Published: 27/03/2003, Volume II3, No. 5848 Page 26 27
Researchers'attempts to find out why doctors are unhappy - and why in particular now - suggest that a perceived erosion of their professional dominance and autonomy is to blame.And their relationship with managers plays a key part, as Lyn Whitfield explains Why are doctors unhappy? Or more to the point, why are they unhappy now?
This is the question that researchers set out to answer in this week's British Medical Journal, before suggesting some solutions.
St Andrews University professor of healthcare and management Huw Davies and Stephen Harrison, professor of social policy at Manchester University, argue one problem is the doctor-manager relationship.
1Over 30 years, doctors have become less dominant in healthcare, while managers have gained power. In the early days of the NHS, Davies and Harrison argue, doctors rather than managers 'had a dominant and pervasive influence'. Services were shaped by 'an accumulation of individual, clinical decisions', and managers tried to 'support and administer' these, rather than challenge them.
The introduction of general management in 1984 led to a new focus on finance. But it 'left patterns of clinical care - and hence influence from doctors - largely untouched'.Managers still saw their 'key clients' as senior clinicians, rather than service users, and tended to react to problems, instead of looking for ways of developing and meeting corporate objectives.
The internal market of the early 1990s, and the new service delivery and accountability regime that followed, changed all this. 'The emergence of (even relatively attenuated) competitive forces... drove managers to be more proactive in developing strategic objectives and plans' to 'maintain and develop their own institutions' facilities'.
As the market was, in turn, supplanted by 'supposedly more co-operative ways of working, supplemented by central diktat', managers' focus switched to meeting national imperatives. '[Senior managers] are now seen more as agents of government than as facilitators of professionally driven agendas.'
The UK is not alone in these developments. Davies and Harrison argue that three trends are visible in most developed liberal democracies.
There has been an increasing 'systematisation' of medical knowledge, focus on finance and increase in state regulation.
Medical knowledge has been systematised through systems that allow clinical work to be measured (for example, diagnostic resource groups), dictate how care should be delivered (clinical protocols) and process patients through the system (clinical pathways).
The focus on finance has led to the introduction of financial incentives for individual clinicians and the institutions in which they work to behave in particular ways, which also require medical work to be managed. New methods of state regulation include the creation of new inspectorates, the introduction of compulsory clinical audit, league tables and performance indicators, all of which aim to modify clinical practice.
Overall, therefore, Davies and Harrison argue: 'The overriding theme of the diverse changes over 30 years has been a substantial erosion of professional medical dominance and autonomy.'
Indeed, they argue a new model of healthcare has become dominant - the 'scientific-bureaucratic' model, which conflicts with the traditional view of healthcare - or 'reflective practice model'.
In the reflective practice model, doctors 'provide care to patients on an individualised basis, work largely independently of organising structures and 'are less concerned with external, formalised bodies of knowledge than with their own expanding clinical understanding and tacit knowledge'.
The scientific-bureaucratic model emphasises robust and objective evidence, formalised into prescriptions for practice and models for service delivery that 'reduce individual discretion about practice patterns'.
Professor of clinical management development Pieter Degeling and colleagues from Durham University offer a similar analysis.
2They argue that healthcare reform has been driven by three issues: the growing cost of healthcare, 'doubts about the appropriateness and value of existing patterns of clinical work' and 'worries about the medical profession's capacity to ensure the accountability of its members'. They say that 'these issues should be addressed at the level at which clinical work is performed' but have instead been addressed by 'top down, bureaucratic mechanisms' to which different groups of professionals respond in different ways.
A survey of more than 3,000 medical clinicians, medical managers, general managers, nurse managers and nurse clinicians in 26 hospitals in England, Wales, Australia and New Zealand (where market reforms were also pursued) shows they have different concepts of clinical work and financial and professional accountability.
Medical clinicians tend to have a highly individualistic conception of clinical work, while general managers tend to have a highly systematised one.Medical clinicians tend to be 'equivocal' about what the authors call financial realism and 'transparent accountability' (accountability through systems), while managers are committed to both.
The new element in the piece by Degeling et al is the introduction of nurse managers and clinicians.
They argue that nurses hold highly systematised conceptions of clinical work, but support 'clinical purism' (as opposed to financial realism) and 'opaque accountability' (accountability to self, colleagues and patients).Degeling et al suggest that doctors and managers should look at the potential of the multi-disciplinary team models championed by nurses as a way out of the 'seemingly unending and discordant medical and management 'two step''.
Integrated care pathways, which specify the sequence of diagnostic and therapeutic processes that patients need, incorporate the views of a range of clinical staff and managers, they say. Therefore, they can provide 'a tool... for empowering clinicians to strike a balance between the clinical and resource dimensions of care and between the requirements of clinical autonomy and transparent accountability'.
Of course, if Davies and Harrison are correct, and the development of team-working and clinical pathways has helped to strip clinicians of their autonomy and so contributed to their unhappiness, this conclusion is going to be optimistic.
Degeling et al admit this by saying it is 'likely to be rejected as culturally difficult and destabilising to established positions of power'.However, they argue this narrows the range of approaches that can be taken to reform.
Davies and Harrison would also like a way out of the current impasse, since 'disillusionment, lack of morale, loss of trust, misalignment and miscommunication' are 'hardly recipes for high quality patient care'.
A shorter piece of research in this week's BMJ adds to the debate while not offering anything major by way of a solution.
Rifat Atun, director the health management programme at Imperial College London, says doctors have little involvement in management and those willing to participate have no management training.
3'The most important barrier is that managers and doctors speak different languages - and the highly codified tribal dialects become more difficult to understand as seniority increases.' Therefore, he argues, more systematic management training is needed - like that developed by the business and medical schools at Imperial, which allows undergraduates to take a one-year BSc in management.
There may be more radical ideas to import from abroad - although these also fly counter to some of the analysis above.
Professor emeritus Laurence Malcolm and colleagues from the Christchurch school of medicine and health sciences in New Zealand say it has gone a long way towards closing the gap between professional and managerial cultures.
4Ironically, however, they argue tight budgets, medical scandals and the imposition of market reforms have been key to this. Tight budgets, they say, forced New Zealand to make 'difficult choices about healthcare priorities' and 'this compelled greater collaboration between clinicians and management'. In some areas of primary care, such as pharmaceuticals, 'major budget management... is being seen as a new form of clinical autonomy'.
The Cartwright Inquiry of 1988 (New Zealand's equivalent to Professor Ian Kennedy's response to Bristol) 'sensitised the medical profession to the need for greater collective professional accountability'.
And while New Zealand's extensive market reforms caused 'open conflict' between clinicians and managers in some hospitals, 'in other settings, managers who were more health oriented collaborated with clinicians to build working partnerships that are now being generally adopted.'
Malcolm et al say this co-operation has been fostered by a centre-left government elected in 2000.
It has created integrated district health boards and drawn up a new contract with them, focused on health outcomes.A 'convergence of cultures' is now visible. 'This has required from the management culture a shift from a preoccupation with resource management to health outcomes as the 'bottom line' for the organisation... [and] the acceptance by clinicians of a key role in managing resources and achieving the organisation's goals.
'Both cultures need to move - and are moving - towards a more trusting relationship based on a shared vision and on shared goals of better outcomes for patients and communities, within limited resources.'
There are similar messages from the US. Kaiser Permanente Federation executive director Francis Crosson says the idea that physicians and managers should share responsibility for the performance of healthcare systems was bitterly resisted 50 years ago, but is key to Kaiser's success today.
5In a final paper, Jefferson Medical College health policy and clinical outcomes director David Nash argues that some of these ideas, including a 'joint report card' for the performance of healthcare institutions and interdisciplinary education and training for clinicians and managers, are needed to overcome US healthcare's generally patchy performance.
6'Physicians focused solely on patient care and administrators focused solely on use of resources and productivity are destined for collision, 'Crosson argues. 'Bringing both sides into a mutually interdependent relationship, where the success of each side is in the hands of the other, forces a powerful alignment of interests that transcends professional or cultural differences.'
1Davies H, Harrison S. Trends in doctor-manager relationships. bmj. com
2Medicine, management and modernisation: a danse macabre? Degeling P, Maxwell S, Kennedy J, Coyle B.Wolfson Research Institute, Durham University. bmj. com
3Atun R. To have a dialogue, doctors and managers need to speak a common language. Imperial College, London. bmj. com
4Malcolm L, Wright L, Barnett P, Hendry C. Building a successful partnership between management and clinical leaders: the New Zealand experience. bmj. com
5 Crosson F. Kaiser Permanente: a propensity for partnership. Kaiser Permanente Foundation.
bmj. com 6Nash D. Doctors and managers: mind the gap.
Jefferson Medical College, Philadelphia. bmj. com