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Interactions between managers, doctors and others

Understanding individuals: Interactions between managers, doctors and others

This section covers: 

Introduction

Definitions

Interaction is a kind of action that occurs as two or more objects
have an effect upon one another. The idea of a two-way effect is essential in
the concept of interaction, as opposed to a one-way causal effect.

Modern definitions see ‘management’ as the method, or process
through which the members of an organisation attempt to co-ordinate their
activities and use their knowledge, skills and resources to fulfil the various
tasks and goals of the organisation as efficiently and effectively as possible
(Parking 2009).

Background

The rise of management in health systems is a global phenomenon progressively
established over the last thirty years. Within the health sector it is a potent
force and holds wide appeal to reforming policy-makers. This has resulted in a
great cultural shift happening in health. Now we are as likely to have patients
and the public involved in managing their health conditions, developing services
and helping to shape learning and development, as clinicians, managers and
commissioners.  The particular drivers for these changes have emerged
through:

  • Lord Darzi’s NHS review of England 2008
  • A range of policy drivers across countries
  • Personalised and patient centred health care services
  • Increase in long term conditions and the need to support people to self
    care.

These changes inevitably effect the interactions between clinical and public
health doctors, managers and their patients.

This module reviews the historical changes and current challenges and
opportunities for building positive and effective relationships across these
domains. The module is presented in three sections:

Section One presents a review of the changing relationships between
clinical doctors, managers, and patients within the NHS.

Section Two presents a review of the changes and interactions within
the Public Health Workforce.

Section Three presents the current challenges and opportunities for
maintaining positive interactions between the patient, the clinician and public
health.

 

Section One

Changing relationships between clinical doctors, managers, and patients
within the NHS.

Before the 1980s, healthcare services in the UK’s NHS were dominated by doctors in terms of both influence over decision making about the distribution of resources and the control of the day-to-day running of healthcare establishments. The Griffiths Report (1983) introduced the concept of general management to the NHS with a single person with overall managerial responsibility, at each level within the organisation, replacing the previous triumvirate (doctor, nurse, administrator) and signalling the future
drive for close parallels with private and commercial organisations. Managers
were empowered for both operational and strategic decision making, becoming a
distinctly different activity from the clinical work of health professionals.

In 1990 the internal market was introduced with small business units created
in healthcare organisations and the relationship between doctors and society,
the doctor–patient relationship, and the environments in which doctors
undertook their training and their practice, began to change. Today, our health
system is typified by a high level of complexity. Many of the pressures and
challenges on the medical profession are not confined to the United Kingdom or to this profession and instead reflect wider social and technological change. These changes have an impact on the expectations of patients and taxpayers, government, and doctors themselves and are typified by:

  • the emergence of an information revolution, which both diminishes the
    apparent ‘infinite wisdom’ of the doctor and also gives patients a
    greater understanding of their own condition as well as of the performance
    of the professional who is treating them;
  • the decline of always believing that the ‘Doctor knows best’;
  • the increasing numbers of females within the profession;
  • the arrival of health managers as powerful players.

This complexity has to be managed with great skill to ensure that the large
but finite resources invested in healthcare are spent cost-effectively. (see
HK 5a:
Understanding
Individuals, Teams and their Development: Personal Management Skills
).

Doctors and Managers

Expansion of the workforce has been central to the government’s plans for
the modernisation of the NHS, with the largest growth since 1997.
 Organisations have progressively transformed from doctor-led into
management-led, focussing on clinical performance and improvement (e.g. the
thinking behind clinical governance includes managerial notions like leadership,
creating development plans, clarifying accountability etc).  Doctors and
managers do share many of the same attributes, not least the desire to create a
superlative healthcare system.

Just as the patient–doctor partnership is a pivotal therapeutic
relationship in medicine, so the interaction between doctor and manager is
central to the delivery of clinical care. However, there are also two main
differences that inevitably cause tensions:

  • doctors have an individualistic focus and want to offer the best
    healthcare for the patient in front of them
  • managers take a broader perspective in terms of patient populations, their
    focus is to maximise resources and provide the best healthcare within the
    identified budget for all the local population.

From an organisational perspective, it is important to understand the
differences in manager and doctor cultures demonstrated below by using a
cultural web:

 

Doctors

Managers

Symbols

Stethoscope, stereotypical attire for speciality, titles, colleges,
terminology

Reserved parking, dark suits, language/jargon, laptops

Power structures

Negotiating committees, cliques of ‘political’ doctors

Executive management team

Control systems

Who knows who, audit

Financial/activity reporting, targets

Rituals and routines

Patient consultations, merit awards

Board meetings, long hours in the office, meetings ad committees

Stories

‘Us and them’, heroes, mavericks, ‘in the old days’

‘Us and them’, things have to change, change is for the best

Paradigm

NHS, a ‘good thing’, should be free at point of delivery, desire
to be the best

NHS, a ‘good thing’, should be free at point of delivery, desire
to be the best

(Brooks 2006)

Sometimes, disputes about resource allocation become major points of public
debate. Social and political factors, together with the achievement and promise
of medical science, have reshaped attitudes and expectations both of the public
and of doctors. At the core of the management revolution in healthcare has been
the view that doctors must increasingly accept managerial responsibility as well
as be managed themselves by non-medical managers.

Dr Gill Morgan, chief executive of the NHS Confederation, recognises an
untapped and undeveloped potential that exists to maximise the partnership
between doctors and managers identifying that, "Doctors and managers have
different but complementary roles and perspectives. Both are valid and both are
crucial to delivering high quality patient care."  Key areas which can
support a more complementary relationship between clinical doctors and managers
has been summarised below:

1. 

The relationship between doctors and managers has a historical
context that impacts on organisations and individuals today. The role of
doctors in management is central to the effective delivery of healthcare
services and doctor-manager posts can be found dispersed across
organisational structures.

2.

Managers and doctors inhabit different cultural worlds.  The
cultures will always be different but there is a need for each to
understand the other and to be aware of how different sources of power
are played out through behaviours observed in organisations.

3.

Organisational structures present challenges for working style and
behaviours. The transformation from essentially bureaucratic
organisational structures to flatter, less hierarchical structures
presents challenges for doctors and managers in organisational
activities such as communication and team working.

4.

Partnership working is the way forward to ensure the strengths of
both groups are deployed effectively to implement change and achieve
excellence. Currently, the emphasis appears to be on managers
stimulating appropriate organisational behaviour from doctors. There is
a need for both groups to understand the huge untapped and undeveloped
potential that could be used to continually improve patient care, if
working more closely to some shared explicit agenda could be achieved.

(Brooks 2006)

Doctors and patients

Changes within the research of doctor/patient interactions have focused upon:

  • the effect of communication in eliciting patient histories and concerns
  • the rise of health consumerism and an increasingly well-educated
    population that is able to challenge a doctors advice
  • the use of healthcare marketing with a focus on the kinds of interactions
    that improve patient satisfaction.

The development of a market-based model of health care consumerism and the
ethical model of patient autonomy, positions the patient as the more powerful,
and possibly sole, decision-making agent (see
HK:
Section
4b: Health Care – Section 8: The Health Professions, Governance, and the
changing doctor-patient relationship
).

This progressive shift in power and control between patients and doctors is
demonstrated in the changes in several aspects of these relationships:

Specific aspects

The Past

Today and the Future

Paternalism

Doctor knows best, dominant.

Patients anxious/fearful.

Doctors in negotiation, more equal relationship.

Patients more involved in their care.

Information revolution

Doctors holding all the information.

Patients not questioning, uninformed, not understanding, no access to
information

Doctors providing more explanations.

Better informed patients, better educated, more informed patients,
public access to information and research.

Consumerism

Doctors offer single health service for the sick.

Patients - passive and grateful recipients of medical and other
services.

Doctors becoming one of many sources of healthcare.

Patients increasing  expectations and choices of service -
helped to improve standards of patient care.

Moves to alternative therapies.

Dialogue

Doctors have limited dialogue with patients and none with the public.

Patients not involved in service planning.

Doctors have greater dialogue with wider public.

Patients/public involved in the shaping of health services.

 

Section Two

Changes and interactions within the Public Health workforce

Those who work in Public Health focus on population-wide issues as well as
providing the rigor and evidence-base required in robust decision-making, rather
than the health interests of particular individuals.  The Chief Medical
Officer in 2001 defined three levels of individuals considered to have a public
health role:

  • Specialists in Public Health: those who have specialist knowledge and
    skills, whose core task is public health e.g. public health teams,
    environmental health etc
  • Public Health Practitioners: those whose role is outside public health but
    a major part of their everyday work involves public health practice, e.g.
    health visitors, community development workers, community pharmacists etc.
  • Wider public health workforce: those that have a role in health
    improvement and reducing inequalities e.g. teachers, youth workers, local
    business leaders, town planners, housing officers etc.

Until the NHS reorganisation in 1974, public health practitioners were
located in local government.  Following the move of community medicine
(public health) into the NHS the management and leadership of public health in
local authority settings transferred to those who had little understanding or
knowledge of public health and often a lack of interest (Hunter 2007). 

Recent developments in healthcare systems have focussed on outcomes, which
may come closer to public health’s concerns.  However, its simultaneous
focus on efficiencies in market-style incentives and individuals as consumers,
runs counter to public health’s values of maximising outcomes for populations
or communities rather than the individual.

Key changes in managerial approaches within the public health sector were
highlighted in the review of public health function led by the chief medical
officer in 2001, who identified that public health leadership requires a
facilitative, influencing style that involves the creation of horizontal
networks as well as vertical ‘command and control’ networks. This led to a
focus upon alliance- building across a range of diverse organisations and
professions as well as the public and these and other more flexible organic
structures began to replace rigid, inflexible bureaucratic structures. 

These changes in structure also prompted the recognition of new skills in
addition to the traditional scientific skills associated with public health,
such as political and managerial skills. Key skills required in good public
health management are the ability to lead without authority and to facilitate
and manage change in complex environments.

Public health professionals as managers

In general, public health professionals are more focussed than their senior
clinical colleagues to managerial perspectives based on collective, whole
population approaches. Although opinions still vary between those engaged in
public health, with some who believe that public health should be an active part
of the management system in order to influence events and others who consider
that public health should remain detached in order to preserve their
independence and professional integrity.

Public health delivery is based upon twin intellectual approaches (Nutbeam
and Wise 2002).:

  1. harnessing public health knowledge
  2. acting upon that knowledge, through the deployment of appropriate
    management and planning skills, the ability to manage change and strong
    negotiating skills.

This synthesis is difficult to achieve due to the challenging demands
requiring well-honed political and managerial skills in addition to the
traditional scientific and epidemiological skills associated with public health.

Within the public health community there is a need for public health
physicians, specialists, the wider public health workforce and managers to find
an intellectual focus for joint working as all have a contribution to make
towards improving health. Managers are required to operate in a
multi-professional, multi-agency environment and be able to achieve multi-sectoral
change that benefits the whole population.

To be effective, public health professionals must possess both public health
and management skills. The tensions which emerge between professional groups is
more likely to be caused by an inability to manage the conflicts which result
from perceived differences or incompatibilities with others and their roles, as
well as the management of the power and authority held (see
HK – 5a: The theoretical and practical aspects of power and authority, role
and conflict
).

 

Section Three

Current challenges and opportunities for positive interactions between the
patient, the clinician and public health.

The two previous sections have identified the tensions that exist within the
NHS decision-making process, where the decisions on the healthcare of an
individual have to be made within the healthcare needs of the whole population.

The table below highlights the dichotomies in the decision-making process and
the challenges:

Clinical practice

Public health

For individuals

For populations

Treatment for those who feel ill

Interventions for those who feel well

Number needed to treat (NNT) to achieve one additional positive
outcome as a basis for using a new, innovative or more expensive
treatment

The weighting and comparison of the NNT in one area of healthcare
versus how the resources can be more efficiently used in another area

Decisions unique to the individual

Decisions common to populations

New innovative treatments resulting from experience and practice

Clinical Governance and the need for evidence.

Difficult to produce systems and guidelines

Easy to produce systems and guidelines

Paradigm problem: a patient who is weak and tired

Paradigm problem: a population at risk of polio

(based on Gray 2001)

Clearly patients’ expectations of healthcare are rising: they bring the
evidence of more effective healthcare treatments to the discussion table with
their clinician, they identify new innovative treatments for difficult clinical
problems, and they understandably want what they consider to be the best for
themselves. There has been a societal change in attitude towards the provision
of goods and services and considerably more input from some patients about the
need to choose their own care. 

It is the role of those in public health to ensure that the evidence that is
used by the patients and clinicians is not only up-to-date but is robust and
valid.  Public health also has the ability to input into the commissioning
cycle to support the delivery of healthcare that:

  • maximises resources for all its patients
  • undertake health needs assessments, health impact assessments, equity
    audits etc
  • finds and appraises evidence for new treatments
  • provides economic appraisals
  • finds and appraises the evidence for exceptional treatments. 

Public Health professionals also have the ability to use the media in an
appropriate way to get over positive messages and avoid further harm from poor
research e.g.
MMR

article by Andrew Wakefield that suggested a link with the w:st='on'>
MMR
vaccine to autism.  Through facilitation, motivation and presenting robust
arguments against poor research Public Health professionals have the ability to
present a clear and accurate picture.

Patient expectations can affect those working in clinical as well as
community settings and raise a number of challenges:

Developments

Current Issues

The involvement of patients in their own care, and both public and
patient involvement in broader health service issues, has increased
enormously.

Many patients still feel uninformed and uninvolved and according to
national patient surveys, about 50% of inpatients and 40% of general
practice patients would have liked more say in treatment decisions.

Shared decision-making is a process in which patients are involved as
active partners with the clinician in clarifying acceptable medical
options and choosing a preferred course of clinical care.

Patients place much greater importance on participation in treatment
choices than on choosing where to be treated, yet the policy emphasis
has been on extending hospital choice, not treatment choice.

The development of ‘informed consent’ offers patients the basic
right to be given a clear explanation of the procedure and treatment to
be given.

However, to obtain true informed consent requires the achievement of
a shared understanding and a shared management plan.

This is not and never can be a framework for paternalistic
consulting.

To achieve these tasks at all requires a belief by the physician that
sharing with patients is a desirable outcome.

For most patients the first and most trusted source of information is their
doctor. However faith in doctors’ expertise is beginning to erode –
especially amongst the younger patients (MORI 2001). People are increasingly
accessing health information, from sources including the internet, where good
quality patient health information, helps patients find out about specific
conditions and diseases, as well as organisations that can offer support.

Information Sources

%

Information Sources

%

Doctor

73%

Newspaper/ magazines

18%

Internet/website

30%

Pharmacist

6%

Leaflets or books

23%

Patient organisations

4%

Nurse/other health professional

22%

TV/Radio

4%

Family & Friends

19%

Advertisements

1%

Other

12%

   

Source: Usage and Attitude survey DH; Mori; Technorati,
April 2007

Another perspective is the type of information a patient may want when they
have been newly diagnosed with a condition or on admission to hospital. Good
patient information is important as it can:

  • Help to ensure that patients are properly prepared
  • Give patients confidence, improving their overall experience
  • Remind patients of what they have already been told (in case they have
    forgotten)
  • Involve patients and carers in their treatment and condition.

Individuals also have a right to apply for access to health information held
about themselves and, in some cases, information held about other people. Recent
guidance (DH 2010) assists NHS organisations in
w:st='on'>
England

, through the process of dealing with an access request in accordance with the
relevant legislation.

The NHS Institute for Innovation and Improvement supports the NHS to
transform healthcare for patients and the public by rapidly developing and
spreading new ways of working.  This includes the relationship doctors can
develop with their patients by developing supportive networks, working in
partnership with patients, carers, service users and their representatives as
well as taking an multi-agency approach and working collaboratively with
colleagues to deliver and improve services.

They envisage that competent doctors will:

  • Identify opportunities where working with patients and colleagues in the
    clinical setting can bring added benefits
  • Create opportunities to bring individuals and groups together to achieve
    goals
  • Promote the sharing of information and resources
  • Actively seek the views of others
  • Initiate meetings bringing together patients, carers and the wider
    healthcare team
  • Able to involve patients and carers in discussions about long term care
  • Creates links with patients, cares and key healthcare professionals to
    develop service jointly.

What is clear is that partnerships between doctors and other health
professionals vary from place to place and person to person. Changing roles and
a variety of contextual factors have necessitated change, but that change is
uneven, and sometimes rests on a fragile and pragmatic consensus of how doctors
should work with and alongside others.

Hunt (2007) sees doctors and NHS managers in future working in harmony,
predicting that, ‘doctors will not only fully understand the complexities of
commissioning but they will also be able to design and lead service improvements
– they may even become managers’.

Moving forward doctors, clinicians, public health and managers would benefit
from joint participation at each stage of the decision-making process, this has
the potential to lead to a shared understanding of each other's cultures, why
decisions are made and the need to maximise our limited resources so that all
our patients benefit.  The messages and decision-making processes can then
be more explicit so that there is no conflict of interest and patients
understand why certain decisions have been made.

Doctors and clinicians who work alongside public health and the commissioners
and are involved in the commissioning cycle have the ability to be the change
agents of the future.  Joint working, positive interactions, tackling
problems together and understanding each other’s culture are all required to
ensure that the right decisions are made for the right people at the right time.

 

References:

Brooks, C. (2006) Working with healthcare professionals. In Walshe, K. and
Smith, J. (eds) Healthcare Management pp253-267: Open University Press

Crosson F. J. (2003) Improving the doctor-manager relationship. Kaiser
Permanente: a propensity for partnership
. BMJ;326: 654.

Lord Darzi (2008)  High quality care for all: NHS Next Stage Review
final report.  ISBN 978-0-10-174322-8

Department of Health (2001) Report of the Chief Medical Officer’s
Project to Strengthen the Public Health Function”

Department of Health (2005) All Staff in the NHS, 1994-2004 London

Department of Health (2010) Guidance for Access to Health Records Requests: Quarry House

Department of Health (2010) The NHS Constitution: Government response to
consultation on new patient rights
 :

Ham C. (2003) Improving the performance of health services: the role of
clinical leadership. Lancet 361: 1978-80.

Hunt L (2007). ‘Medical leaders. The long engagement’. Health Service
Journal
, vol 117, no 6070, pp30–1.

Hunter, D. (2007) Managing for Health: Routledge

Gavett, J. W., Drucker, W. R., McCrum, M. S., & Dickinson, J. C. (1985). A
study of high cost inpatients in Hospital Rochester: Rochester Area Hospital Corporation and the University of Rochester.

Gray, M. (2001) Evidence-based Healthcare How to make Health Policy and
management Decisions 
: Churchill Livingstone

Knaus WA, Draper EA, Wagner DP, Zimmerman JE. (1986) An evaluation of outcome from intensive care in major medical centers.  Ann Intern Med
104:410-8.

Korsch, B.M. and Harding, C. (1997) The Intelligent-Patients Guide to the
doctor-patient relationship
Oxford University Press

Levenson, R. Dewar, S. and Shepherd, S (2008) Understanding Doctors,
Harnessing Professionalism
  Kings Fund

Parkin, P. (2009) Managing Change in Healthcare London: Sage

Postgraduate Medical Education and Training Board (2008) Patient’s Role
in healthcare-the future relationship between patient and doctor

Royal College of Physicians (2005) Doctors in society: medical professionalism in a changing world.
Report of a Working Party of the Royal College of Physicians of London. London : RCP

Reeves S and Lewin S. (2004)  Interprofessional collaboration in the
hospital: strategies and

meanings. J Health Serv Res Polic 9:218–25.

Stewart, M.A. and D.L. Roter (eds). (1989) Communicating with Medical
Patients
. Newbury Park, CA: Sage Publications

Sullivan, E.J. and Decker, P.J. (2009) Effective Leadership and Management
in Nursing
London: Pearson Education International

Tamblyn, R. Abrahamowicz, M. Dauphinee, D. Wenghofer, D. Jacques, D. Klass,
D. Sydney Smee,S. Blackmore, D Winslade, N. Girard, N. MSc; Du Berger, R.
Bartman, I. D.L. Buckeridge, D.L. Hanley, J.A. (2007) Physician Scores on a
National Clinical Skills Examination as Predictors of Complaints to Medical
Regulatory Authorities  JAMA; 298(9):993-1001.

Young A.E. (2003) The Medical Manager London: BMJ Books

Sources:

© K Enock and
S Markwell 2010