doctors in management : The NHS plan makes a point of strong clinical and managerial leadership.Robert Palmer and colleagues conducted a survey to see how training should be tailored to reach this goal

Dr Robert Palmer is associate postgraduate dean, West Midlands postgraduate medical and dental education; Peter Spurgeon is professor of health services management, Birmingham University; John Clark is acting director, health services management centre, Birmingham University.

Getting clinicians involved in management is an aim increasingly pursued by most health systems. In the past, this reflected a desire to control costs and a need to integrate clinical and managerial perspectives.Many senior clinicians arrive in management roles with relatively little managerial training. Subsequent provision can often feel urgent and remedial.

The NHS plan stresses the need for clinical and managerial leaders throughout the health service. It also maintains that leadership development in the NHS has always been ad hoc and incoherent, with too few clinicians in leadership roles. The plan also advocates management support for clinical and medical directors to equip them better for their leadership tasks, including tailored support for clinicians and managers with leadership potential at different stages in their careers and for those already in leadership roles.

How should management training be delivered?

Some have argued that doctors should not be developed in isolation from other types of managers.

1But others believe it is difficult for doctors to develop management competencies during their training years, when their overriding concern is to develop clinical skills. It has been suggested that there should be joint training early on in the careers of doctors and managers.

2We carried out a survey of opinion among doctors and managers in the West Midlands region to establish their views of the best time for management training.

We sent the questionnaire to 320 staff, including medical students, pre-registration house officers, senior house officers, specialist registrars, consultants, clinical directors and medical directors, and received replies from 108 (34 per cent).

We also sent the questionnaire to 140 managers including chief executives, executive directors, business managers and management trainees.

Sixty-one (44 per cent) replied.

Respondents, whose replies were anonymous, were asked what they considered to be the best time for training in a variety of topics, including:

organisation and structure of the NHS; self-management skills; interpersonal/team management skills; performance management; staff recruitment, selection and training; audit and service quality; business management; decision-making;project management.

There were also questions on doctors' involvement in management and learning together.

There is clear consensus between doctors and managers about which competencies should be taught at which stage of doctors' careers (see box above).

Ten questions concern the relationship between doctors and managers. There is agreement for only two responses: both groups agree that doctors should be involved in management but they are equivocal about their willingness to participate.

However, several important differences of opinion emerge. Doctors feel more strongly than managers that present medical and managerial values are different and that there is insufficient time and resources to take on managerial responsibilities.

Managers feel more strongly than doctors that:

medical students should receive managerial training; the science of management is useful for practising doctors; manager/doctor collaboration is more effective than in the past; management is essential for effective medical practice; managers are willing to share authority and responsibility with doctors in management.

There is significant disagreement about the control of resources. Doctors think clinical resources should be under doctors' control and managers are opposed to this.

Managers are strongly opposed to the possibility of doctors receiving management training in doctors-only groups. Doctors are generally in favour of training in mixed groups.

Our findings suggest there is agreement that clinical work and management are inter-linked, and acceptance that doctors should be involved in management. There is also a general consensus that management training should be spread throughout a doctor's career, with various topics being covered at different stages.

But the survey shows that there is still a 'them-and-us' culture in the NHS, even though this might be less marked than in the past. Resources, particularly time, remain an issue, and stereotyped differences persist about controlling resources.

Several responses show that managers are more optimistic than doctors, who still have suspicion of managers' intent. This may be overcome by joint training for doctors and managers, shown to be acceptable to both groups.

Interestingly, though, doctors are equally happy to receive training in a doctors-only group, in contrast to the managers, who want training to occur jointly.

This may reflect the relative isolation of medical training in the past.

It is important to distinguish between joint training for mixed clinical groups (doctors, nurses and other professions allied to medicine), and joint training for doctors and non-clinical groups (hospital managers). Clearer definition is needed.

The term 'multiprofessional' is useful for the former and 'multidisciplinary' for the latter.

The delivery of management training for medical staff needs a fresh approach. Doctors want to contribute, but their perspective is different from managers'.

It may be best if managers move away from making doctors in management in their own image, and for both groups to find common ground.

Doctors need to feel comfortable with the principles of management and their application to everyday activities. Ownership of managerial issues and problems is essential for successful outcomes.

The way forward may be to develop doctorfocused management with problem-based delivery.

Medical students would be more stimulated to learn about the management issues of transferring a patient from a GP's care to hospital than by learning about the structure of the NHS. Specialist registrars might be more eager to learn about 'getting a consultant job' than 'staff recruitment and selection'.

Consultants would rush to hear about 'what factors determine whether I get merit points', but might show little interest in clinical governance and service quality.The clinical director would be more pleased to hear about 'how do I increase my directorate budget to get a new consultant?' than attend a seminar on business planning.

The NHS depends on doctors developing managerial skills, and on there being a good relationship between doctors and managers.The gap that exists may be closed by 'doctor-focused management', recognising clinicians' different needs and demands. l

REFERENCES 1Fitzgerald L, Sturt J.

Clinicians into management on the change agenda or not?

Health Services Research 1992; 5: 137-146.

2Clark J, Palmer R, Balderson S. Bridging the Divide, HSJ 2000; 110 (5727): 30-31.

Key points

A survey of doctors and managers found agreement that management training should be given at various stages of a doctor's career.

Managers felt strongly that doctors should receive management training in groups with other staff.

Doctors believed clinical budgets should be under doctors' control, but managers were opposed to this.

The results suggested that a 'them and us' culture persists between managers and doctors in the NHS.

Level best: catching the moment

Optimal career levels for management development for doctors Medical students and pre-registration house officers Organisation and structure of the NHS; government health strategy; role of culture; structure and rules; operational and strategic issues; funding and resources self-management skills; critical thinking; time management; self-presentation; decision-making; recording and storing data; analysing information to support decision-making.

Senior house officers Audit and service quality; using quality indicators; clinical audit; clinical governance; implementing patient satisfaction surveys; handling official complaints.

Specialist registrars Interpersonal/team management skills; chairing and managing meetings; making presentations; managing change.

Consultants Performance management; staff appraisal; allocation of work; setting work objectives; providing performance feedback; staff motivation; staff recruitment; selection and training; determining staffing requirements; recruitment strategies; selection procedures; identifying training needs; managing training provision.

Clinical director Business management; accessing and regulating resources; controlling expenditure against budgets; managing budgets; negotiating contracts; developing business plans.

Medical director Leadership; advising on ethical issues; dealing with the media; resolving large conflicts; conducting grievance and disciplinary interviews.

Clinical director and medical director Project management; preparing and planning project activities; coordinating activities; resources and plans; evaluating project implementation.