Education And Debate

Management for Doctors: Handling the conflicting cultures in the NHS

BMJ 1995; 310 doi: (Published 22 April 1995) Cite this as: BMJ 1995;310:1054
  1. James Drife, professora,
  2. Ian Johnston, director of hospital servicesb
  1. a Department of Obstetrics and Gynaecology, University of Leeds, Leeds LS2 9NS
  2. b General Infirmary, Leeds LS1 3EX
  1. Correspondence to: Professor Drife.

    Case study: working to contract

    St Duncan's and St Kenneth's United Hospitals Trust, like other hospitals, is now funded by contracts which specify how much work is to be undertaken in each specialty or subspecialty. Like many hospitals in the real world outside London, the trust has only one major purchasing authority. In the case of one specialty, ontological surgery, the volumes set for the contract are reasonable but tight. The ontological surgeons (all men, incidentally) have always run an excellent service, including giving dates for admission within a few months to outpatients. During the year they have improved on their already impressive performance, and waiting times for admission are now a matter of weeks. The problem with this is that the hospital is now well ahead of contract and the health authority can afford to pay only for the agreed contract volumes. The health authority has also said that if it did have more money it would want to use it in specialties that were having difficulty with waiting lists.

    The managerial culture requires, broadly, that the contract numbers are adhered to, and the consultants have been required to restrict their activities. The doctors, however, know that there are patients waiting for treatment. They want to treat them and they believe that the health authority's problems are not theirs. They feel that if other specialties have excessive waiting lists they should be required to get their house in order before being given extra funds. The managers and the doctors have reached an impasse.

    The NHS is a multicultural society. Each profession—medical, nursing, management, and many others—has its own identity, culture, and subcultures. Within medicine there are various specialty groupings, such as surgeons, psychiatrists, or general practitioners, with different characteristics and aims. The potential for conflict arising from cultural differences is almost limitless—a problem not, …

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