Two years ago today, Robert Francis QC published his report into the failures of care at Mid Staffordshire NHS Trust. The report found that one of the contributing factors was a focus on finances at the expense of patient care within the trust.
In this election year, the NHS is bending under what is in effect a frozen budget, while trying at the same time not to lose its focus on patients. Cracks are beginning to show. We don’t have to look too far to see what can give when cost containment becomes a most pressing consideration.
The current challenges in A&E in many parts of the country can be traced to a variety of capacity issues in different parts of the health and social care system (read: cost and investment constraints ). We can expect more of this, as ‘easy’ savings are squeezed from the system and only difficult choices remain.
At the heart of the NHS lie decisions and trade-offs that seek to reconcile the irreconcilable: perennial tensions between cost, quality and access.
Making, communicating and enacting these decisions within the constraints of policy and regulatory frameworks is the day-to-day business of NHS managers (both clinical and non-clinical). But such work is enmeshed in a complex social web of interactions and relationships between managers and clinical staff, particularly doctors.
Managers and doctors are typically conceived of as rather distinct groups of people. Perhaps they have some common goals, but they also often have different ways of working, different incentives and different tribal loyalties. Indeed, the Francis Report drew attention to the gulf between clinicians and managers within Mid Staffordshire and the NHS more generally. These key groups are also shaped by different sets of assumptions about how the world is or ought to be, and a wariness or even suspicion about the knowledge, capacities and motives of others. Struggling to reconcile these differences and tensions around often shared (but sometimes sharply divergent) objectives is central to managing doctors and doctors managing.
Previous research , even in the days of significant real-term investment in the NHS, certainly found tensions and suspicions between these two key groups. But how are things now, two years after the Health and Social Care Act, in austerity Britain, in a cash-strapped NHS and post-Francis world?
It would be surprising if those tensions have eased, and there are reasons to suspect they may have not.
When the BMA annual meeting voted in 2013 that managers should be subject to professional regulation “so that they can be held accountable for their actions and omissions”, one sensed genuine frustration, as well as suspicion amongst doctors that managers were doing the bidding of political masters. But magic-wand solutions cannot replace the painstaking day-to-day work of building better local interactions.
Yet how do we accomplish this when we know relatively little about the troubled professional relations at the heart of the NHS?
Amid this complexity and uncertainty sit clinical managers. A keystone of policy for some years now has been the encouragement of greater engagement of clinicians – especially doctors – in managerial roles. But what becomes of those who take up the challenge? Do ‘doctor-managers’ remain doctors at heart or adopt the views and methods of non-medical managers? Or are they in the process of becoming new hybrid professionals who can genuinely bridge clinical and managerial goals?
We still know surprisingly little about these new roles and identities, and the emerging professional relationships that ensue. And there is much to uncover. Are relationships between doctors and managers improving or getting worse, and how, and why? And what – if anything – can we do to accentuate positive trends and ameliorate the dysfunctions?
Addressing these challenges will require more sophisticated insights to a range of further questions: how do managers and doctors differ in their assumptions and presumptions about care and its organisation? In what practical ways do managers manage doctors, and how do doctors manage being managed? And given the current policy direction to encourage more clinicians into management, can clinical managers more effectively ease the cost/quality/access tensions that permeate our health services?
There is much to find out – from reviewing fieldwork carried out more recently in the NHS, and through gathering fresh data. Indeed, new work on management culture in the NHS funded by The Nuffield Trust – a mixture of literature review and fresh empirical work – is to be carried out by the end of 2015 by the University of St Andrews.
My suspicions are: that supportive words across the doctor-manager divide may mask a more complex and more conflictual reality; that these tensions are becoming starker in the face of ever-more-stringent financial constraints and complex organisational challenges; and that senior managerial roles (both clinical and non-clinical) are losing whatever appeal they may once have had. But let us see where the data takes us.
Huw Davies is a Professor of Health Care Policy and Management at the University of St Andrews. Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors’ own.
To find out more about The Nuffield Trust's new work on NHS management and culture with the University of St Andrews, or offer your views, please contact Ruth Thorlby at the Nuffield Trust or Huw Davies at the University of St Andrews.
Davies H (2015) ‘Managing doctors, doctors managing: Troubled relations at the heart of the NHS’. Nuffield Trust comment, 6 February 2015. https://www.nuffieldtrust.org.uk/news-item/managing-doctors-doctors-managing-troubled-relations-at-the-heart-of-the-nhs