Unless doctors and managers are less tribal and listen to more patient voices, NHS services will struggle to improve, argue Phil Banfield and Marcus Longley

Relationships between medical and managerial tribes are rarely characterised by mutual understanding, harmony and common purpose. We may all be in it together, but we often wish we were not.

We can no longer deliver the “martini solution” for healthcare – anytime, anyplace, anywhere – but as the Welsh NHS is firmly committed to collaboration and cooperation, what gets in the way of our doctors and managers developing a shared view for the future?

Clinical information everyone trusts

Rational decision making depends upon knowing how well services are performing. There are huge gaps in available data, and quite often the data that do emerge leave clinical teams frustrated and suspicious. No one defends decision making in the dark, but this is precisely what follows.

Managers accuse doctors of not cooperating in the improvement of data; doctors accuse managers of failing to invest in data collection and credible feedback. Meanwhile, we sail on unaided into waters that are increasingly resource shallow. 

Clinical managers need not cross the Rubicon

With such limited resources, those making clinical decisions ought to manage more than just the patient in front of them and clinical management should support this process directly. Yet a universally successful way of harnessing doctors to the management process proves elusive. Too many people report frustration with the complexity and slowness of the system, which is unsurprising when doctors are trained to make clinical decisions and choices rapidly.

‘Perpetuating the dysfunctional aspects of our healthcare system in a mutual standoff serves no one’

Many doctors believe the root of the problem to be the subordination of “clinical” to “managerial”. In Wales, clinical management initiatives have been inadequate because they’ve served largely to let doctors cross over to the managerial sphere, rather than linking clinical-managerial spheres together; and it’s one way traffic – there have been few effective ways to make managers more clinically savvy.

Consequently, a service manager without the confidence of clinical colleagues cannot effectively lead, nor will clinicians be effective followers.

You cannot plan a workforce when you don’t know what you are planning for

One of the greatest frustrations facing both groups is the apparent disconnect between service and workforce planning. This isn’t just getting the numbers wrong, it’s also about a reluctance to think through what services are really appropriate to patient needs in Wales.

“Doctors” say services will close because of a “shortage of doctors”; “managers” retaliate, highlighting more hospital doctors now than ever before. Politicians may appear Teflon-coated and above the fray, so is it surprising that the public are understandably and increasingly confused and frustrated, too?

Personal interest and parochialism paralyse

Doctors are often portrayed as putting their own financial and self interests first. Managers describe doctors’ “shroud waving” and refusal to acknowledge common problems. Doctors perceive here-today-gone-tomorrow managers enthusiastically implementing the latest vacuous political nostrum as they transit through.

Unlike doctors, managers rarely have to face the human consequences of their decisions. This tribal incompatibility arises due to differing time horizons – clinicians may be wedded to their service for 25 years or more, yet managers often move on after two or three. Such divergence makes cooperation and mutual understanding much harder.

It’s not just ‘them and us’

The closed nature of this doctor-manager dualism excludes the voice of patients. Doctors and managers both have their own partial understanding of what patients and the public want, but neither has much of an opportunity really to listen to these views, still less to have a meaningful dialogue with them. 

Solutions urgently needed

Perpetuating these dysfunctional aspects of our healthcare system in a mutual standoff serves no one. It cannot continue. The answer lies in redoubling our efforts to address them together.

‘The clinical team is no longer only doctors, but a whole host of professions allied to medicine who support patients and provide care’

First, we need a proper strategy on clinical information, by agreeing what data should be collected and how they are used. Both managers and doctors readily understand the critical importance of good clinical data to both quality and efficiency, and we need to assure its place in the Welsh NHS – now.

Second, we need a grown up discussion on the pattern of services that Wales needs now and into the future. The clinical team is no longer only doctors, but a whole host of professions allied to medicine who support patients and provide the right care at the right time in the right place. It also – most challengingly of all – includes the patient. Wales has some defining features, such as rurality and significant deprivation, yet politicians of all hues tell the people of Wales that they have a right to expect world class care. Both doctors and managers must aspire to reconcile this conundrum.

We suggest that perhaps doctors and managers should be a little less tribal. They all need to find ways of listening to patient groups, the public, other clinical practitioners, and have a dialogue among equals, based around commonly agreed information. We can all be in this together, and the NHS needs us to be.

Dr Phil Banfield is chair of the BMA Welsh council and Marcus Longley is professor of applied health policy and director at the Welsh Institute for Health and Social Care