A well functioning relationship between doctors and managers is crucial if government plans for “modernising” the NHS are to deliver real service improvements.1,2 We aimed to shed some light on current perceptions of the doctor-manager relationship by examining areas of convergence or divergence of views among a large sample of doctors and managers in the NHS.
Participants, methods, and results
We conducted a postal questionnaire survey in NHS acute trusts across Great Britain during the summer of 2002. The survey included a census of chief executives and medical directors (from 197 trusts), together with a stratified cluster sample of both medical and non-medical managers at directorate level (clinical directors or their equivalent and non-medical directorate managers or their equivalent) randomly selected from 75 trusts. Comparisons between these different role groups form the central part of the analysis; we assessed variations across all four groups using χ2 tests.
We received replies from 103 chief executives, 168 medical directors, 445 clinical directors (or equivalent), and 376 non-medical directorate managers (or equivalent). The response rate was 66% at board level and 73% at directorate level, giving a total of 1092 respondents.
Overall, chief executives were the most optimistic about the state of doctor-manager relationships, and clinical directors the least. About three quarters (78/103, 76%) of chief executives rated the quality of current doctor-manager relationships as 4 or more on a scale of 1 (poor) to 5 (excellent), compared with just 37% (164/443) of clinical directors. Further, 78% (80/102) of chief executives thought that doctor-manager relationships would improve over the next year, compared with just 28% (123/439) of clinical directors (indeed, 26% (113/439) of clinical directors thought that the relationships would deteriorate). Differences across all four groups were significant at P<0.01.
Questions about specific aspects of the doctor-manager relationship showed some areas of good agreement but also highlighted issues where views diverged significantly between the four groups (table). Only rarely was the most obvious divide between those medically qualified and those not. More often, the differences were between senior managers (board level) and middle managers (directorate level). Most striking was that clinical directors often seemed to have views markedly divergent from—and much less positive than—the views held across the other three groups.
Typically, clinical directors were the least impressed with management and the most dissatisfied with the role and influence of clinicians. For example, whereas almost all (95% (610/640)) chief executives, medical directors, and directorate managers agreed that “managers allow doctors sufficient autonomy to practise medicine effectively,” 27% of clinical directors disagreed. Further, as a group, clinical directors were less likely (P<0.01) than each of the other groups to agree that “management staff in this hospital are consistently of high quality” (53% v 77% (average across the other three groups)), that “managers are well versed in clinical activity” (47% v 81%), and that “doctors have sufficient influence on hospital management” (48% v 85%). Indeed, for almost all positive statements about doctor-manager relationships at least a quarter of clinical directors disagreed. The only statement that received near unanimous approval from clinical directors (90%) was “medical staff in this hospital are consistently of high quality.”
Comment
Doctors and managers in the NHS are often dissatisfied with doctor-manager relationships but differ in their views depending on their role in the organisation. In general, senior managers were more positive than staff at directorate level, and lay managers were more positive than medical managers. Clinical directors (or those in equivalent roles) were easily the most disaffected, with many holding negative opinions about managers' capabilities, the respective balance of power and influence between managers and clinicians, and the prospects for improved relations. Unless such divergence is addressed, further difficulties in delivery of the government's ambitious agenda for modernisation are likely.3
Table.
Agreement with statements about doctor-manager relationships among 1092 survey respondents. Values are the percentages (numbers) of respondents in each group who agreed with given statement
| Statements
|
Chief executives (n=103)
|
Medical directors (n=168)
|
Directorate managers (n=376)
|
Clinical directors (n=445)
|
Overall (n=1092)
|
|---|---|---|---|---|---|
| Issues of relative power | |||||
| The relative power and influence between management and medical staff is about right | 74 (75) | 73 (123) | 54 (199) | 45 (198) | 55 (595) ** |
| Doctors are adequately involved in hospital management activities | 78 (79) | 75 (124) | 68 (253) | 63 (282) | 68 (738) ** |
| Doctors have sufficient influence on hospital management | 92 (95) | 77 (127) | 87 (320) | 48 (211) | 70 (753) ** |
| Managers allow doctors sufficient autonomy to practise medicine effectively | 97 (99) | 95 (157) | 95 (354) | 73 (317) | 86 (927) ** |
| Management do not exert pressure to reduce use of tests or services† | 75 (76) | 88 (147) | 83 (306) | 76 (330) | 80 (859) ** |
| Management do not exert pressure to discharge or transfer patients early† | 50 (51) | 52 (87) | 49 (179) | 55 (241) | 52 (558) |
| Perceptions of staff calibre | |||||
| Management staff in this hospital are consistently of high quality | 81 (82) | 70 (114) | 78 (292) | 53 (232) | 67 (720) ** |
| Medical staff in this hospital are consistently of high quality | 92 (94) | 91 (148) | 85 (316) | 90 (397) | 88 (955) * |
| Managers are well versed in clinical activity | 84 (85) | 76 (124) | 83 (311) | 47 (206) | 68 (726) ** |
| Managers have confidence in clinical leadership capabilities | 68 (70) | 67 (111) | 69 (253) | 71 (310) | 69 (744) |
| Doctors have confidence in management leadership capabilities | 87 (89) | 63 (105) | 55 (202) | 42 (184) | 54 (580) ** |
| Views on goals, decision making, and team working | |||||
| Hospital managers and doctors are largely in agreement on the overall goals of the institution | 96 (99) | 83 (140) | 81 (302) | 78 (343) | 81 (884) ** |
| Management is driven more by clinical rather than financial priorities† | 78 (80) | 44 (71) | 53 (197) | 24 (104) | 42 (452) ** |
| Managers and doctors focus together on patient need | 87 (88) | 80 (134) | 82 (306) | 61 (267) | 74 (795) ** |
| Doctors view the management decision making process to be fair | 74 (75) | 60 (99) | 40 (148) | 36 (159) | 45 (481) ** |
| Doctors generally are supportive of management decisions | 90 (93) | 77 (127) | 64 (231) | 52 (224) | 63 (675) ** |
| Doctors and managers work well together as a team | 91 (94) | 87 (141) | 82 (303) | 73 (315) | 80 (853) ** |
| Continuous improvement is undertaken on the basis of partnership and teamwork | 90 (92) | 79 (131) | 82 (305) | 70 (303) | 78 (831) ** |
| Communication issues | |||||
| Management is good at providing feedback to doctors about service delivery | 75 (76) | 63 (104) | 73 (272) | 51 (223) | 63 (675) ** |
| Doctors are good at keeping management informed about service development issues | 66 (67) | 55 (93) | 42 (155) | 56 (246) | 52 (561) ** |
| The use of clinical performance data stimulates good practice and strengthens service management | 93 (96) | 86 (142) | 84 (310) | 74 (321) | 81 (869) ** |
| The availability of clinical performance data improves the doctor-manager relationship | 83 (84) | 73 (121) | 70 (257) | 61 (266) | 68 (728) ** |
| Resource issues | |||||
| There is an adequate number of consultants to provide quality patient care | 32 (33) | 24 (39) | 41 (153) | 14 (62) | 27 (287) ** |
| Within this organisation there are generally sufficient clinical resources | 24 (25) | 18 (29) | 25 (92) | 9 (38) | 17 (184) ** |
| Management is generally responsive to requests for additional clinical resources | 86 (87) | 69 (114) | 76 (282) | 38 (167) | 61 (650) ** |
| Doctors prioritise effectively when making requests for additional resources | 39 (40) | 32 (53) | 23 (86) | 47 (204) | 36 (383) ** |
Some denominators are reduced because of missing data (never more than 3% for any individual question).
P<0.05 for χ2 test of equality across groups.
P<0.01 for χ2 test of equality across groups.
These statements were “reverse worded,” and values have been adjusted accordingly.
Footnotes
Funding: Nuffield Trust, London, and the Commonwealth Fund, New York. The guarantor accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.
Competing interests: None declared.
References
- 1.Edwards N, Marshall M. Doctors and managers. BMJ. 2003;326:116–117. doi: 10.1136/bmj.326.7381.116. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Protopsaltis G, Fulop N, Edwards N, Meara R. Failure and turnaround. London: NHS Confederation; 2003. [Google Scholar]
- 3. McLellan A. A nasty kick in the ballots. Health Serv J 2002: 14 November, pp18-19.