Intended for healthcare professionals

Education And Debate

Medicine, management, and modernisation: a “danse macabre”?

BMJ 2003; 326 doi: (Published 22 March 2003) Cite this as: BMJ 2003;326:649
  1. Pieter Degeling, professor of clinical management development (,
  2. Sharyn Maxwell, research fellow,
  3. John Kennedy, research fellow,
  4. Barbara Coyle, research associate
  1. Centre for Clinical Management Development, Wolfson Research Institute, University of Durham, Queen's Campus, Stockton on Tees TS17 6BH
  1. Correspondence to: P Degeling

    To break their destructive antagonism over issues of health service modernisation, doctors and managers should engage more directly with nursing and allied health professionals when responding to reform initiatives

    Edwards and Marshall have recently called for constructive dialogue to replace the mutual suspicion between doctors and managers.1 They suggest that the recent tensions over the negotiation of the new UK consultant contract should be seen as part of a “deeper problem [with] a long history.” They propose that doctors' and managers' very different approaches to issues such as accountability, use of guidelines, and finance are the result of each discipline's training, beliefs, and experiences. Finally, they suggest that, left unresolved, these differences have the potential to threaten individual institutions and perhaps even the future of the NHS.

    Summary points

    Calls to modernise health services require health professionals to accept that all clinical decisions have resource dimensions, recognise the need to balance clinical autonomy with transparent accountability, support the systemisation of clinical work, and subscribe to the power sharing implications of team based approaches to clinical work

    There are consistent and marked differences in how medical, nursing, and managerial staff across countries evaluate individual aspects of such a reform programme

    Policy authorities' efforts to overcome resistance to reforms by widening the scope and reach of “top-down” performance management and regulation are self defeating

    What is required is more support for clinicians and others (including nurse managers) to pursue modernised clinical work practices

    Re-establishing “responsible autonomy” as the primary organising principle of clinical work will empower health professionals to strike a balance between the clinical and resource dimensions of care and between clinical autonomy and transparent accountability

    In this article we offer a brief analysis of the wider nature and the essential elements of the reforms being sought by governments. We offer some …

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