Things do not happen in isolation, nor can change be arbitrary. A full and contemporary understanding of today’s culture and attitudes requires an awareness of essential history.
In the early 1800s, health was not articulated as a political issue and central government was largely laissez-faire,despite public health being a real social concern among the labouring classes, doctors and philanthropists.
The first Public Health Act (1842) was forced by the Chadwick Report and a cross party reformist political pressure group, ‘The Health of Towns Association’, which highlighted the link between squalor, poverty and disease.[i] Crucially, it initiated central government intervention in public health – albeit limited – within the localities, against the objections of vested commercial interests and local authorities.[ii]
Through the mid- to late-1800s, direct state intervention in health care steadily increased, providing and financing an ever-increasing range of health services, through the mechanisms of the poor law, public health, education and health insurance – until by 1939 some of the more affluent and progressive local authorities were close to boasting a comprehensive health service. ii
The NHS was established in 1948, as part of a new social order – the welfare state – based on finance from general taxation. This adopted a command-and-control system of service, which lasted for over half a century.
The state, anxious to recruit privately working doctors to the NHS gave them large financial rewards, with virtually no accountability. Doctors retained a lot of clinical freedom owing to the unspoken consensus with the State to ration clinical provision on its behalf and safeguard the exchequer.[iii]
Specialisation was a powerful driver and science was a cardinal value, with communication and teaching relegated to lesser value status. iii
The consensus effectively ended with the Thatcher government which, sensitive to changing public expectations, signalled that the public and patients had to come first.iii Successive Conservative governments introduced modern general management, the first strategy for health and a competitive internal market, in an effort to decentralise decision-making, get value for money, secure higher quality outcomes, institute more explicit accountability and, finally, create a Patients Charter.
For over 40 years, an employer/ producer rather than patient orientation prevailed. This significantly influenced the formation of protective attitudes and the toleration of much incompetent practice. Thus, the medical profession was excessively paternalistic and used to defining accountability on terms that suited it.
This, in its turn, led to a system of medical regulation which was reactive, insular and unresponsive, and attentive only to the worst abuses. iii
All this was against a backdrop of tremendous changes in society. People had higher income and expected partnership and control in decisions affecting their lives.iii
Quality-enhancement initiatives by healthcare professionals had the disadvantage of being voluntary in nature. There were also no well-founded local arrangements for ensuring quality practice – and the GMC acted only on complaints.
The Bristol tragedy and its mass media coverage drove home the message for radical change, compelling legislation and professional initiatives for quality and safety, which included, among many others, revalidation of doctors’ registration, and the creation of institutions to guide and review clinical quality.
Since then, people have wanted more openness and accountability for doctors in return for more trust.
The Griffiths’ inquiry (1983) into NHS efficiency found an “absence of … general management support … [with] no driving force seeking and accepting direct and personal responsibility for developing management plans, securing their implementation and monitoring actual achievement”.
Against a background of greater public awareness and expectation, coupled with poorly performing primary and secondary healthcare services, it recommended bringing in professional managers/ administrators having non-medical backgrounds.
The Tory and New Labour parties established an internal market model as a plan to bring better quality healthcare based upon competition, a better investment in the workforce, and savings from efficiency.[iv]
The most sensitive and complex areas of the state-medical profession relationship lie in the areas of:
- Loyalty and accountability of the professions
- Autonomy and priority differences
- Communication channels and diversity of opinion
Loyalty and accountability
The idea of loyalty is intertwined with the idea of corporate accountability.
Loyalty refers to the doctor’s ideological attitude to patient-centred care. Today, doctors’ loyalty is having to straddle the gap between ‘concern for their patients and obligations to the corporations that pay them.’
Accountability refers to doctors’ willingness to accept formal responsibility. There is unequivocal evidence of a divergence in the accountabilities of medical professionals. Clinicians have strong bonds with their professional bodies (the Royal colleges and BMA) on the one hand, and to the State (the manager, deaneries and protocols) on the other. This conflict reflects a complex interaction of interests and fears.[v]
Management of this complex situation requires a sensitive awareness and informed interaction between clinicians and managers. The BMA has published guidelines to provide medical directors help in their post.
Medical directors consider a key part of their role to be bridging alternative perspectives. They are accountable to medical professional bodies and to the management board, including the chief executive. It is, however, the chief executive who is accountable to the chairman and non-executive members of the board for ensuring that its decisions are implemented and that the organisation works effectively.[vi]
Junior doctors are more accepting of the managerial role and more adherent to the guidelines and protocols.[vii]
There is now a noticeable trend for British doctors to consider management and administrative roles within health services. This should, ultimately, improve the communication between doctors and central government. Evidently, the NHS is moving toward a plurality of stakeholding, notably among clinicians, managers, public and politicians, with little room for elitist or class ruling.
The international situation
Growing pressure upon the medical profession, from the public and politicians, has transformed the state-society relationship in many countries. Underlying these transformations are a rising general education among the population, rapidly growing mass communication technology – and global capitalism.
Global capitalism has brought a business model marketing-competitive structure into the health system – and new insecurities. With this new era of global capitalism “public health services will have to compete to attract workers and the employment is less secure even when it is better paid; exploitation is intensified, even when incomes are higher”.[viii]
The enrolment of European doctors into the management aspect of health organisations predates that of British doctors. Note, that there is considerable similarity in the British and Danish medical institutions: a history of command-and-control policy and a newly-developed state control national health system.[ix]
In Finland, medical professionals have, relatively willingly, taken to involvement in management and gained the requisite communication skills. ix The Finnish health system aims to increase productivity with a stronger, more effective management committee. The idea is that, eventually, the medical and nursing professions (the main two health cadres) dominate hospital management. ix
Transformation in medical institutions is even more dynamics in modern China.[x] From a communist-controlled health system, that abolished professional power, to corporatism – or a Confucian medical organisation – and later to Clientelism. The latter is still the dominating relationship between state and medical professionals, facilitating communication and policy implementation in the Chinese health system. However, the power is still in the hands of the State, with a little autonomy for doctors within their local authority.
The main reasons for these changes in China’s health system and in the relationship-style were globalisation and a rapid economic development. The societal culture of Chinese-Confucians being complete loyalty and obedience, combined with a communist political structure, means that the medical professions express little, if any, resistance to the State’s policies.
Autonomy and priority
Introducing management professionals - chief executives and non-executives – as decision makers has created an uneasy environment within the NHS. The NHS chief executive is now the champion who takes leadership and wields significant power. viii
The main concern now, as historically, to the profession, is loss of control over their work. It is regarded as an incidental to the priority of the State to save money. One example is that, since 1985, general practitioners are not at liberty to prescribe high cost drugs. ii
A misconception of state managerialism is incentivisation of “higher performance … [by] financial reward”.[xi] This aims to boost frontline staff within the NHS and provide a higher overall standard of healthcare.
This logic is opposed by voices in the medical profession as unimaginative and detrimental to the to the image of care: motivation within (and recruitment to) healthcare settings is not about material self-interest, but involves ethical/ moral attitudes as a person;[xii] money is a ‘hygiene factor’ only, though it is fair to say – as suggested by Le Grand (2003) – that knights and knaves co-exist within NHS, at different levels and among all the groups, whether they be medical professionals or managers.[xiii]
Another management-mode misconception is that of regarding the NHS as a service that can be decided and delivered in the fashion of a corporate organisation, wherein success is measured economically and its achievement attained by following rigid protocols. The priorities of the medical and nursing professions become subordinated to other sterling outcomes, and patient care is affected.[xiv] These variations in attitude and thinking demonstrate the ideological divergences behind the tense relationship, plus the misunderstanding and in some cases the breakdown of trust between these groups.[xv] There is a perception amongst doctors, and scholars of the political economy of the health service, that central government health policies show insufficient empathy or regard to their thinking on these matters.
The chairman of the BMA’s Consultants Committee expressed concern, in the Wanless Report BMA (2007) about patient care and current medical practice, which slow-go policies were at fault for the low productivity of medical specialists. [xvi]
Paradoxically, while there is thoroughgoing evidence that command-and-control is an outmoded model of medical professional practice, there is a growing fear and sense of threat of a paternalistic NHS culture becoming imposed by State management. [xvii]
While managers are the major players in framing policy, they do not and cannot control implementation without cooperation from clinicians. For this reason, it is crucial that there be mutual respect and rapprochement on key issues.
The international situation
A management system run by professional managers, whether from medical or non-medical backgrounds, is now common practice in many countries. Danish doctors actively participate in reform and show capabilities in management and administration.ix In China, doctors have been less concerned about professional autonomy, and have readily accommodated to changes issuing from global capitalism, demands for technical efficiency and cost control.
By contrast, in the USA, the state has had but a very limited effect on health organisations. Clinicians and medical insurance companies have the ultimate power on health policies, and the best recent example of that power is the rejection of the Clinton Plan.[xviii]
Communication channels and diversity of opinion
Historically, clinicians have been knowledge specialists in healthcare and have practiced with considerable autonomy from the state. Their view on patient-care and appropriate patient management can vary substantially from the agenda set by managers.
Over the last twenty years doctors have perceived many attempts by the State to re-structure NHS culture to expressly undo clinical autonomy. The very incomplete success of these measures has increased tension between clinicians and managers.
Where top-down policy implementation is concerned, clinicians have weighed-up policies before practically effecting them, demonstrating the power of bottom-up influence by the agent-practitioner.[xix] This phenomenon demonstrates the lack of interpersonal proficiency among these two broad groups of professionals and reflects the structural differences of their respective institutions.
When this author reviewed consultants’ responses on health reforms through the BMA survey, the demoralising and adverse effect of malcommunication between the two power groups was unmistakeable.
“Four out of five leading hospital consultants in England [81%] say they have initiated changes to improve patient care in the last year, but many are being hindered by ill-thought out government health policies”.
So, it appears that health reforms have acted as a block to innovation in patient care. xvi
The political masters could do more to listen and senior doctors could participate more constructively and pro-actively. Dr Fielden (BMA, 2007) makes the observation that there is “… a culture of fear in the NHS and doctors are under severe pressure to meet targets and keep their mouths shut”, despite the reality that doctors, “… want to be at the forefront of health reforms, both locally and nationally, to ensure government policy has clear benefits for patients.”
At higher education level, more radical changes are doubtless required to educate both medical students and students of business/ administration in the very human – but much neglected – art of communication.
The international situation
Medical education has been overhauled in many universities and medical schools in the United States, the United Kingdom, Germany, Australia, and the Netherlands to include accounting and managerial skills. Training has also been modified and clinical auditing, for example, has become a regular even compulsory practice in the United Kingdom, the United States, Germany, and Belgium.[xx]
Conclusion and recommendations
The substantial issues are, one, deep-rooted shortcomings in the culture and regulation of clinicians and, two, serious flaws in the management and capacity of the NHS. iii
Bringing clinically experienced practitioners to the role of healthcare management appears to be a constructive measure for rapprochement, bottom-up innovation and quality assurance. The ultimate beneficiary is, of course, the patient.
This measure needs proper envisioning and translation, to overcome the concern of genuinely interested doctors who, nonetheless, wish to avoid a negative relationship with colleagues and detachment from clinical practice and to retain a patient-centred commitment. Getting doctors into NHS management clearly requires care and sensitivity.
This author contends that central government needs to put more investment in human skills and managerial/ administrative education, at the level of medical schools and in the training of junior doctors. This should go along way to closing the gap between doctors and managers. The facility for clinicians to train in such programmes should be promoted and incentivised, as with the MBA health executive programme.
[i] Alderslade, P., Hamlin, C. (1998), “Revolutions in Public Health: 1848, and 1998?”, BMJ 317: 584-591
[iv] Secretaries of State for Health (HMNO 1989), Social Services, Wales, Northern Ireland and Scotland – “Working for Patients”
[v] Morris, Z.S. (2005), “Policy futures for UK health”, Radcliffe press
[vi] BMA (2007), “Guidance for developing the role of medical directors, Clinical and Medical Directors Subcommittee”
[vii] Newman, K., Pyne, T., Cowling, A. (1996), “Junior Doctors and Management: Myth and Reality”, Health Manpower Management, volume: 22, 32-38
[viii] Paton, C. (2006), “New Labour’s State of Health: Political Economy, Public Policy and NHS”, Ashgate
[ix] Kirkpatrick, I., Dent, M., Jespersen P. et al. (2007), “Professional Strategies and the New Public Management in Healthcare: Comparing Denmark and the UK”, Paper presented at Critical Management Studies Conference, UK
[x] Yaning, Y. (2007), “The Changing Relationship between the State and Medical Profession in Contemporary China: Case studies in Beijing”, Department of Public and Social Administration, City University of Hong Kong press
[xi] Pay advisory Bulletin (2002) No.3 for employers’ organisation, October 2002, p2
[xii] Smith, T. (2006), “Changing relationships between doctors and organisations”, BMA-website, winter 2006, issue: 3
[xiii] Le Grand, J. (2003), “Motivation, Agency, and Public Policy: Of Knights and Knaves, Pawns and Queens”, Oxford University Press
[xv] McCartney, S., Brown r., Bell, L. (1993), “Professionals in Health Care: Perceptions of Managers”, Journal of Management in Medicine, Volume: 7, 48-55
[xvi] BMA (2007), consultants’ response on health reforms, Issued Wednesday 07 March 2007
[xviii] Davies, P., Waldstein, F. (1996), “Political Issues in America Today: The 1990s Revisited”, Manchester University press
[xix] Davies, H., Nutley, S., Smith P. (2004), “What Works?”, Evidence-based Policy and
Practice in Public Services”, The Policy Press
[xx] Walshe, K. (2002), “The rise of regulation in the NHS”, BMJ 324: 967-970
Dr Kawa Amin is a SpR in care of elderly at King George Hospital