When I am engaged in yet more discussions on what we do, why we do it, how we do it, to formulate yet another options document, assessment of service document, taking stock document, predicting the future document... there is one observation that I believe illustrates the starting positions of two subcultures in the NHS.

I was intrigued to watch the change in the body language of a manager as we discussed the formulation of yet another one of those documents you will be very familiar with.

As a clinician, I started by articulating what was in effect a core clinician value - a service rooted in quality and clinical effectiveness, acting in the best interest of the patient - ending with the argument that based on these core values activity would follow and, with that, increased income.

There was a stillness from across the table transformed to almost excited animation; "Quality" did not excite. "Clinical effectiveness" did not excite. "Increased activity" did.

That is not to conclude that managers do not understand or share clinician core values, but PbR has altered thinking and now behaviour. Activity is everything, because activity is income. I reflected my observation back to the manager as I watched it happen - my weakness of saying it as I see it - the Emperor thing.

The very reasonable defence is that increased income enables investment in services. But that short but very telling encounter is revealing about the starting point of the clinician and the starting point of the manager.

As we, the clinician and the manager, work together in the hope that we 'move forward' along a common path, that assumes that even though we are starting from different points, we will meet at a common point (V) and then stay as one (Y) - or will we simply cross and continue on in our own diverging directions (X), giving a whole new health care perspective to Douglas McGregor's 'theory X and theory Y'?

Question: Does having clinicians professionalised and embedded in the management and leadership of clinical services move us, clinicians and managers, away from X and closer to Y?

Answer: Yes, with many examples outside the NHS and many more needed in the NHS.

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