Education and debate

Trends in doctor-manager relationships

BMJ 2003; 326 doi: 10.1136/bmj.326.7390.646 (Published 22 March 2003)
Cite this as: BMJ 2003;326:646

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  1. Huw T O Davies, professor of health care policy and management (hd@st-and.ac.uk)a,
  2. Stephen Harrison, professor of social policyb
  1. a Centre for Public Policy and Management, University of St Andrews, Fife KY16 9AL
  2. b Department of Applied Social Science, University of Manchester, Manchester M13 9PL
  1. Correspondence to: H T O Davies

    Doctors are discontented, and one reason is their dissatisfaction with their relationship with managers. This article explores how management structures have changed over the past few decades and explains how a better understanding of the dynamics behind healthcare delivery might help to ease the tensions between doctors and their managers

    Doctors are increasingly unhappy in a changing world.1 Although the reasons for this are broad and far reaching,2 some of this discontent results from the doctor-management interface.3 The rejection of the new NHS consultant contract in England and Wales seemed to crystallise this discontent, hinging as it did on issues of professional autonomy and a lack of trust.4 But such a crisis should not be seen in isolation. We can better understand the current predicament by, firstly, reviewing the history of the doctor-manager relationship in the United Kingdom over recent decades, and in particular seeing this relationship as shaped by the changing structural arrangements from within which health care is delivered. Secondly, such changes are in turn part of an international phenomenon, related in particular to perceived crises of healthcare funding and consequent attempts to improve efficiency.

    This overview aims to summarise each of these elements. We draw on a recent review of international developments,5 pre-existing reviews charting changes in the doctor-manager relationship in the NHS 6–8, and a range of more recent empirical studies.9–14

    Summary points

    One reason for the high level of doctors' discontent lies in the doctor-manager relationship

    Such discontent reflects international trends that have led to diminished autonomy and a reduced dominance of doctors in health care

    In recent years the “scientific-bureaucratic” model of healthcare delivery has risen to prominence

    This model emphasises external robust evidence over personal professional expertise, with patterns of care driven more by …

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