Intended for healthcare professionals


Views of doctors and managers on the doctor-manager relationship in the NHS

BMJ 2003; 326 doi: (Published 22 March 2003) Cite this as: BMJ 2003;326:626
  1. Huw T O Davies, professor of health care policy and management (hd{at},
  2. Claire-Louise Hodges, research fellowa,
  3. Thomas G Rundall, Henry J Kaiser professor of organised health systemsb
  1. a Centre for Public Policy and Management, University of St Andrews, Fife KY16 9AL
  2. b Division of Health Policy and Management, University of California, Berkeley, CA 94720, USA
  1. Correspondence to: H T O Davies
  • Accepted 4 March 2003

A well functioning relationship between doctors and managers is crucial if government plans for “modernising” the NHS are to deliver real service improvements. 1 2 We aimed to shed some light on current perceptions of the doctor-manager relationship by examining areas of convergence or divergence of views among a large sample of doctors and managers in the NHS.

Participants, methods, and results

We conducted a postal questionnaire survey in NHS acute trusts across Great Britain during the summer of 2002. The survey included a census of chief executives and medical directors (from 197 trusts), together with a stratified cluster sample of both medical and non-medical managers at directorate level (clinical directors or their equivalent and non-medical directorate managers or their equivalent) randomly selected from 75 trusts. Comparisons between these different role groups form the central part of the analysis; we assessed variations across all four groups using χ2 tests.

We received replies from 103 chief executives, 168 medical directors, 445 clinical directors (or equivalent), and 376 non-medical directorate managers (or equivalent). The response rate was 66% at board level and 73% at directorate level, giving a total of 1092 respondents.

Overall, chief executives were the most optimistic about the state of doctor-manager relationships, and clinical directors the least. About three quarters (78/103, 76%) of chief executives rated the quality of current doctor-manager relationships as 4 or more on a scale of 1 (poor) to 5 (excellent), compared with just 37% (164/443) of clinical directors. Further, 78% (80/102) of chief executives thought that doctor-manager relationships would improve over the next year, compared with just 28% (123/439) of clinical directors (indeed, 26% (113/439) of clinical directors thought that the relationships would deteriorate). Differences across all four groups were significant at P<0.01.

Questions about specific aspects of the doctor-manager relationship showed some areas of good agreement but also highlighted issues where views diverged significantly between the four groups (table). Only rarely was the most obvious divide between those medically qualified and those not. More often, the differences were between senior managers (board level) and middle managers (directorate level). Most striking was that clinical directors often seemed to have views markedly divergent from—and much less positive than—the views held across the other three groups.

Agreement with statements about doctor-manager relationships among 1092 survey respondents. Values are the percentages (numbers) of respondents in each group who agreed with given statement

View this table:

Typically, clinical directors were the least impressed with management and the most dissatisfied with the role and influence of clinicians. For example, whereas almost all (95% (610/640)) chief executives, medical directors, and directorate managers agreed that “managers allow doctors sufficient autonomy to practise medicine effectively,” 27% of clinical directors disagreed. Further, as a group, clinical directors were less likely (P<0.01) than each of the other groups to agree that “management staff in this hospital are consistently of high quality” (53% v 77% (average across the other three groups)), that “managers are well versed in clinical activity” (47% v 81%), and that “doctors have sufficient influence on hospital management” (48% v 85%). Indeed, for almost all positive statements about doctor-manager relationships at least a quarter of clinical directors disagreed. The only statement that received near unanimous approval from clinical directors (90%) was “medical staff in this hospital are consistently of high quality.”


Doctors and managers in the NHS are often dissatisfied with doctor-manager relationships but differ in their views depending on their role in the organisation. In general, senior managers were more positive than staff at directorate level, and lay managers were more positive than medical managers. Clinical directors (or those in equivalent roles) were easily the most disaffected, with many holding negative opinions about managers' capabilities, the respective balance of power and influence between managers and clinicians, and the prospects for improved relations. Unless such divergence is addressed, further difficulties in delivery of the government's ambitious agenda for modernisation are likely.3


Contributors: HTOD and TGR designed the study; C-LH collected the data and did the analysis; HTOD led on writing the paper, with substantial contributions from TGR and C-LH. HTOD acts as guarantor.


  • Funding Nuffield Trust, London, and the Commonwealth Fund, New York. The guarantor accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.

  • Competing interests None declared.


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