'A meeting of minds gets enormous impetus when the fog of data is converted into information'

Clinical engagement is a high-profile issue. Connecting for Health includes a call for it, so does the South East London organisational change project, our own First Choice King's programme and our ambition to build inclusive strategy. Given this, where is the vast pool of knowledge about how to engage clinicians? There is much talk, but I have yet to come across anything resembling a theory of how to do it.

Occasionally I mention this in meetings and seminars and the point is challenged. I have been sent publications by people anxious to disabuse me. For instance, I had a pleasant trip down memory lane reading about the introduction of models for, and evaluation of, clinical directorates. A close friend kindly sent me a book chapter she was writing about her work on engagement with another trust, which looks very promising.

But I have yet to find a theory that has been empirically tested using robust research designs and methods. It is surely something for the NHS service delivery and organisation research and development programme (and as vice-chair of the SDO programme board, I have to confess guilt here).

There is a seemingly infinite supply of explanations about why it is difficult to engage doctors. Last week I read that doctors are largely from middle-class backgrounds while managers often hail from the working classes. This was a new one on me.

A common thread seems to be that it is difficult for doctors to accept the legitimacy of the manager role. This represents something deeply embedded in the British psyche, as in Chaucer's description of the steward in The General Prologue to the Canterbury Tales, or Shakespeare's treatment of Malvolio in Twelfth Night. It is no wonder a consultant last week mentioned that as a medical director he had crossed to the 'dark side'. As Master Yoda would have said: 'Revealed, the prejudice is.'

I would suggest two antidotes to this tradition. The first is brains. I have noticed the Mr Spock-like tendency of senior medical colleagues to scan incoming managers, from the chief executive downwards. The level of subsequent engagement is based on the results of the scan: the bigger the manager's brain, the more they are willing to engage.

The second is commitment - to the service and the institution. Longevity tends to reflect commitment, and a committed manager is taken seriously by the troops. I remember a striking instance in my previous job. We had an organisational development director who had been in or around that locality's health services for more than 30 years. We also had a hard-working but vehemently anti-management orthopaedic consultant. One day, waiting until he wouldn't be noticed, the doctor knocked on the director's door and said, 'Bill, I've got an idea for a hip pathway.' So there's engagement and there's clandestine engagement.

But focusing on personal qualities has its limitations. What happens when the irresistible force of the target-wielding manager meets the immoveable object of the clinician with patient and service priorities? Small wonder that an important study found female middle managers among the most stressed work groups.

This context needs empathy, not just personal but also organisational. If the trust or a particular service has a history of working out problems mutually, I suspect engagement persists. External bad guys come in handy here. I think it was one of JFK's advisers who said if you don't have an enemy you had better invent one. In the world of acute trusts there appears to be an inexhaustible supply. How many of us have heard or said something like: 'If we don't do this we will lose out to trust X'?

In fact, the new challenge is how we reconcile a competitive history with the need for engagement through a more complex environment of competition and collaboration.

A meeting of minds gets enormous impetus when the fog of data is converted into information. I suspect we have all seen too many Venus and Mars-type conversations about performance and budgets where figures are not recognised, clinical work done does not appear on the spreadsheet and eventually the entire reality of the position is questioned. Of course, some of this can be denial. But whether it is or not becomes redundant if transparency is achieved. Easy to say, but remarkably difficult to achieve.

At King's it has taken two years so far to build performance data on the basis of clinical team as well as corporate needs. It will take longer to convert our activity-based management programme into monthly profit and loss statements for clinical teams, though we are making great strides.

But the rising tide of enthusiasm based on what we have done so far has been enormously helpful. I wouldn't pretend that we have comprehensive clinical engagement, but we have moved a long way from working
with a minority of torch bearers.

Does this seem a bit one-sided? Should we also ask how our clinicians might engage us managers?

Many do. Hence the business cases which reflect ambition for a particular service, but add the bait of corporate bi-products such as helping with waiting times, making money or avoiding loss to the competition. The challenge is to turn bi-products into main products. That means getting tougher on the corporate side of the bargain. The engagement process is then a balanced one. We are back to achieving change by doing deals.

This does not cover those seeking a quiet life in a clinical or managerial career or those focusing their efforts outside the trust. But at a time of growing transparency, accountability and information, how many can enjoy that position for much longer?

Whether through choice or necessity there will be a need for engagement.

Malcolm Lowe-Lauri is chief executive of King's College Hospital trust.