A significant proportion of managers are also nurses - but great suspicion still exists between the two groups.Andrew Cole delves into the background to the distrust

There are not many certainties in today's health service. But nearly everyone - from politicians to the public - would agree with two propositions. The first is that managers are hardhearted 'grey suits'; the second that nurses are selfsacrificing saints. The contrast in how the two groups are perceived could not be greater. Managers are exorbitantly paid to close down hospitals, ignore the needs of patients and focus on the bottom line.

Nurses, on the other hand, are abysmally paid, dedicated to a fault and uniformly 'wonderful'.

It is a myth that most people - including many within the NHS - are happy to accept. But the reality is, of course, very different. Even the gulf in pay is narrowing. The typical third-level manager such as a contract or business manager now earns£29,000-£30,000. This compares to£23,000-£28,000 for a ward sister.

The perceived dichotomy also ignores the fact that a significant number of managers actually are nurses. In 1998 no less than 17 per cent of all non-medical managers were nurse managers - a figure exceeded only by senior managers and administration and estates managers.

Yet despite all this, most nurses continue to regard managers - even nurse managers - with suspicion, not to say outright hostility. Why should this be?

June Andrews, director of nursing at Forth Valley health board, has been on both sides of the fence, having previously been secretary of the Royal College of Nursing's Scottish board. When she moved from the RCN, she recalls, many accused her of being a poacher turned gamekeeper. 'But That is wrong. It is more like poacher turned pheasant.'

'Management is a lonely place. Nurses complain about you being invisible and the public see you as responsible for everything that goes wrong.'

She believes much of nurses' suspicion of managers derives from the belief that nursing is work of social worth because it has a direct impact on the patient, and that the further you move from the bedside the less you are able to influence patient care. The fact that you seem to get rewarded more for doing this adds to nurses' sense of injustice.

But Ms Andrews feels she has a greater impact on the healthcare of patients in her current role than any previous post she has held.

The irony is that the skills required to be a good nurse are in many respects precisely those needed to be a good manager. As she points out: 'The fundamental skills of management are time management, communications combined with a bit of legal and technical knowledge, and lots of stamina and energy. By the time a nurse has reached ward sister level she should have all these skills.'

But some tension between managers and clinicians is almost inevitable. For while nurses and doctors rightly see their responsibility to the individual patient, managers are ultimately responsible for the collective good. It is also fanciful to think managers can do their job without encountering unpopularity, even hostility.

But there is equally little doubt that the Griffiths reforms of the late 1980s, which introduced general management, marked a dramatic downturn in relations. Suddenly nurses were answerable to a new breed of manager who might have no background in health, let alone nursing. The RCN ran a campaign complaining that nursing would be run by people who didn't know 'their coccyx from their humerus' and the battle lines were drawn.

The result was the virtual decimation of nursing management - a process in which nurses themselves readily participated. Andrew Wall, visiting senior fellow at Birmingham University's health services management centre, was a hospital manager at the time and recalls how hostile many bedside nurses were to their nursing superiors. This was compounded by managerial colleagues who seized the chance to sweep away several layers of nurse management.

The reorganisation, combined with the introduction of the internal market a few years later, tended to make finance and efficiency most managers' top priorities and to leave many nurses outside the loop. It is only relatively recently that clinical priorities have been added to managers' agenda and nurses welcomed back into the fold.

Perceptions, however, still lag a long way behind reality. And this is not helped by continuing, well-publicised examples of incompetent and highhanded management. The recent inquiry into failures at John Radcliffe Hospital's heart centre in Oxford, for instance, highlighted arrogant and complacent management and castigated the nurse director for failing to provide support, supervision or guidance.

Many practising nurses still feel unsupported and pressurised by their immediate managers, who are never there when they need them, but breathe down their necks when they do not.

Emma White, a research and development nurse with Bradford Hospitals trust, believes that many middle managers are out of touch with bedside issues. She hated her own experience of management, which seemed to consist largely of endless meetings and producing reports that noone read. She also found that many nurses seemed frightened to voice their concerns about patient care to managers.

Chris Hart, a team leader at the Royal Bethlem and Maudsley trust, attacks management where bedside staff voicing clinical concerns or pressing for changes are met by procrastination. 'It then becomes a matter of how hard clinical staff are prepared to press for change.

'I think for some managers there is a safety zone which is to bury yourself in paperwork so that you're not confronted with the awkward situations which clinical staff face daily.'

As chief executive of the Institute of Healthcare Management, but with a daughter who is a staff nurse, Stuart Marples hears both sides of the argument and accepts the justice of some criticisms of managers. He agrees it is difficult for managers to call clinicians to account when they themselves are not professionally accountable.

But he rejects the notion that they have a different set of values to clinical staff. 'Managers go into healthcare for many of the same reasons that other professionals do and share equally the values of caring for the patient.'

One way forward is to devolve responsibility to the directorate level. But this can end in tears - as in Carmarthenshire trust, recently criticised by the Commission for Health Improvement after a patient had the wrong kidney removed, where the nursing budget and management remained centralised yet clinical responsibility was handed to the directorate.

Most agree that building bridges between management and nursing and giving nurses more control over practice is the key to better relations. Shared governance (see box, left), clinical governance and nurse consultant posts are all encouraging moves in this direction.

The appointment of hands-on nurses to the boards of primary care groups and primary care trusts is also giving nurses a say in decision-making at the highest level. Margaret Stockham, chief executive at Bedford PCG, says that having two nurse representatives on the board has helped to improve communications between management and frontline staff. It has also made the decisionmaking process more democratic and, as a result, she feels they are reaching better decisions.

That is the good news. The bad news is that many managers - and nurses - still fail to measure up to these standards. Nurses can find it convenient to blame all their problems on managers, says Ray Rowden, director of healthcare programmes for training provider Gatehouse, and a former nurse and manager. 'Sometimes there is a degree of protection in playing the victim. It is safer than taking ownership and driving change yourself.

Some nurses are comfortable to be seen in that victim role.'