A troubled role
Clinical directors have seemingly never been terribly happy. Numerous studies show that doctors often struggle with this managerial role. More problematically, while some clinical directors actively choose the role, others have it foisted on them.
Even those who initially welcome the opportunity can find it tough. Clinical directors often have to juggle a heavy clinical workload with the day-to-day challenges of managing a clinical service. They work with management colleagues who are also multi-tasking, and who often have high turnover: no sooner are relations negotiated than they get disrupted.
On top of these challenges clinical directors also face the hostility of some medical colleagues: ‘going over to the dark side’ is a persistent refrain. In fact, losing clinical credibility and clinical skills is a real fear for many clinical directors.
So what does our study on the relationships between doctors and managers add to this fairly bleak picture?
Pessimistic about the future
We surveyed both non-medical managers and doctors in management positions in the second half of 2015, and added to the findings with interviews and a focus group. We included managers and medical managers at board level (chief executives and medical directors) and at directorate level (directorate managers and clinical directors).
The findings from the 150 clinical directors included in the study should be a cause for real concern: on almost every issue, clinical directors were significantly less positive about working relationships between doctors and managers.
Compared to other managers, clinical directors were less optimistic and more pessimistic about the future of their working relationships:
- Clinical directors were less likely to believe that relationships would improve in the coming year (only 35% thought so, about half the rate in the other management groups).
- Clinical directors were more likely to believe that relationships would deteriorate in the coming year (51% thought so compared to only 29% of directorate managers, their non-medical equivalent).
Specific bones of contention
When asked about a variety of issues at the heart of doctor-manager relationships, clinical directors took a consistently more gloomy view than other managers. Overall, clinical directors were:
- The least likely to say that the balance of power and influence between management and medical staff is about right (only 44% thought so compared to 70% of chief executives).
- The least likely to say that doctors have sufficient influence on hospital managers (only 46% thought so compared to 81% of directorate managers and chief executives).
- The least likely to say that managers and doctors focus together on patient need (only two thirds of clinical directors thought this, compared to seven out of eight in the other managerial groups).
- The least likely to say that managers put clinical priorities ahead of financial ones (only 43% of clinical directors said this compared to 96% of chief executives).
These headline findings give few grounds for optimism, but the detail is very variable.
Glimmers of hope, amid a sea of concerns
We did hear reports of good working relationships between doctors and managers in many acute trusts, and of some improvements over time: “when I was clinical director the unit managerial structure was chaotic and hopeless, and I had no time in my role to perform a managerial role: so, a disaster. Now, the move toward time allocation and quality staff has made a massive difference.”
Nonetheless, comments by clinical directors suggest that divisions between managers and doctors were an ongoing and live issue: “many consultants wouldn't believe that the managers want best care for patients, such is the depth of paranoia” and “clinical and management teams work to different agendas”.
More commonly, comments suggested that relationships were under strain not primarily because of hostility between the two groups but because of the pressures on both managers and doctors. The complex challenge of managing health care made for few easy answers: “it's very difficult just to identify what really represents 'for the best', unless you're very narrow-minded and can only see one point of view!”
Moreover, some clinical directors were candid in recognising that some doctors made poor managers or were unable to take a perspective beyond their own clinical area: “most doctors are focused on obtaining resources for their own area of interest and rarely step back to see the bigger picture.”
Let’s focus on the hope…
More positively, we heard of some hospitals where a structured programme of training and support has lifted the clinical director role from a frustrating detour for the unwilling to an integral and satisfying part of the career pathway for some doctors. We were told that the lack of a national framework for clinical director posts is contributing to the variation in arrangements across the UK. It might be that hospitals that have been leading the way on developing these programmes could provide a useful template for this.
And what of the future?
This study was carried out before the EU referendum, and so before Brexit discussion swamped the airwaves. The NHS will face specific staffing challenges in the event of a hard Brexit, but in any case will suffer from a distracted government and a policy already creaking under its own contradictions. Yet more must be done to build strong doctor-manager collaborations in the NHS.
What else would help? The past decade has seen a range of local initiatives, including joint training, paired learning and ‘buddying’ or mentoring schemes for doctors and managers. We heard of successful coaching initiatives, and programmes where participants were supported to manage ‘real life’ challenges in their own organisations. Our work suggested that these initiatives are not yet widespread – management training for doctors is common but fewer than one in five clinical directors have paired learning in their trust.
So, there is more to learn about what doctors and managers would find most useful and how to integrate these programmes into working lives. Your suggestions here are most welcome. Essential, even, if these hard-pressed but crucial lynchpins of the NHS are to flourish.
Jeremy Hunt’s remarks this week that “we should today ask whether the NHS made a historic mistake in the 1980s by deliberately creating a manager class who were not clinicians, rather than making more effort to nurture and develop the management skills of those who are” seem likely to reinvigorate the unhelpful historical dichotomy between clinical and non-clinical managers. As the studies show, this has always been a challenging relationship. Yet both managers and health professionals in many trusts have worked hard to foster good working relationships and to overcome their differences in perspective and experience – struggling largely with the challenge of doing so in the external context of the churn of often-conflicting policy and regulatory changes and financial cuts.
Evidence has been aggregating for some decades that a degree of organisational stability and a sustained period of appropriate resourcing without radical policy change are essential to allow complex health care systems to deliver high quality, cost-effective and safe services. Providing these would be the most effective way that Hunt could improve the management of the NHS.
Powell A and Davies H (2016) ‘ What does the future hold for clinical directors in the NHS?’. Nuffield Trust comment, 1 December 2016. https://www.nuffieldtrust.org.uk/news-item/what-does-the-future-hold-for-clinical-directors-in-the-nhs