmithSmith, 2003). Both professions usually attract individuals that work selflessly and hard, sometimes to their own detriment. Career paths are long and arduous, and incorporate an ethical dimension. Doctors and (obviously) managers respond to financial incentives and prerogatives, and both must assess and take risks. In both professions there are specialists, and both have the need for effective communication but a reputation for excessive use of jargon.

Despite these common factors, their different cultures and pressures can cause considerable difficulties in their relationships with each other.

The perpetual changes that clinicians are experiencing reflect the attempt of governments to grapple with what appear to be insuperable problems. Conflict usually arises out of financial considerations, but in the new climate of accountability, management also now monitors risk and handles complaints against clinical staff, suspensions, internal inquiries and external consultations.

An important dimension of mutual interdependence is whether both partners are equal. Doctors can manage, although perhaps not with the same level of expertise, but managers can't doctor. Managers will say that in order to manage effectively they need the support of doctors, but doctors rarely think that they need management support in order to practise effectively. Management skills are, however, essential for doctors heading a unit or clinical team.

Medical managers

In conjunction with these changes there has been a concerted attempt by government to involve doctors in management domains and thus take greater responsibility for the thorny and politically sensitive issues of resource management. This started with the Griffiths Report on management within the NHS (Department of Health and Social Security, 1984) and has gradually developed with the introduction of clinical and medical directors. Medical managers find themselves at the nexus between management and clinical agendas and predictably find their role stressful and demanding (Reference GoodwinGoodwin, 1996; Reference ThorneThorne, 1997). Their capacity to maintain a relationship and identity with their physician colleagues as well as fulfil management expectations is sorely tested both institutionally and within themselves.

In describing aspects of the doctor–manager relationship we may have given the impression that only the manager has to face issues such as limited financial resources. Doctors have to manage their time and resources too. Giving more time to one patient will often mean less for another. In managing their clinical workload they rely on their ‘internal manager’ to deal with the relentless clinical demand. Unfortunately, doctors are susceptible to overwork and many are not good at looking after their own needs (Reference GabbardGabbard, 1985). Like doctors, most healthcare managers also have an internal wish to care/cure, and some find themselves trapped by the expectation of fulfilling every patient's needs. This is more likely to occur when they are dealing with complaints, as this more direct contact with patients and families can lead to the loss of boundaries.

The dialectic is thus not just between doctors and managers, but is also an internal struggle within all of us and it can become a particular problem for medical managers.

Reference Simpson and SmithSimpson & Smith (1997) have pointed out advantages of being a medical manager: their position as clinicians gives them increased credibility in the boardroom, and the fact that they have alternative careers, should management not work out, makes them more likely than their non-clinical management colleagues to speak out against what they consider to be unworkable decisions. Box 5 shows some of the downsides and the rewards of being a doctor in management.

Local solutions

The following vignettes illustrate some of the points we have described, showing local solutions to difficulties that might arise between doctors and managers.

Scapegoating

The common theme in the three vignettes above is the search for someone responsible for the problem, when in fact it is a consequence either of failures in the healthcare system or of clinical demands. Scapegoating is ubiquitous in society and has become particularly prominent in mental health services with the recent plethora of suicide and homicide inquiries (Reference SzmuklerSzmukler, 2000). The concept of the scapegoat derives from a religious ceremony in biblical times. The essence of the procedure was the transfer of a person's guilt by means of a magic rite onto an animal such as a goat. The sacrifice of the goat resutled in exorcism of blame. Reference Kraupl Taylor and ReyKraupl Taylor & Rey (1953) note that such procedures have been closely associated with aggressive and excessively punitive attitudes.

Scapegoating can bedevil doctor–manager relationships in a process of cyclical transferences. Societal guilt regarding insufficient finance for the NHS is transferred onto managers, accused of poor financial and organisational acumen; to avoid becoming sacrificial goats the managers displace the guilt onto the doctors, who are then questioned about their skills and rational use of health resources. This dynamic can operate in the reverse direction. Doctors also struggle with feelings of guilt that they might not have done enough, or might have recommended insufficient or ineffective treatment for their patients. This unpleasant doubt is often displaced onto managers, who are blamed for not offering enough resources or facilities to improve patients’ ill health. These dynamics can only exacerbate the cultural differences between doctors and managers and can cause damaging splits in an organisation.

A systems approach

Using a systems approach to review these problems can be helpful in avoiding pitfalls in the relationship. A particularly impressive example is that adopted by the aviation industry, in an approach pioneered by Reference RaisonRaison (2000). His work was instrumental in stopping the aviation industry from making the automatic assumption that an accident was caused by pilot error if mechanical failure had been excluded (compare this with the assumption that suicide or homicide must be due to a medical error). His basic premise is that humans are fallible and errors are to be expected. Well-functioning organisations develop systems of support and strategies to mitigate such human vulnerabilities. This is an organisational task in which all staff need to work together. In Raison's model, it is when the gaps in the tiers of organisational support and protection align themselves that errors come through the system and become manifest. Thus, identification of risk requires examination of the system as a whole. This is a model that can be very helpful in analysing and finding solutions to perceived clinical and managerial failures.

What can be done to improve the relationship?

It is important to acknowledge from the start that when doctors and managers first interact, a background of distrust exists between them for all the reasons outlined above. How do we overcome this inauspicious beginning? As with all biases and preconceived assumptions, it needs to be put to the test, both by joint working arrangements and frank and open discussions.

When the pressure is on it is easy, and perhaps understandable, to retreat to a ‘them and us’ position, which tends to reconfirm old ideas and sour relationships. The committee meeting becomes a battlefield, following diverse and sometimes irreconcilable agendas, rather than an opportunity for joint and realistic resolution of problems. Reference Malcolm, Wright and BarnettMalcolm et al (2003) suggest that unless a ‘third logic’ is accepted, the gap between doctors and management will remain. They advocate the restoration of clinical autonomy as opposed to purely market or bureaucratic models, with clinicians becoming collectively and professionally accountable for the quality and cost of their decisions.

A large healthcare organisation in the USA has fostered a change in organisational culture, based on joint leadership and an acknowledgement of mutual dependence through the alignment of objectives that are not focused solely on individual patient care, use of resources or productivity (Reference CrossonCrosson, 2003). It also provides management education strategies for clinicians wishing to take up leadership roles.

In The Netherlands, external peer review often reveals managerial rather than clinical problems. This suggests that self-regulation by doctors is likely to be more successful than regulation imposed by clinical managers (Reference Plochg, Lombarts and WitmanPlochg et al, 2003).

A comprehensive review of the problem (Reference EdwardsEdwards, 2003) suggests that redefining clinical autonomy in order to preserve it and ensure that it encompasses accountability and responsibility would be an important step and would facilitate clinical leadership. Such issues need to be dealt with at the meta-organisational level. Within an organisation attention needs to be focused on understanding the psychological processes that are taking place at the individual, group and systems level (Reference Obholzer and RobertsObholzer & Roberts, 1994).

Various authors have put forward suggestions for establishing more common ground between doctors and managers (e.g. Reference AtunAtun, 2003; Reference Edwards, Marshall and McLellanEdwards et al, 2003; Reference MüllnerMüllner, 2003; Reference NashNash, 2003). Box 7 shows a distillation of these, and Box 8 gives the website addresses of a few organisations that offer further healthcare management information and training.

Box 8 Useful information on

The following may be useful to those wishing to seek further information or training:

http://www.gmc-uk.org/standards/manage.htm	General Medical Council (1999) Management in Health Care – The Role of Doctors
http://www.bamm.co.uk	British Association of Medical Managers
http://www.aamc.org/	The Association of American Medical Colleges gives details of joint MD/MBA training programmes offered by universities in the USA
http://www.nihcm.org/	The National Institute for Health Care Management Research and Education Foundation, another US organisation, hold forums and briefings for various healthcare bodies

As with all complex problems, a variety of approaches need to be taken, and these rely on an understanding of organisational and group behaviour, systems theory and psychodynamics. Just as important is the supplementation of any solutions with more educational and developmental work in which doctors and managers can jointly participate.

MCQs

1. 1 The following cultural differences distinguish doctors from managers:

   1. a managers tend to use jargon

   2. b doctors are good team players

   3. c doctors focus on the individual

   4. d managers have to move jobs to gain promotion

   5. e managers focus on the organisation as a whole.

2. 2 Which group is least supportive of managerial modernisation initiatives?

   1. a trust board non-executives

   2. b chief executives

   3. c doctors

   4. d nurse-managers

   5. e financial directors.

3. 3 Managers and doctors have the following areas in common:

   1. a both professions have specialists

   2. b both have long career paths

   3. c both have an interest and expertise in finance

   4. d both have ethical responsibilities

   5. e both are skilled in navigating complex bureaucracies.

4. 4 Scapegoating is:

   1. a a desire to raise standards in the organisation

   2. b a method of transferring guilt

   3. c a recent phenomenon

   4. d often associated with extra-punitive attitudes

   5. e a magical way of dealing with guilt feelings.

5. 5 The doctor–manager relationship could be improved if:

   1. a both doctors and managers were educated about psychodynamic processes within an organisation

   2. b interdisciplinary education were fostered early

   3. c regulation of clinical activity by external agencies was increased

   4. d greater managerial staff stability were ensured

   5. e respect for differences between managers and doctors were engendered.

MCQ answers

1		2		3		4		5
a	F	a	F	a	T	a	F	a	T
b	F	b	F	b	T	b	T	b	T
c	T	c	T	c	F	c	F	c	F
d	T	d	F	d	T	d	T	d	T
e	T	e	F	e	F	e	T	e	T