Managers and clinicians in health and social care are committed professionals working towards a common goal - achieving better patient outcomes - but tensions in the relationship can risk getting in the way of driving forward service improvement.
Managers and clinicians, in whatever area of health and social care they work, are on the same side. Both strive to provide the best possible patient experience of care in an increasingly challenging environment, bringing to their roles enormous professionalism, experience and commitment. However, as in all relationships, unhelpful tensions between the two can - and do - arise, not least because within the overriding desire to improve services, conflicting priorities sometimes emerge.
So what of the history of this relationship? The griffiths report (1983) heralded the age of general management in the NHS. A move towards managers having operational control at every level of the organisation and relieving clinicians of strategic responsibility was seen as the way to transform healthcare to resemble successful private and commercial organisations.
Clinicians may not have agreed. Literature confirms that non-engagement between themselves and managers is a longstanding, multi-factorial and international problem. A 2007 review from the Health Foundation noted:
“Different health professional groups largely inhabit separate hierarchies and networks, often with surprisingly little inter-communication. Thus, different professional groups often do not define quality in the same way. Moreover, the processes of determining what constitutes good or quality practice within an individual profession are complex and sometimes divergent between different professional groups.” (Davies et al. 2007).
Change is a constant in health and social care. In more recent years there has been an increasing importance placed on clinicians working in multidisciplinary teams and across professional and organisational boundaries. Indeed the High Quality Care for All report from Lord Darzi put clinical leadership at the heart of improving the National Health Service (NHS) (Department of Health 2008). In some cases, such as at Hinchingbrooke Hospital, Cambridgeshire, clinicians were put in charge, as it was deemed that they understood what worked best, and that giving power back to them was the way to drive up productivity.
This change in emphasis is supported by a growing body of evidence, which shows that clinical leadership improves quality and outcomes for patients (Mountford and Webb 2009). Kirkpatrick and Veronesi (2012) found that those NHS hospital trusts with larger proportions of doctors on their boards were more likely to achieve high quality ratings, lower morbidity rates and higher patient satisfaction.
The evidence also shows a clear link between an organisation’s performance and a good level of engagement between clinicians and managers (Spurgeon et al. 2011).
Where are we in 2015? The endless cycle of reform in the NHS has not been helpful. Structural change within any organisation almost invariably leads to tensions, and one of these strains has been on the relationship between clinicians and managers, which has been described as ‘fraught’ and ‘tense’ (Mountoute 2012).
A small survey of just over 200 managers, carried out by IHM recently, confirms this. Nearly three-quarters of managers (73%) said they thought the relationship between the two groups of professionals could be defined as “a partnership with areas of tension” or “a relationship of tolerance with frequent tensions”. A similar number (73%) thought the relationship would stay the same or get worse over the next five years (Institute of Healthcare Management 2014).
Isolated Versus Powerless
The differing ways in which the two professions approach the challenge to improving health contribute to the tensions between them. Clinicians focus on the patient in front of them, aiming to offer that individual the best healthcare they can. But they can be frustrated by, among other things, financial constraints.
Being a doctor often does not feel powerful, as the 2012 King’s Fund report Leadership and engagement for improvement in the NHS: together we can noted:
“They may have no budget, no status to make demands on the administration, no power to hire and fire, and little influence over the organisation’s goals. Yet the decisions they take not only have a profound impact on patients, but on the quality of care, productivity and reputation of their employer.”
The strains on managers are different, but no fewer. Their focus is on broader patient populations and allocating resources within a budget at organisation level to maximise health outcomes. It is a huge job, and, although the days of the ‘heroic leader’ are clearly numbered or even over, sometimes isolating. They are often caught in tensions between financial, safety and quality requirements and, although they may share the same goal as clinicians, the context and structure they work in may have a set of parameters and limitations that the clinicians do not fully appreciate.
Clinicians and managers have both highlighted a number of facilitators to fostering a positive relationship. They include trust, mutual respect, support, accessibility, visibility, good communication, close proximity, mutual interdependence and friendship (Mountoute 2012). Identifying and listing positive facilitators is easy. However, successfully implementing them in a working environment is much more difficult.
Calls to Action
Without the engagement of clinicians, it is clear that managers may find themselves fighting a losing battle to implement the required changes to address the improvement agenda. With this in mind, the IHM is making a number of calls to action.
One way for clinicians and managers to explore each other’s roles and responsibilities is through paired learning and shadowing initiatives. Paired learning initiatives, such as those piloted at Imperial College Healthcare NHS Trust during 2010-11, invite both clinicians and managers to spend time learning about each other’s roles and responsibilities (Imperial College Healthcare 2015). By spending time training with and shadowing those in different roles, clinicians and managers can better understand one another’s viewpoint when making important decisions.
IHM believes that joint management training programmes and events should support these initiatives. Clinicians, like managers, need development and support. The IHM survey suggested that they would benefit, in particular, from training in managing staff and budgets, business planning and organisational change (Institute of Healthcare Management 2014).
It will also be important to create working environments that encourage informal interactions between clinicians and managers to help build trust and interdependence between the two professions.
Small, informal changes in the working environment have the potential to improve the clinician-manager relationship. Close proximity to one another can lead to relaxed, spontaneous contacts outside of the formal working setting. Sharing an office, being down the corridor or sharing a kitchen area have all been cited as possible ways to enhance accessibility and cultivate strong relations (Mountoute 2012).
In the past, doctors have been accused of cynicism and suspicion regarding managerial motives (Wilkinson et al. 2011). Frequent informal interactions can help alleviate these uncertainties and build trust between professions who are ultimately striving to achieve the same goals.
IHM believes that the involvement of doctors, nurses and other clinicians in leadership roles, working closely alongside their managerial colleagues, must also be a priority for the current and successive governments in the UK. An organisation as large and complex as the NHS cannot be run without high-quality management and leadership. People in those roles must be trained, empowered and valued whatever their background.
It should also be recognised that individual clinicians and managers bear some responsibility for deciding on the changes they can make to improve their relationships with one another.