Agreeing objectives could help doctors and managers work well together

EDITOR—Doctors and managers obviously need to work together. To have two powerful groups not working together is likely to frustrate the efforts of both and to damage the service offered to patients. Why then is the relationship between doctors and managers often strained and currently perceived to be at a low ebb? Why is it that two groups, both protesting a desire to put patients at the centre of decision making, often find it difficult to find common ground?

(Credit: KEVIN NICHOLSON/BMJ)

Although doctors and managers apparently agree about the objectives of the NHS, the reality is that the views of the medical profession about its purpose are different from those of managers. This is not surprising given the different backgrounds of doctors and managers.

Doctors are trained in medicine; they tend to be numerate and are trained in the scientific method. They are socialised into a professional model that values both individual and professional autonomy. Many value medicine more highly than they do the NHS. Some perceive themselves as advocates for their patients in the face of governmental and managerial intervention.

Contrast this with managers, who are essentially selected for various characteristics, including good communication skills, ability to create change, and assertiveness, as well as a knowledge and experience of how the NHS functions. Managers have a clear sense of hierarchy and are less concerned with personal or professional autonomy. They recognise lines of accountability and accept that these extend outside their organisation, ultimately to the secretary of state and to government.

How can these two groups be successfully brought together?

To assume that doctors and managers agree about objectives when they meet may be wrong. In practical terms, therefore, it is often worthwhile making certain that objectives are shared before debating the process. If agreement cannot be reached then there is little point in debating process—the debate needs to be more fundamental. But if agreement can be reached about the objective then the collective creativity of doctors and managers working together can be exciting, worthwhile, and rewarding.

“You just don't understand”

EDITOR—Whether this cry is that of a beleaguered health service manager or a consultant who feels that his or her powers have been eroded a little more, the lack of understanding between managers and doctors is manifest.1 Why is this so?

The degrees of certainty and agreement in medicine are often perceived to be greater than they are. Although evidence based medicine informs us that treating hypertension is a good thing, that same evidence will remind us that it is impossible for a doctor to discern whether the patient sat in front of them will be the 1 in 500 people to benefit from the antihypertensive drug on offer. By the time patients have pondered the side effects and remembered something that they were told in the pub it is almost a matter of chance whether they will take the drug—and there are many more barriers to prescribing bendrofluazide.2 Yet, patients with hypertension would benefit from the input of a manager to support the interaction between patient and healthcare system, without which the system will fail.

We argue that the reason these tensions exist lies in the opposing world views held by both groups: clinicians see their work as an art to be expressed in the unique care afforded to each patient, and as such intrinsically immune to the homogenisation of management. But managers' world view consists of precisely that—the broad thrusts of commissioning, audit, and risk management.

Both are right. There is depth and mystery in much of medicine, but to stop there would be inadequate. Sense is needed to cope, assure, and improve. Managers need to understand that the process of dividing into manageable parts has real dangers—a loss of meaning. Doctors meanwhile need to understand that through such division, their complex art can be more easily understood. World views can be different and still be complementary.

We commend the notion of professional permeability. Let ideas spread by osmosis between the groups by seeking out the other's perspective. What about doctors and managers sharing a community of practice?

No—they wouldn't understand.

Should we make managers more accountable to doctors?

EDITOR—General practitioners are in a privileged position to know how the health and social care system as a whole is working. However, many general practitioners think that managers do not pay sufficient attention to their concerns and issues.1 They feel marginalised in decision making. This can lead to conflict, “tribalism,” and dysfunctional relationships between doctors and managers. Steps should be taken to improve this relationship.

One way to do this is to explore the issue of accountability of managers. Although several degrees of accountability of managers exist in the NHS, virtually none relates to a major stakeholder group—that is, the doctors. Managers impose a huge accountability on doctors for performance and use of resources but no routine mechanism is in place for doctors to hold managers to account.

I believe that this should be changed. If doctors sensed that managers also had a degree of accountability to them, then this could transform the relationship. Although managers might view this with suspicion as a “controlling” mechanism, I believe that it could actually improve the relationship and promote trust. It should be doneconstructively and positively, and not become bureaucratic. The elements of accountability would need to be defined in a framework. This would be an instrument that would codify the relationship, expectations, rights, and responsibilities. This, like the doctor-patient relationship, should be based on respect and should be seen as a mutual investment.

The British Department of Health should consider expanding the NHS corporate governance framework to include a formal annual accountability agreement between managers and doctors in trusts. Improving accountability can lead to major improvements in the effectiveness and efficiency of public sector organisation and can deliver radical change.2

Problems in Dutch hospitals resemble those in British hospitals

EDITOR—As in the United Kingdom, relationships between doctors and managers in Dutch hospitals are problematic. The divide between management and doctors seems to exist everywhere, independent of health system characteristics.

Dutch hospitals are private not for profit organisations financed through social and private insurance schemes. Specialists restrict their work to one hospital only and are paid through salaries (35%) or on a fee for service basis (65%). Bringing specialists together in a collective body, the medical staff initiated the integration of specialists in hospitals. Past government policies formalised this integration.1 However, the divide has not diminished. The reality is a strategic control battle between hospital management and the medical staff.2

Unlike in the United Kingdom, the medical profession itself is responsible for the development of practice guidelines, indicators, and external peer review mechanisms (visitatie). This choice has not lessened the problems either. Our research has led to the following insights.

• Integration among professional activities seems more important to enhance coordination than assigning management responsibilities3

• External peer review activities of specialists emphasise managerial rather than clinical problems, thus enforcing the need for managerial solutions on the operational level of clinical care4

• Management styles that promote self-regulatory capacities of specialists seem more promising than the concept of physician managers

• The central coordination mechanism should be the management of expertise instead of further industrialisation of the medical working processes to nurture professionalisation in a hospital.

There is no alternative to professional expertise. Hospital managers should acknowledge this and find management styles based on the acceptance of mutual roles and responsibilities. The reasons for the control battle are obvious. However, both specialists and managers should be wise enough to see that the problems in patient care ask for re-engineering of the clinical working processes.