Intended for healthcare professionals


Doctors and managers

BMJ 2003; 326 doi: (Published 18 January 2003) Cite this as: BMJ 2003;326:116

A constructive dialogue has to replace mutual suspicion

  1. Nigel Edwards (nigel.edwards{at}, policy director,
  2. Martin Marshall, professor of general practice
  1. NHS Confederation, 1 Warwick Row, London SW1E 5ER
  2. National Primary Care Research and Development Centre, University of Manchester, Oxford Road, Manchester M13 9PL

    The rejection of the contract for UK consultants has brought the relationship between doctors and managers into sharp focus. The BMA and consultants got a bad press. Managers were characterised as everything from the unwilling pawns of a malign government to intellectually second rate, morally bankrupt outsiders who do not understand health care and exist only to frustrate good patient care. This caricature of doctors fighting with managers is strange as many of the managers who would have been responsible for implementing the contract were in fact doctors. Some serious work by managers and doctors is needed to understand the nature of the problem and develop new ways of working together.

    It is helpful to see this latest upset as part of a deeper problem, which has a long history. In 1920 Sir George Newman, the first chief medical officer at the Ministry of Health, speaking to the BMA, said: “The state has seen in the profession a body insistent on the privacy and individuality of its work, the sanctity of its traditions and the freedoms of its engagements. The profession has seen in the state an organisation apparently devoted to the infringement of these traditions and incapable of putting anything worthy in their place. It has feared the imposition of some cast iron system, which might in practice make the practitioner of medicine servile, dependent and fettered.”1 The introduction of managerial reforms in the 1980s and the split between purchaser and provider in the 1990s highlighted this tension further.

    The tension may reflect real and important differences in the way that doctors and managers see their roles and responsibilities, which means that important issues, such as accountability, the use of guidelines, targets, and finance are approached in quite different ways. This may be the result of the different training and beliefs that underlie the two disciplines and which the education and experience of both groups tends to reinforce. As the BMJ has noted before, longstanding unhappiness prevails in the medical profession in many countries, which is related to a change in the expectations placed on doctors and the extent to which this is different from the original conception of the job or “psychological contract” they signed up for.25 This unhappiness is perhaps being taken out on managers since from a doctor's perspective they are such a visible manifestation of the problem.

    This problem is a fundamental issue for the NHS because of the pivotal role and influence that doctors have in the organisations in which they work. We are cautious of military or sporting metaphors in management, but in this case the lesson that teams or armies that do not enjoy the full commitment of key members will fail sooner or later is supported by studies of organisational failure6 and a recent examination of failing hospitals.7 If not addressed, the problem threatens individual institutions, the successful implementation of the health service reforms, and perhaps even the future of the NHS.

    Once we have identified clearly the nature of the problems, the next step is to start to look for solutions. Many of those proposed have been simplistic, impractical, and strikingly free of evidence. The BMJ will be devoting the issue of 22 March 2003 to the relationship between doctors and managers, and a companion edition of the Health Services Journal will be published on 27 March. Although time is short and we cannot promise publication, we would be interested in submissions describing the relationship between clinicians and managers and how to improve it. This work will help to inform a summit meeting on 27 March between leaders of the medical profession and organisations that represent NHS management, to discuss a new understanding of how managers and doctors can work constructively together.


    • Competing interests NE is director of a charity that has received grants for work on improving relations between management and the medical profession.


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