Building a successful partnership between management and clinical leadership: experience from New Zealand

Recent New Zealand studies have shown important progress in addressing a key issue facing all health systems: the gap between clinical culture and governance or managerial culture. 1 2 The key terms in this progress are partnership, quality, clinical leadership, and professionalism.

Three factors have been important. Firstly, New Zealand—with a national per capita income some 20% below the mean for member countries of the Organisation for Economic Co-operation and Development—has had to make difficult choices about health priorities. This has compelled greater collaboration between clinicians and management. In primary care, major budget management—of drugs, for example—is being seen as a new form of clinical autonomy. 2 3

Secondly, the Cartwright inquiry of 1988, perhaps New Zealand's equivalent of Britain's Bristol inquiry, played a key part in sensitising the medical profession to the need for greater collective professional accountability. The inquiry has also been a critical factor in the promotion of a culture of quality.

Thirdly, the commercially driven reforms of the 1990s, perhaps more radical and damaging than the reforms in Britain, led to a major shake up of the clinical culture. In some secondary care settings a widening gap between clinical and management cultures led to open conflict. 4 5 However, in other settings managers who were more health oriented collaborated with clinicians to build the working partnerships that are now being generally adopted.1

The formation by a new centre left government in 2000 of fully integrated district health boards has further promoted this partnership, perhaps best described as a “convergence of cultures.” This convergence has required from the governance or management culture a shift from a preoccupation with resource management to health outcomes as the “bottom line” of the organisation. This commitment is reinforced by the contract between government and district health boards, as set out in the New Zealand health strategy.6

Convergence also means the acceptance by clinicians of a key role in managing resources and in achieving the organisation's goals. Both cultures need to move—and are moving—towards a more trusting relationship that is based on a shared vision and on shared goals of better outcomes for patients and communities, within limited available resources. This partnership is a critical factor in quality improvements reported in New Zealand studies. 1 2 7

(Credit: KEVIN NICHOLSON/BMJ)

Clinical leadership is playing a key role in this partnership. But clinical leaders, although appointed by management, remain clinicians. They have not crossed to the “other side.” They are being helped by the relatively new Clinical Leaders Association of New Zealand. 1 2 Through clinical leadership, the New Zealand health system may be implementing what the sociologist Eliot Freidson calls the “third logic,” an alternative to market or bureaucratic models.8 In contrast to the failings of these models, a new professionalism may be emerging—but with clinicians becoming collectively and professionally accountable for both the quality and cost of their decisions, in a new and successful form of clinical autonomy.