The Nuffield Trust’s new survey shows that much is still to be done to encourage clinicians to pursue strategic positions, writes Nigel Edwards

At the NHS Providers Annual Conference on Wednesday, health secretary Jeremy Hunt emphasised the need for more clinicians to assume leadership roles and highlighted a lack of strategic engagement among medical staff.

There is no doubt that the NHS is only going to be able to solve some of the many challenges it faces through constructive local conversations between managers and frontline clinicians.

To respond to financial, demographic and other pressures, NHS organisations will need to change the ways in which patients move through the system, how medicine is practised and how people work together. Incentives, contracts and the usual mechanisms of health policy are fairly ineffective at doing much more than removing obstacles and providing a nudge.

Despite the need for close working between managers and clinicians and the strong connection between the engagement of medical staff and organisational performance, bringing them closer together is something that many health systems have difficulty with – and the NHS is no exception.

Reasons for doctors not applying to be chief executives include a potential loss of income, professional identity and potentially friends; as well as an awareness of the very negative perception of managers

Nonetheless, a long history of difficult relationships at the national level has obscured the fact that relationships locally are often better than might be expected – managers generally may be more suspect than one’s own local manager.

While Jeremy Hunt’s speech focused broadly on clinicians, bringing doctors in particular into these leadership roles has been particularly difficult in the NHS. The Nuffield Trust has today published the results of a new survey looking at the relationships between doctor-managers and general managers in the NHS.

In the publication Doctors Managing, Managing Doctors, Huw Davies and Alison Powell have revisited research from 2002 to look at the nature of the relationships within NHS organisations. There is still quite a difference between how frontline clinicians and medical directors and chief executives view things.


The good news is that the gap in perceptions has narrowed and there is more mutual understanding. Not so encouraging is a strong view that the growing pressures in the NHS are likely to cause the tensions to increase and the gap to widen.

Getting more doctors into management positions may help. Health systems in other countries often have more top leadership drawn from the medical profession and other clinical disciplines, and there is some research to support a link between clinical leadership and improved performance. However, the new survey shows that many clinical directors feel frustration about their roles. This is not going to be a simple issue to tackle.

There are many reasons that doctors are not applying to be chief executives. They include a potential loss of income, professional identity and potentially friends; as well as an awareness of the very negative perception of managers – both by public opinion and in the media – and the way managers are treated by the punitive culture in the NHS.

Embedded cynicism

For doctors wanting to get involved in improvement and change at a more ‘shop floor’ level there are other obstacles. A lack of training in some of the key skills, the reduction in the hours in their contracts to do this work, resistance from their colleagues and support from senior management may all be part of the problem.

Some of these issues can be fixed by national policy, actions by regulators or changes in approach by professional bodies. However, many of them require action at a number of levels within NHS organisations.

Finding the time and space to do this is challenging and the process may take some time, especially in those organisations where there is embedded cynicism and a long history of failure.

However, there are an increasing number of examples, some mentioned by the health secretary yesterday, where this transformation is being led by leadership teams drawn a wide variety of professional backgrounds. This permits us some optimism about the future.

Nigel Edwards is chief executive of the Nuffield Trust