doctors in management : Successive NHS reorganisations have failed to sweeten the doctor-manager relationship.So why should the latest attempts to end adversarial attitudes be any more successful? Mike Pollard reports

The latest NHS reorganisation, outlined in Shifting the Balance of Power in the NHS, promises a move towards clinical teams, and giving clinicians in trusts more responsibility for delivering and developing services. It is a bold experiment, but will it work?

A huge cultural shift will be required to reshape doctors' professional behaviour to produce some sort of convergence of their clinical freedom and their new managerial responsibilities.

But if doctors do not take up their leadership roles, it will be like watching Hamlet without at least a walk-on part by the Prince of Denmark.

Past attempts to create a convergence between medical and managerial cultures have failed.We need to account for that failure and to learn from it.

If we do so, we may find ways of unleashing the potent synergy which currently lies dormant.

The delivery of the NHS plan may depend on it.

In February 1989, a three-way conversation took place in the pages of the British Medical Journal between Dr Richard Smith, then BMJ assistant editor, Cyril Chantler, then professor of paediatric nephrology at Guy's Hospital, London, and Sir Anthony Grabham, a consultant surgeon and former 1It was prompted by doctors' emerging interest in taking on managerial responsibilities within the then pre-trust hospital service. At the time, the NHS was tooling up for the Thatcherite internal market health reforms, which were to be introduced less than two years hence.

The issues raised by this conversation resonated with the thinking of the architects of this new regime.

The principal reasons cited by Professor Chantler and Sir Anthony as to why doctors should take on managerial roles were revealing and faintly insulting. Professor Chantler said: 'Doctors must play a bigger part in managing the health service to protect their clinical freedom.'

And, he added, 'in most hospitals they have been around much longer than anyone else (and certainly longer than the administrators) and have some vision of where the hospital is going'.

Asked if doctors needed extra training for management, Professor Chantler replied: 'I do not think they need much. The important thing is to be interested and willing to learn.

'It is worth attending a few management courses and reading some books, but mostly you can learn from the people around you. The idea that you need a complicated training is a nonsense: you are not there to be an administrator.'

Sir Anthony said: 'Doctors are potentially the best managers in the health services. They have the longest and the best education of all those in the hospitals, the most experience, and are responsible for most of the decisions that lead to expenditure.'

These were - and remain - essentially protectionist and defensive motives. They imply a consolidation of a position in the face of a threat, rather than migration from one position to another. Thus doctor-managers have not been the generals and the majors who have led their troops towards new corporate territory.

They have instead acted primus inter pares - negotiating and mediating the clinical and managerial divide rather than, through their attitudes and behaviours, effecting a convergence between the two.

The creation of trusts from April 1991 promised something rather different. A new role - medical director - was created and embodied in statutory regulation. The medical director would sit and make decisions at the highest level in these new, self-governing organisations. In prospect were powerful local internal alliances between managers and doctors who, with a shared ethos, would together deliver greater system efficiency.

In those heady, far-off days it was easy to be seduced into thinking that peace had broken out.

Was this the end of the 40 years'war between a quasi-autonomous clinical workforce and those - politicians at first, and then the new cadre of general managers - who sought to impose financial and managerial discipline upon them? It was easy, then, to believe that the dream ticket - this now much sought-after convergence of medical and managerial cultures - was but a fingertip away.

True, most chief executives can now just about recruit to vacant doctor-manager positions in their institutions. But there is rarely intense and widespread competition for these posts. Indeed, apocryphal stories still abound of newly appointed doctor-managers being blanked by erstwhile colleagues in hospital car parks, or being dropped from dinner party guest lists. They have remained true to the Chantler-Grabham faith.

Indeed, when BMA chair Dr Ian Bogle launched his vituperative sideswipes at the government's health policy at this year's annual conference, he was interrupted by emotional standing ovations from the floor.We might argue that clinicians are further from the body corporate of the NHS than at any time in the last 10 years.

What is to be done to transform the mindsets of doctors when this empowerment is so imminent?

Perhaps we should begin to understand the polarities - from the perspective of the medical community - and develop a strategy that reflects that understanding.A good place to start might be this year's annual conference of the Royal College of Surgeons in Birmingham.As usual, it was a highly organised, well-attended affair with scores of parallel and interlocking sessions reflecting the profession's increasing sub-specialisation. The usual array of gowned and chained office-holders and academics was present. But the event really belonged to the practising frontline surgeons from across the land who had come to present their work to their peers.

These presentations were data-rich, methodologically robust expositions of clinical results. There were a number of challenges from the floor but they were respectful and constructive, guided and informed by the transparent scientific evidence which had been placed before them.

How do such data-literate scientists perceive the behaviour of managers? To most, managers' behaviour is based on a curious mix of unscientific, data-deficient assertions and assumptions.

A consultant appointed in 1975 will have experienced five major reorganisations of the NHS - each one represented as the final solution to the ills of the reorganisation which preceded it.

Each reorganisation leads inexorably to managerial departures - either out of the service altogether or into new positions within it. As a consequence, detailed service knowledge and previous managerial commitments to clinical priorities leak out of the local NHS. Long-serving clinicians constantly fight the same battle: to get their agenda reconfirmed by the new incumbents.

Or not, as the case may be.

It is not possible to overstate the almost palpable bewilderment and despair which clinicians feel when structural change is proclaimed yet again from the centre.

And there are other differences. The art of management contrasted with the science of medicine; the generalist versus the specialist; those who manage transience, complexity, and ambiguity marshalled against those who are enduring, in it for the long haul, and who prize long-standing relationships.

To be responsible for a multitude of disparate tasks without the means to exercise discretion and choice as to how they should be performed is often taken as a definition of occupational stress.

Doctors have been subject to intense and sustained efforts to improve productivity, redesign patient processes, comply with an increasingly onerous clinical governance regime, provide goldstandard educational programmes for doctors-intraining and, crucially, to be both generalists and clinical sub-specialists at one and the same time.

While this burgeoning agenda is necessary - and common to most countries in the developed world - the pace of change on so many fronts, without the opportunity to consolidate and reflect, is pushing clinicians further into professional unionism.

If it were possible to double the basic salary of a consultant, we might palliate these negative feelings. But they would undoubtedly re-emerge within months, if not weeks, because material reward paid en bloc is to miss the point. Something serious has to be done to motivate and realign clinical attitudes and behaviours, and provide conditions which make empowerment possible.To restore professional control and to incentivise consultants offers the best line of inquiry.

And there are models for how it might be done.

Thriving in many district general hospitals are 'anaesthetic clubs'where anaesthetists come together - either in formal or informal partnerships - to pool skills and resources. In these settings, consultants both honour their NHS commitments and optimise their personal incomes by supporting surgeons working in the private sector.Clinical performance and the behaviour of individuals are highly regulated, informally by peer pressure, but in extremis by the threat of expulsion. Such clubs are characterised by high levels of collegiate working, self-determination, problem-solving and accountability - all underpinned by clear material incentives.Here medical and managerial cultures have converged.

With a clock ticking on empowerment, we need to fathom the behaviours which inhibit or encourage engagement and to map out the terrain before we set foot on it.We also need to learn from the past - being prudent in our estimation of what is possible in the short-term. Simply to parcel up packages of managerial authority and drop them in the laps of consultants will not work.

As any first-year medical student knows only too well, attempts to graft alien tissue on to a patient risks catastrophic rejection.

REFERENCE 1Grabham A, Chantler C.

Doctors becoming managers.

A conversation among Richard Smith, Sir Anthony Grabham and Professor Cyril Chantler. Interview by Richard Smith. British Medical Journal 1989; 298 (6669): 311-314.

Key points

The latest NHS reorganisation proposes that doctors in trusts should be given more managerial responsibility.

Attempts to involve doctors in NHS management over the last 10 years have not been wholly successful.

The constant reorganisation of the NHS hinders the integration of clinicians in management.

Mike Pollard is chief executive of Essex Rivers Healthcare trust.