At the Nuffield Trust Health Policy Summit, Professor Huw Davies takes a closer look at the parlous relationship between managers and clinicians. He discusses recent research which follows up on a survey from the early 2000s.

1. #ntsummit
Managing doctors: doctors managing
Professor Huw Davies, Professor of Health Policy and
Management, University of St Andrews @univofstandrews

2. Professor Huw Davies
Dr Alison Powell
School of Management
University of St Andrews
Supported by:
MANAGING DOCTORS, DOCTORS MANAGING

3. THE DOCTOR-MANAGER RELATIONSHIP
- AT THE HEART OF THE NHS -
• Perennial part of the political
and public discourse ------------>
• Prominent in policy reviews
(Darzi, Dalton etc.)
• Indicted in failure inquiries
(Kennedy, Francis etc.)

4. from Administration to Management
• Slow diminution of doctor
dominance and autonomy?
• Counter-balancing growth
of managerial influence?
• ‘Managing Doctors’, and
‘Doctors Managing’…

5. Some NHS work over a decade ago
(in NHS Acute Hospital Trusts)
BMJ 2003; 326:626-8
“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.”

6. But what of doctor-manager relations in a
post-Francis world and an austerity NHS?
• New national survey in UK acute hospitals
• Total of 472 respondents (88% in England)
– Chief Executives (n=59)
– Medical Directors (n=131)
– Directorate Managers (132)
– Clinical Directors (150)
• Additional depth interviews,
plus focus group (n=22)
Supported by:

7. Are relationships between doctors and
managers improving or getting worse?
• Narrative of continuing challenge…
• Lack of regard/respect/trust…
• Defensive and oppositional behaviours…
• Widespread view that clinical power retained
• Some pockets of effective working
»
• Local,
• Local,
• Local…

8. Chief
Executives
(n=59)
Medical
Directors
(n=131)
Middle
managers
(n=132)
Clinical
Directors
(n=150)
Positive
ratings
72% 62% 64% 50%
Negative
ratings
10% 9% 6% 19%
Relations
likely to
improve
80% 66% 67% 35%
- Around a quarter or more of each group dissatisfied with
resources and effort devoted to nurturing local relationships
Strained Doctor-Manager Relationships
- national UK survey NHS Acute Trusts, 2015
Relations
likely to
deteriorate
18% 27% 29% 51%

9. Power tensions between Doctors & Managers
Statement:
Trust
Chief Exec
(n=59)
Medical
Directors
(n=131)
Middle
managers
(n=132)
Clinical
Directors
(n=150)
‘The relative power and
influence between
management and medical
staff is about right’
70% 68% 55% 44%
Percent agreeing with statement:
‘Doctors have sufficient
influence on hospital
management’
81% 62% 81% 46%
‘Doctors have confidence
in management leadership’ 79% 56% 59% 34%

10. Resource tensions between Doctors & Managers
Statement:
Trust
Chief Exec
(n=59)
Medical
Directors
(n=131)
Middle
managers
(n=132)
Clinical
Directors
(n=150)
‘Management do not
exert pressure to
discharge or transfer
patients early’
53% 33% 34% 22%
Percent agreeing with statement:
‘Management do not
exert pressure to reduce
use of tests or services’
78% 79% 68% 61%
‘Management is driven
more by clinical rather
than financial priorities’
96% 70% 71% 43%

11. (How) does the policy context shape
relations between doctors and managers?
• Funding constraints, moving targets,
regulatory and media pressures and
frequent redisorganisation…
• Managerial capacity: loss and churn;
• Managers seen
as the agents of
government…

12. Conclusions
• Relatively little change since 2002 – is this
good or bad?! Clinical directors a concern…
• Positive views and optimism holding up;
but hardening of pessimism looking forwards;
• Whatever the national picture, local relations
matter more…
• The broader policy context shapes
interactions…
• An area warranting investment…??

13. Investing in the
Doctor-Manager
relationship…
Understanding the
dynamics and
impacts;
Seeking greater
functionality.