opinion: TEAM TALK

Published: 27/03/2003, Volume II3, No. 5848 Page 18

The problem of how doctors and managers get along has been put into sharp focus by the rejection of the consultant contract in England and Wales.

This has coincided with a political push against management, which is being used as a stick with which to beat the government. Columnists claiming that there are more bureaucrats than beds has not helped.

There is still a view that health services should not really be managed, often linked to nostalgia about hospitals run by matron, the medical superintendent and the hospital secretary.

These commentators want 'management-lite' in which car parks and filing and support services are sorted out but clinical services are off-limits. These are the same people who complain about poor organisation, long waits and inefficiency.

There is a strong case that better-managed healthcare improves outcomes.Many doctors in leadership positions say they need more management support and appreciate the managers who work with them, even if they are suspicious of management more generally.

The reason that doctors and managers find it hard to get along is well understood; it is the result of a paradox.We need the great strengths of medicine - autonomy, individual focus and scientific discipline - and we need the strengths of management - focus on populations, emphasis on accountability, capacity to make work systematic.

The commentators are nostalgic for the days when the length of stay for a hernia operation was 10 days rather than six hours, there were fewer expensive interventions and patients had very different expectations.Now the pace of healthcare is faster and there are resource and external pressures which make the paradox less easy to live with.

What is surprising is the shortage of credible solutions from clinicians.Many of those proposed are variants of the 'leave us alone' approach.

The proponents do not explain why doctors, rather than any other health professionals, should be the model to follow. But the main criticism of this approach also applies to making doctors think more like managers; it fails to recognise that both groups have unique contributions to make.

A further set of solutions involves improving the quality of management.

Studies by the Hay group and Beverley Alimo-Metcalfe argue that there are no significant differences between the quality of managers in the NHS and those in the corporate sector. It suggests some of the concern about the quality of NHS management may be prompted by the complexity of healthcare.

It also implies that there may be insufficient engagement between leaders and followers. I was struck by the case of a failed medical group in the US, whose ex-chief executive officer told a familiar story.

'Physicians did not demand an acceptable level of performance from their leaders. Consequently, systematically evaluating their leaders became impossible.

'There [was] also a sinister lack of directness between the governed and the governing. Physicians who were only too happy to pontificate in the doctors' lunchroom did not take the time to cultivate the same sermon in the boardroom.'

1The case studies in this week's HSJ (cover feature, pages 28-33) show that doctors and managers can learn to live with the paradox rather than looking for simplistic ways of ignoring or resolving it.

But it is a difficult process.

Managers need to be consistent, to work transparently, to use evidence where it is available and be honest about the constraints under which they work. There is still scope to be better at understanding the position of doctors and other professionals.

The development of more medical leaders will assist with this.

But leaders are nothing without followers who understand and can deal with management and organisational issues. This means better preparation for working in complex organisations than is available for consultants.

The Department of Health can help by ensuring that planning and performance management does not add to the tensions by removing space for local discretion or giving frontline doctors the impression they are being asked to do things that run counter to deeply held principles.

The solution cannot be blaming each other or resorting to personal criticism and abuse.

Instead, there needs to be a partnership between managers and clinicians in which differences are recognised and valued, sustained by continual honest conversation. This already exists in many places and it needs to exist in many more - very soon, or it will be too late. l REFERENCE 1Rubin IM and Fernandez CR.My pulse is not what it used to be: the leadership challenges in healthcare.

Kingsham Press. Second edition, 2003.

See news focus, pages 14-15; comment, page 17; opinion, pages 26-27; features, pages 28-33, 44.

Nigel Edwards is policy director of the NHS Confederation