Trends in doctor-manager relationships

Abstract

Management and structural change in the NHS For a quarter of a century after the foundation of the NHS, its main structures stayed largely intact. After 1974, however, reforms occurred increasingly often, culminating in almost perpetual upheaval in the past five years. Three key reorganisations were the introduction of general management in 1984, the opening up from 1991 of an internal market, and the repeated rounds of performance and accountability initiatives after the election of a “new Labour” government in 1997. The shifting patterns of doctor-manager relationships over these periods can then be examined in terms of two key issues—how the relative influence of doctors and managers has changed and what were and are the main determinants and focuses of managerial agendas. Relative influence of doctors and managers From the early days of the NHS, doctors rather than managers (then, tellingly, officially called administrators) had dominant and pervasive influence. The shape and distribution of services arose from an accumulation of individual clinical decisions, with managers supporting and administering these arrangements rather than seeking to challenge them.15 The introduction of general management in 1984 provided a focus for financial administration but left patterns of clinical care—and hence influence from doctors—largely untouched.6 However, the development of the internal market in the early 1990s, the subsequent increasingly strident set of demands about service delivery and accountability, and most recently the introduction of clinical governance have all enabled managers to drive through substantial restructuring of clinical services, sometimes in the face of outright physician dissent.16 Throughout this period there were many attempts to involve doctors more fully in management activities,9 including the statutory role of the medical director and the development of clinical directorates. Such participation by doctors in management has not been easily accomplished, with medical directors experiencing considerable workload challenges and stress17 and clinical directors displaying high levels of disenchantment.11 Thus, despite this rebalancing of power between doctors and managers, a sense often remains among both groups that the important power lies elsewhere, so that a degree of disempowerment is frequently felt on both sides. Aspects of clinical autonomy7 Control over diagnosis and treatment—Decisions about which tests and examinations are appropriate; the drugs and procedures to be used; who to refer and where; and the nature of follow up care Control over evaluations of care—Judgments about the appropriateness of either the care of individual patients or the overall patterns of care provided Control over nature and volume of medical tasks—The extent to which doctors are left to determine their own priorities, workloads, and supporting activities, including the location and timing of these activities Contractual independence—The extent to which doctors have unilateral rights to engage in extracurricular activities such as teaching, research, royal college or BMA business, commercial consultancy, or private practice (Credit: SIMON FRASER/SPL) Determinants and focus of managerial agendas Administrators in the 1970s and early ‘80s tended to be reactive to emergent problems rather than proactive in developing corporate objectives. The key clients in terms of determining managerial activity were senior clinicians rather than service users.18 At the same time, political control was relatively loose, although this tightened in the 1980s as general management provided a focal point for political leverage. The emergence of (even relatively attenuated) competitive forces in the 1990s drove managers to be more proactive in developing strategic objectives and plans to meet these. 19 Thus managers increasingly had a corporate outlook, seeking to maintain and develop their own institutions' facilities. As the market was replaced by supposedly more cooperative forms of working—supplemented by central diktat, the national performance framework, star ratings, and a plethora of regulatory and inspection mechanisms—the focus of senior management changed such that they are now seen more as agents of government than as facilitators of professionally driven agendas. Although these changes are hugely important, they should be seen as gradual shifts and accumulations over time rather than as stark discontinuities resulting from specific policy initiatives. Furthermore, although doctors resisted (sometimes vociferously) many of the underlying changes, they quickly assimilated the changes and their corollaries12 and seemed to have little desire to revert to prior arrangements.8 In this there may well be substantial age related effects—for example, junior doctors are keen to be more involved in management roles.20 Specialties may also differ, with some—such as radiology, pathology, and psychiatry—being more sympathetic to a managerial culture.13 The changes, however, have not been without consequence for professional practice.