What can more productive relationships deliver?

Productive relationships between management and medicine lead to better patient outcomes according to Becky Malby & Professor Ian Kirkpatrick, two of the authors of new a report from the Centre for Innovation in Health Management

The well documented difference of perspectives of managers and doctors, and the difficulty of engaging doctors productively in health management, has not been overcome by structural or contractual solutions. In fact we believe that these have at times exacerbated the differences. Both managers and doctors have a history that makes mutual engagement problematic. The difficulties remain. However there are some places where productive relationships have been forged, and managers and doctors are working together – where the two perspectives have been a catalyst for service development.

The NHS reform agenda has been costly. There are questions about the return on the public’s investment in the NHS. Whilst the service is improving, the rate of change is viewed as too slow, particularly by politicians. The fact that doctors are central to reform and that improvement in services is dependent on doctors engagement in the management and delivery of health services is not disputed. However the process of sustainably engaging doctors – how to do it over the medium to long term – remains elusive. It seems that structural changes on their own are not enough. In fact they may not be the answer at all.

The National Inquiry into Management and Medicine sought to hunt out examples of where managers and doctors were working productively together. This collaborative inquiry used a number of ways to complement the traditional witness based inquiry. The process engaged a health constituency in exploring the issues, formulating the questions, exploring the possibilities for working differently and taking these into their management practice. The witness-based, and written evidence elements pursued approaches that overcome the difficulties between the two disciplines. International examples acted as catalysts to exploring options for health systems design.

The process did not focus on another version of ‘what’s wrong’, but explored how health organizations and systems have found ways of making the most of the potential offered by both doctors and managers in managing health services.

What can more productive relationships deliver?

The starting assumption for this inquiry is that more productive relationships between managers and doctors will deliver better health services.

Clinical-management engagement is often associated with improved productivity through the redesign of clinical work and enhanced capacity for change and innovation. A number of studies have found that poor performance and clinical failure were linked in part to a ‘disconnect’ between medicine and management. Many have also identified a positive link between effective clinical leadership and improved patient care. There is then some evidence to suggest that improving the capacity of doctors and managers to co-produce services will add value in the system.

By listening and analysing stories and working with policy makers and international academics we found doctors and managers work best together when the following conditions exist.

There is a clear focus on the clinical business

Space is created for local innovation by the executive team managing upwards

Decisions are devolved to the right level with doctors and managers collaborating on solutions that work for them locally.

There is continuity over time – of senior managers leading the trust

Complacency is avoided by seeking internal and external challenge to strategies, ways of working and improvement.

Interests are aligned through rewards, information, and performance management.

Doctors and managers make sense of the external environment together - interpreting national policy, stakeholders behaviours, and working out what this means for the trust.

There is frequent dialogue to build a shared purpose – a sense of ‘being in it together’.

Differences are seen as an asset – conflict is used positively as a way of finding new answers and possibilities.

Managers and doctors understand each other – they take time all the time to step into each others shoes, so that they can really understand each other’s perspective.

There is investment in organisational change, doctors and managers learn together, and locally relevant performance management systems are developed.

Where productive relations have become most established it was clear to us that significant shifts had occurred in the way doctors and managers see the world. This new worldview was not some kind of fudge or compromise. It was a partnership, in which each side made the most of what the other had to offer.

Management was not seen as something to be tolerated, a necessary evil, or a tick box exercise. It was seen as integral to delivering clinical services. This did, however, mean managers getting closer to the clinical work – asking questions, understanding patient’s experiences, being aware of clinical developments.

Similarly, doctors were closer to the managerial work. They were beginning to understand the impact of clinical decisions on how the service is organised, develop strategies to ensure the whole made the most of its parts, and look at viability - even financial viability.

The full report and a short easy read version can be downloaded at www.cihm.leeds.ac.uk

Becky Malby & Professor Ian Kirkpatrick

Centre for Innovation in Health Management

University of Leeds

T: 01133438036

Where productive relations have become most established it was clear to us that significant shifts had occurred in the way doctors and managers see the world.

“If the managerial agenda isn’t a clinical agenda, then what is it?”

chief executive

Productive relationships are characterised by:

Working for the whole: Shared sense of endeavour across the whole of the Trust, and collective responsibility between managers and clinicians for managing the service. Ambitions for the service are shared, as are questions about future design and delivery.

Working together: Participative and open decision-making. An inclusive approach to information; feedback processes at personal, team and organisational levels; and a culture that makes the most of ‘differences’ seeing conflict as a possibility for further options.

Collaborative leadership. A more distributed model, shifting away from traditional notions of elitist, expert, positional leadership. Where general managers are concerned this involves a shift towards partnership and facilitator roles. New clinical leadership roles are also apparent. These are associated with increased capabilities to balance corporate and clinical priorities and a more effective change agent and ‘boundary spanning’ role.

Shared decisions: Greater alignment of in decisions at all levels, with a narrowing of the gap (or tension) between managerial and clinical domains of work, and greater understanding of interdependency

Our business is health: An organisational focus on the centrality of managing the means of production – “… it’s not rocket science is it, our product is delivering healthcare”. In particular this is modelled at the top by the chief executive and executive team, and by the board. It is reflected in internal performance metrics, and the internal conversations and decision-making of the organisation. The clinical business really matters, and this is evidenced in the attention given to it across the organisation. The top team really understands the clinical work and patients’ experiences.

“I remember a case in the past where we had a whistle blowing complaint. The medical director and I worked very closely together and we set up an investigation. The serious allegation was that a particular consultant’s mode of practice was putting patients’ lives at risk. This wasn’t substantiated in the end but what did emerge was a history of evidence of the consultant making individual decisions without regard to other members of the team. The investigation gave us the opportunity to state that this was totally unacceptable and non-negotiable. You may not like your colleagues but no matter, you have to work as a member of a team and there’s no future for you at this hospital unless you do. This message is now accepted across the board. Five or seven years ago it is much more questionable whether it would have been.”

“One of the things that clinicians have responded well to has been the invitation to take a hard look at what the strategies for their specialties should be. They’re excited by that. We support them in this process by what we call a Change Leaders Team, which comes under Strategic Developments. We’ve had success in that which in turn breeds confidence across the trust. It has taken investment and we brought in consultants, external support, to help identify and establish a transformational programme. The acceptance of partnership working was brought about by this type of intervention.”