Involving Clinicians in Management: A Challenge of Perspective

• Abstract
• Introduction
• An Historical Perspective of Medicine in Society
• Challenging the Culture
• Clinicians in Management: The Role and Contribution
• References

Abstract

In the UK, the growth of managerialism within the public sector and the emerging role of managers empowered to enforce government policy have brought to a head inherent tensions between doctors and managers. Historically, both groups have held distinctive perspectives on the nature of their contribution and role in the delivery of health care.

Doctors have typically enjoyed high social and professional status and public support. Consequently, they have derived tacit authority from the community to exercise high levels of discretionary judgement. The dominance of the medical model in health care systems has seemed to reinforce this position. Further, general recognition that doctors are the prime allocators of health care resources has dictated that doctors be closely involved in the health care managerial process.

Attempts to do this, particularly in the 1980s, were centred on financial constraints, were largely unsuccessful and were rejected. More recent initiatives have, in some ways, been slightly less direct as they have involved structural changes in health service operations. These have consequently been rather more successful. Nonetheless, many conflicts of managerial and medical cultures and perspectives remain to be resolved.

As health care reform continues world-wide, the issue of how best to integrate managerial and medical perspectives into health management - and with what success this might be achieved - continues to be debated.

This paper explores these theories, primarily from the perspective of the UK health system, which has seen a series of initiatives aimed at involving doctors more closely in the processes of health service management.

Introduction
The question of involving clinicians in health services management has, at times, been viewed as if it were something that simply must happen and that the solution is merely a matter of facilitating that involvement most effectively. This is especially true in those studies that take an education and training view of roles such as that of Clinical Director. For example, Mitchell (1998) sees management in very functional terms. He acknowledges that clinicians need a management skills and knowledge base as they take on management roles and he provides a list of formal requirements such as formal experience and qualifications, including, finance, budgeting, human resource management, etc, as well as more informal skills such as time management, ability to negotiate, delegation, chairing meetings, etc. He recognises that the latter may be more difficult to teach but suggests that they are in most cases innate.

Other studies such as that by Gatrell & White (1994) similarly list a whole range of management areas in which, they suggest, the provision of training would be valuable. Both sets of papers also argue for management training or exposure to the practice of management to be introduced into the education of doctors at a much earlier stage than it is now. However, this approach seems to overlook the very heart of the problem. As many a frustrated Medical or Clinical Director has expressed it, "we can be trained in any number of management techniques but nothing will change until doctors recognise that they have to become part of a managed workforce". This captures the wider context, that of understanding the role of doctors in management, and points to the issues that will be explored further in this paper, notably the historical, cultural and social factors which have influenced approaches to, and reaction to, attempts to engage clinicians in the managerial process. The paper primarily refers to the UK health system, which has seen a series of initiatives aimed at involving doctors more closely in the processes of health service management

An Historical Perspective of Medicine in Society
"The moment you become a consultant (in Britain), you are omnipotent. You don’t have to pay attention to your colleagues; you don’t have to pay attention to anybody." - Emeritus Professor of Surgery (in Rosenthal (1995))

Although a rather extreme view, and one that would probably be publicly disowned by most medical practitioners today, I suspect most managers will recognise a thread here that leads to some of their own difficulties in attempting to manage doctors.

The power-base of the medical profession is clearly a reflection of its evolutionary path. However, it is a legacy of historical attitudes that are self-sustaining and continue to be felt in modern health systems. The factors that have combined to create this formidable force are discussed by Thorne (in press). She suggests that doctors enjoy relatively high status in most societies and that their expertise, typically expressed as clinical autonomy, is endorsed and legitimised by public support.

Similarly, the medicalisation of the process of health care has resulted in a situation where:
1. a patient’s health problem can only be tackled through the use of medical expertise, and
2. that medicine is then inevitably the dominant health service profession

This may be seen in the tremendous asymmetry of power in the doctor-patient relationship and, indeed, in the relative subservience of the other health care professions in the initiation and management of patient care. Crucially, this imbalance spills over to the way doctors relate to their employers, since doctors are the pre-eminent decision-makers in determining health care priorities and the allocation of organisational resources. An illustration of how an historical power base can become a culture may be seen in the comments of two eminent doctors in 1989. When asked about the role of doctors in management Professor Chantler said, "Doctors must play a bigger part in managing the health service to protect their clinical freedom". And Sir Anthony Grabham suggested that, "Doctors are potentially the best managers in the health services. They have the longest and the best education of all those in the hospitals, the most experience, and are responsible for most of the decisions that lead to expenditure." (Grabham & Chantler 1989). As Pollard (2001) comments, apart from their implicit arrogance, the views are essentially protective and defensive, as if noting a threat on the horizon but one which can be safely navigated. Buchanan et al (1997) has noted that a great many health services’ reforms involve some form of negotiation about the relationship between the medical profession and management. The historical precedents that created the medical power base led initially to doctors existing in a closed sub-culture cushioned from scrutiny and challenge from others within the system. The individualistic culture affirmed by doctors’ training served to support and reinforce this position. The public, too, were keen to endorse such an individual focus, believing that doctors should be concerned primarily with their patients and that health care organisations had some sort of secondary existence with the purpose of facilitating medical activity. Gradually, as one reform or initiative was met with resistance then subsequently incorporated into the status quo, it was recognised that somehow doctors had to be brought into the management process.

Challenging the Culture
As long as the UK health service remained a largely administrative system, conflict with doctors was limited to personality clashes at an individual, rather than collective or corporate, level. Perhaps the first systematic attempt to involve doctors as a group in the management process was the Resource Management Initiative of the early 1980s (Spurgeon 1987). This was an initiative, as the name implies, particularly concerned with the management of resources and an explicit acknowledgement that the flow of resources within the UK National Health Service (NHS) could not be managed effectively without doctors individually determining the allocation of resources through their decisions about patients. The Resource Management Initiative was largely unsuccessful, partly because information systems at the time were not sufficiently developed to provide good financial and activity data such that allocative decisions could be tracked and evaluated. The approach also failed because, unfortunately, it sought to engage clinicians in a management process which was quite overtly directed to restraining use of resources - unlikely to be popular with a culture based on the exercise of clinical freedom in determining the care patients received. However, the initiative is of special interest in the debates about how to involve clinicians in management since it was still working at the level of the individual clinician, by seeking to influence their resource allocation decisions, rather than seeking to obtain some form of collective response. As such, it was probably the last initiative to operate at this level. Its failure prompted a belief that more fundamental and structural reform was required to tackle the power ability of the medical profession to resist change.

Perhaps the clearest recognition of the unsustainability of the relationship between doctors and managers was embodied in the Griffiths Report (1983). There, it was made clear that the lack of accountability for the provision of health services could no longer continue. Managers (or administrators) sought to contain budgets and to meet service targets while, effectively, doctors who remained immune to these demands were the ultimate determinants of their achievability. This was deemed to be unacceptable and, as a consequence, general managers were introduced. These managers were appointed as heads of unit or hospital and soon acquired the title of Chief Executive. The management model used was drawn from the private sector and clearly implied the managerial accountability to the Chief Executive of all who worked in an organisation - including doctors. In effect, the emergence of managerialism into the health service was an attempt to give managers a structural power as a counterbalance to the expert power of the medical profession.

However, in reality, the proposition that a newly created cadre of managers could control a long established, very powerful medical profession was probably naïve. A few charismatic individual managers began to exercise a form of personal control but once again the medical profession withstood an initiative designed to bring them within the managerial ambit.

Relatively soon after this change further structural reform was introduced separating the purchase of health care from its delivery. This was classic managerialism, whereby the services expected of a professional autonomous group became subject to specification and, as a consequence, control through a contractual relationship. The contract for services approach could be said to be partly successful but mainly only in respect of small changes at the periphery of the service. They did, though, incur significant and unnecessary transactional costs and produced in most doctors an antagonistic response. It had been hoped that by involving doctors in managing the delivery of a contract for service they would come to see successful delivery as an essential part of their job and hence become part of management. For the most part this failed with managers predominantly taking the lead on financial negotiations and doctors feeling even more detached as the recipients of the outcome of contract discussions when they had had no involvement

Alongside the purchaser-provider separation, a clinical management system was created, which involved a Medical Director who had a place on the Trust Board - the most senior executive body responsible and accountable for the running of the organisation - and Clinical Directors who were responsible for health care services in a defined area of medical specialty. These areas of service within the organisation were known as Directorates. A number of studies have been conducted to examine the functioning of these Directorates and the role of Clinical Directors as an explicit attempt at managerial integration.

Burgoyne and Lorbiecki’s (1993) research concluded that clinicians were becoming involved in management but without any resulting major change in medical culture. The transition of clinicians into management required new skills and ways of learning, and these were seen as possible. The main limitation on the transition was, though, seen as the maintenance of their credibility and esteem, to themselves, their medical colleagues and the public. This was viewed as being firmly determined by the medical culture, which if left intact, would preserve this important characteristic of the clinical role. The view of the researchers was that this was a fundamental element of the medical culture, which left intact, would preserve this important characteristic of the clinical role.

From this research Burgoyne and Lorbiecki believed the clinical director model to be sustainable if:

1. the medical culture and the doctors’ perceptions of their own professional self image could adjust to this model, common for other professionals (accountants, solicitors, lawyers and indeed private practice doctors) or professional groups in a free market; and
2. a way of reconciling medical needs and available resources was found elsewhere in the system, without passing this problem onto hospitals and clinical directors.

Dawson et al (1995) found the key issues for clinical directors in meeting the managerial challenge were as follows:

1. The main barriers that prevented clinical directors from doing the job were approximately one-third each from internal management constraints and lack of resources, with the balance from operational overload.
2. Clinical directors were concerned about the time taken in managerial activity encroaching on their clinical activity, in terms of detracting from their ability to keep up to date clinically and to maintain their earning capacity in private practice.
3. Succession planning was also something that concerned many. Some felt they were trapped in the managerial role since few colleagues appeared interested in taking over. Others, however, were unhappy that once established in a managerial role they would have to revert to a more limited clinical position when others were given the opportunity of managerial responsibility.
4. The thing clinical directors found most difficult was to manage, direct or cajole their colleagues into particular courses of action when previously they could ignore them if they encountered major areas of disagreement. The "election" of clinical directors was a complex balance of acceptability to the chief executive and other executive directors and the consultants. The differences in expectations between these two groups were recognised. However, some of the newer, younger clinical directors, perhaps from relatively "unfashionable specialties" that previously had not been high in the "pecking order" of hospital consultants, were eager to embrace what they saw as an alternative source of power in the organisation.

Dawson et al argued that if clinicians were to continue as part-time leaders in the health system there would have to be considerably more investment in their training, development and support. They also discussed the fact that the medical profession, as with other professions, had rarely been in the forefront of initiating organisational change. That discussion reminds us that monopoly suppliers of professional services, with carefully controlled entry and prescribed forms of training, have enormous power in determining the form in which their services will be supplied (Johnson (1972); Friedson (1988); Clarke and Lawry (1988)).

Recently published research by six medical doctors (Hearing et al (1999)) took an enquiry action learning approach to looking at the problems doctors encounter when assuming a management role. They also focused on how clinical directors felt the UK NHS could make undertaking managerial duties more attractive to doctors. Problem areas for doctors going into management were: the conflict between the focus on the individual patient and the use of resources for the benefits of patients as a whole; time pressure; potential loss of income if management responsibilities encroach on private practice; the lower respect and confidence accorded managers than doctors; and the attitude of colleagues. It was seen as important that doctors be convinced of the relevance of their input to the management process. In addition, the above problems need to be addressed to encourage consultants into management roles, although this research does not purport to offer solutions to these.

Clinicians in Management: The Role and Contribution
As we have seen, early efforts to involve clinicians in the management process seemed to be motivated by a desire to control expenditure. Preparation of clinicians for this particular managerial roles emphasised operational management skills and, perhaps rather oddly, produced a duplication of skill sets already provided within the service by the existing non-medical managers. It may be that this rather traditional conception of the management role was responsible for the disillusion felt by many of the clinical directors. As McKee et al (1999) suggest doctors in roles of this type described themselves as constantly battling with financial and staff crises with little scope for managerial or medical innovation or strategy development. More pejoratively, clinicians had come to view management as shuffling bits of paper and had no desire to commit to such roles full-time or, indeed, long-term. In these part-time, operational, managerial roles, clinicians often found themselves grappling with day-to-day tasks for which they were ill-equipped and had insufficient time.

The focus for involving doctors in management should surely be upon identifying and understanding the particular "added value" perspective on management clinicians can bring to the task because of their different training and expertise.

What is really required from clinicians (meaning doctors in this instance) as managers? If brutally honest and at its most basic, I suspect the key requirement is to manage their clinical colleagues because no other process has managed to do so with any consistent success. If we accept this, the role and training definition of the desired role and the appropriate training starts to become clearer. Certainly there is a need for doctors to be aware of and to understand management processes to a much greater degree than their current educational pattern delivers. But this is an understanding of rather than doing.

The role of the clinician in management would seem to be fundamentally one of influence - influence over other clinical colleagues and influence in shaping the future pattern and shape of health care services and also with providing a unique medical perspective on the complex, rapidly changing external requirements of the health system. The role, then, is one of strategic direction and clinical leadership - perhaps, at one and the same time, more appealing and a more appropriate use of scarce and special skills.

There is, of course, a cultural change required of the process of involving clinicians in management.

The cultural change involves recognising and accepting that doctors are part of a managed health care community and that management is a valued and important process. I do not believe we have achieved this acceptance yet. However, processes linked to clinical governance such as consultant appraisal can be interpreted as this culture developing.

A recent visit to the Health Services Management Centre, University of Birmingham, (HSMC) of a group of clinical and medical directors from Denmark brought home the importance of a positive cultural acceptance of the role of clinicians in management. The most dramatic difference between the two groups of clinicians both involved in management was that the Danish group were all full-time managers They had given up their clinical practice to be clinical managers/leaders. In the UK this, of course, always provokes the responses:
1. this will engender a lack of credibility with my colleagues; and
2. what happens when I give up being the Clinical Director?

The great culture gap is contained within the reply of the Danish visitors. They saw credibility as having been earned by their previous excellent records in clinical work - not by their current activity. Secondly, they saw their appointment as clinical leaders as emerging as senior clinicians into a high status role valued by peers. They did not expect to return to clinical work but, if someone did, the system provided one month’s re-training for every year out of practice. It might be worth contrasting this scenario with one with which many in the UK will be familiar: that of clinical directors being involved in their role because nobody else would do it and being keen to leave the role as soon as the standard three-year term is up.

Simply advocating and encouraging clinicians to become involved in management has not worked on a sufficient scale to attract the number and quality of individuals needed. More system-based changes may ultimately be more successful. For example, the clinical governance requirements in the UK have necessitated the involvement of clinicians in reviewing their own practice and indeed that of their colleagues. The growth of care pathways, which nationally introduce greater consistency in care provision, also create a managerial framework whereby deviation from the accepted pattern at least provokes enquiry and discussion. Finally, the concept of consultant appraisal as part of the governance process reinforces the managerial role of medical and clinical directors involving, as it does, some degree of examination of the practice of colleagues.

This type of process, of course, goes right to the heart of the dilemma of doctors’ involvement in management, ie, infringement of the autonomy of another clinician. A gradual cultural acceptance of such managerial approaches by more junior doctors will probably be the smoothest route to proper involvement of doctors in management. It may be, too, that the term "management" is in itself unhelpful. The thesis of this paper is that doctors must provide clinical leadership not duplicate middle management.

Finally, if the UK NHS is moving towards a model of clinical leadership, then it is also necessary to consider what training doctors are given and when in their career this should happen. A recent study by Palmer, Spurgeon & Clark (2001) examined the views of over 300 clinicians and over 100 managers as to the appropriateness of training content and its timing. Over the 10 areas of management examined there was remarkable agreement between doctors and managers (correlation ranging between 0.88 and 0.93) as to what material should be offered and when it should be offered. If such a model were to be adopted, it would have the great merit of providing a sense of cumulative development such that medical students and Senior House Officers, etc, would acquire the awareness and understanding of management practices at an early stage and more strategic skills would be developed at a later stage, with clinical staff equipped with an appropriate platform to acquire these leadership capabilities.

References
Mitchell D. What you need to learn as a clinical director. Hospital Medicine 1998; 59(8):576-579.

Gatrell J, White J. Medical student to medical director. NHS Training Division, Bristol; 1994.

Rosenthal M. The incompetent doctor: Behind closed doors. Milton Keynes: Open University Press; 1995.

Thorne M. Colonising the new world of NHS management: the shifting power of professionals. Birmingham: Health Services Management Research. (In press).

Pollard M. On the side walk. Health Service Journal 2001; November; 22-24.

Grabham A, Chantler C. Doctors becoming managers. A conversation among Richard Smith, Sir Anthony Grabham & Professor Cyril Chantler. Interview by Richard Smith. BMJ 1989; 298:(6669) 311-314.

Buchanan D, Jordan S, Preston D. Doctor in the process - the engagement of clinical directors in hospital management. Journal of Management in Medicine 1997; 11(3): 132-157.

McKee L, Marnoch G, Dinnie N. Medical managers: Puppetmasters or puppets? Sources of power and influence in clinical directorates. In Mark A, Dopson S (eds). Organisational behaviour in health care - the research agenda. Basingstoke: Macmillan; 1999.

Palmer R, Spurgeon P, Clark J. Career view mirror. Health Service Journal 2001; 29 November; 111(5783): 26-27.