Editorials

Doctors and managers: a problem without a solution?

No, a constructive dialogue is emerging

In preparing this theme issue on doctors and managers we were offered many sophisticated descriptions of the origin and nature of the tension between doctors and managers but fewer credible solutions. The fundamental problem is a paradox between calls for a common set of values and the need to recognise that doctors and managers do and should think differently. If managers suddenly became preoccupied with the needs of an individual patient, irrespective of the consequences for others or for their budget, then the health system would collapse. If doctors decided that their principal concern was to ensure the smooth running of the system and the delivery of policy irrespective of the consequences for the patient in front of them, then both the quality of care and public support would collapse. Doctors worry about patient outcomes. Managers worry about patient experience (which includes outcomes, but only as part of a mix to be met out of finite resources). Patients are, again, best served by a tension between the two.

Admitting that this paradox exists is a good place to start. Both Davies and Harrison (p 646),¹ and Degeling et al (p 649)² address this issue. They explore the traditional values of clinicians, such as professional autonomy, the focus on individual patients, the desire for self regulation, and the role of evidence based practice. They compare these values with those of managers: the emphasis on populations, the need for public accountability, the preoccupation with systems and the allocation of resources. They emphasise the importance of the historical roots of the relationship, when hospitals were run by a matron and the small number of administrators knew their place. Systematic management skills were less important when the length of stay for a hernia operation was 10 days rather than six hours, when there were fewer expensive interventions, and when patients had different expectations. In those days the paradox could be ignored but we no longer have that luxury.

Some commentators espouse simple solutions to the paradox. One answer is to deny the legitimacy of any management involvement in clinical issues. This argument ignores the mounting body of evidence that badly managed organisations fail patients, frustrate staff, deliver poor quality care, and cannot adapt to the rapidly changing environment in which they operate. ^{3 4} Both public and politicians are increasingly intolerant of this type of well meaning incompetence and are no longer willing to commit vast sums of money without accountability. Reports from the Bristol Inquiry⁵ and the Climbié Inquiry⁶ both describe how poor management practice is at least as lethal as poor clinical practice. By contrast, we know that good managers can create an environment that supports clinicians and in which high quality care prospers. ^{7 8}

A second species of simple solution is to improve the quality of health service managers. This view seems to be based on the premise that there is a particular problem with managers in health care in comparison with the corporate sector. There is little evidence to support this view and some to the contrary,⁹ though there is no doubt that the complexity of health service management demands exceptional skills.

A third solution is to make managers think and behave like doctors or vice versathis may not be possible or desirable. Doctors and managers have much to learn from each other but each group has a unique contribution, which needs to be respected and valued. There is undoubtedly much more scope for mutual understanding. Education, training, induction, and possibly regulation can contribute to this but we should not pretend there are no differences between the way that doctors and managers see the world.

Our contributors offer some possible solutions in this theme issue but are conscious of the complexity of the situation. Although there is little research, there are examples of organisations where doctors and managers have worked out how to live with these paradoxes. Next week's Health Service Journal carries several case studies of organisations that strive to find a balance between autonomy and accountability and between the needs of individual patients and those of populations. They favour open discussion about a shared purpose and mutual respect rather than conflict, personal abuse, and blame. Both sides aim to find ways to work towards the common goal of better patient care.

Organisations that hold healthcare providers to account, such as governments, can help by ensuring that their approach to planning and performance management does not add tension but allows space for doctors and managers to agree shared objectives. Educators can do more to prepare doctors better for living and working in organisations and equip managers with an understanding of the approach of professionals. Solutions can be found that involve constructive dialogue, improved understanding, and mutual respect, but they have to be discovered locally and continually maintained. This requires hard work, intellectual effort, and the maturity to live with differing points of view. If we do not we will surely fail our patients, the public, and ourselves.

Nigel Edwards, policy director. 

NHS Confederation, London SW1E 5ER (nigel.edwards{at}nhsconfed.org)

Martin Marshall, professor of general practice. 

National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL

Alastair McLellan, editor. 

Health Service Journal, London NW1 7EJ

Kamran Abbasi, deputy editor. 

BMJ

Footnotes

Competing interests: none declared.

Additional articles on doctors and managers working together appear in this week's Health Service Journal and its website www.hsj.co.uk