doctors in management : Jeremy Davies canvasses the wards and the offices

Dr Jenny Simpson, chief executive, British Association of Medical Managers 'The merging of the medical and managerial cultures is happening in some trusts extremely well.

We have come a long way in the past 10 years. In some places, where relationships are good, you wouldn't know if you were speaking to a doctor or a manager from the way people talk. I know one trust where the chief executive and medical director have the same first name, and if you went in and asked a question, you'd get exactly the same response from whichever one happened to reply first.

But in some trusts, one despairs of there ever being a meeting of minds. It is very perplexing as to why that is, and I have a great deal of sympathy with good managers trying to deal with these situations, which can often come down to one or two stroppy doctors.

Looking at it geographically, I would say that, broadly speaking, progress has been inversely proportional to trusts' distance from London. In the capital, the incentives are much more highly geared towards consultants doing private practice. It is not just that this takes them away from other work, such as medical management duties, It is also possible to develop a mindset where your priority is to fulfil your NHS obligations and then to put in long hours only for big financial returns.

What these doctors do not realise is what they're missing out on by offering such resistance. In the worst trusts, medical management is undoubtedly about hitting your head against a brick wall, but in the best ones it stretches your mind enormously and enables the whole medical community to flourish.

As for the future, I do not think training is necessarily the answer, or at least not in the sense of 'sheep dipping' doctors through management courses. It is about developing organisations that welcome clinicians' input.More protected time through a more modern consultant contract would also help a great deal.

'Dr John Riordan, medical director, North West London Hospitals trust 'I've been medical director at Central Middlesex Hospital since 1991, working more or less full-time since 1995. I gave up clinical work completely earlier this year, and in the past two years have taken on more management responsibility as the trust merged with Northwick Park.

Central Middlesex Hospital has a long history of medical management - even in the 1930s it had a medical superintendent.More recently, there have been several big-name clinician managers here, like Martin McNicol in the early 1990s. Because of this, there have always been strong links between doctors and management. Doctors have even been involved in managerial appointments.

That is not to say there haven't been tensions. I remember one senior doctor advising me and some other colleagues that we were 'far too matey'with Neil Goodwin (formerly unit general manager at the Central Middlesex, now chief executive at St Marys trust) - he said we should treat him like one of our senior registrars. Fortunately, that kind of attitude is becoming a thing of the past - even then he was out of step with the organisation as a whole, which was extremely 'flat'. The attitude we try to foster is that everyone, regardless of background, should always do their best for patients, should sort out problems themselves if they can, and should divide up the bigger issues into chunks and focus on finding solutions rather than apportioning blame. Flexibility and devolved responsibility are the name of the game.

It is difficult to reproduce genuinely co-operative cultures, though, and even from my experience of a trust merger, I know it certainly can't be achieved overnight. The government says it wants more doctors in management and it always expects measurable results by the end of the year, but cultural shifts take time.You need the right incentives in place to make them stick, and a lot of the attitudinal changes are not easily measured, for example.

I would like to see the Commission for Health Improvement introduce a methodology that allows us to start measuring organisational cultures. Then, rather than focus on the current, rather limited performance framework, we could test qualitatively how good we are at strategising and creating 'hightrust' cultures in our organisations.

'Dr Peter Hawker, consultant physician and chair, British Medical Association central consultants and specialists committee 'We have come on in leaps and bounds since the days when becoming medical director meant being pressurised into something no-one wanted to do.

Once, it was almost a case of the guy who took two steps backwards when everyone else took three, getting the job.Now a spell in management is looked on as a legitimate expression of your interest in medical care, and a way of using your clinical background for the benefit of patients.

Becoming chief executive of a trust is not a bad way of rounding off your career once you hit your mid-50s.

A lot of my colleagues get cross about the fact that doctors who go into fulltime management sometimes get talked down, as if they've gone over to the other side by taking the 'management dollar'. There is no doubt these doctors are making a sacrifice in the sense that most of us went into medicine in order to treat patients, but they're still making their contribution, and It is often the case that the best doctors are also the best managers.

What's vital is that doctors' involvement in management is taken seriously. All too often they're doing full-time clinical work and then management stuff on top. That is got to stop - if a job's worth doing, It is worth doing properly. If that means the trust taking two days off your clinical workload and appointing another consultant, or simply recognising that its waiting-list targets are not going to be met, so be it.

'Dr Rodney Cove-Smith, associate medical director, South Tees Acute Hospitals trust 'We introduced clinical directorates here in 1988, following the model first introduced at Guy's Hospital, London, and in 1991 added clinical chiefs of service to oversee groups of directorates, with direct responsibility to the chief executive.

In the old days, the managerial and medical cultures were very separate, but here they're well integrated - the sensible clinicians realised that in this way, things have become pretty much consultant-led, with a managerial structure that beavers away quietly in the background.

Clinical directors get paid the equivalent of one session, and chiefs of service two sessions per week, for the management work they do.

Each session is worth about a tenth of their salary.

It is up to them whether they drop clinical work correspondingly or do longer hours and earn more as a result.

Under our system, directorates present a business case if they want to develop a new service or whatever, and that principle underlies the way the whole hospital operates.

If a consultant complains, 'They will not let me do this', the obvious question is, 'Who's they?' because We are central to the whole organisation.We do still have issues that cause a lot of anxiety, such as the use of relatively unproven, expensive drugs.

It is tough for doctors because they're the ones who have to tell the patient that they can't have a drug because there is not enough money.

But whereas in the past that might have led to resentment, now our consultants are inculcated with the need to balance individual and 'corporate' needs.

I think the younger consultants are more keenly tuned in to this way of working already, and that can only continue as time goes on.

'Dr Steve Atherton, medical director, St Helens and Knowsley Hospitals trust 'We have been a trust since 1991, and every year since then We have delivered on our financial and activity targets, despite having fewer staff than other hospitals of a similar size. In many ways I would put this down to the fact that doctors and managers here sing from the same hymn sheet.

Medical management is about making all doctors into managers who reflect on their practice and think about the bigger picture - not just tossing a coin for who's going to attend trust board meetings.

You can't sort out these issues by publishing a guideline and ticking a few boxes.Trusts need a clear vision - and even then they'll get problems, especially with individuals who refuse to accept anything other than a culture built around absolute freedom for clinicians.As time goes on, though, the ones who are not prepared to adapt tend to get weeded out and a forward-looking culture can develop.

I think one of the big battles is removing the isolation of some hospital consultants.Consultant appraisal is absolutely crucial in this respect. It is no good expecting consultants to work efficiently and get their heads round multidisciplinary approaches if you do not back that up by listening to what's going on in their lives and making sure they get decent continuing professional development.They're much less inclined to behave like gods if you treat them like valued partners and enable them to work effectively in a team environment.'