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Health policy review

Winter 2006

Issue 3: Changing relationships between doctors and organisations
This journal is produced by the Health Policy and Economic Research Unit and is designed to stimulate debate. The views expressed do not necessarily represent BMA policy.

Editorial - Tom Smith
The government’s programme to reform the NHS has reached a critical point with the next stage including fundamental changes to organisations and clinical services. Policy change so far has been invisible to the public, this next stage will see visible change.

New efforts to increase productivity, redesign processes and reorganise services depend on constructive and effective relationships between doctors and organisations so as to manage this complex change.

Despite this need, relationships between doctors and managers are not uniformly good and tensions persist. The fundamental problem is a failure to relate very different perspectives and, more broadly, a failure to reach accommodation on the basis by which healthcare should be governed. Recent years have seen battles between the two sides as the management perspective has come to dominate the professional one within organisations. This relationship is not conducive to effective service change,

Why are relationships between doctors and organisations so complex and difficult to shape? What kind of organisational model could better align the perspectives of organisational and clinical management? What drives hospital doctors and what does research tell us about the effectiveness of incentives to change medical behaviour? How is the manager-doctor balance within general practice changing as a consequence of a health service that is becoming more primary-care led? Across healthcare and traditional boundaries, what potential is there for a fundamental reengineering of the doctor-organisation relationship?

While each of these questions is critical none has received much attention in the context of the current reform programme. The papers in this issue draw on these questions to explore changing relationships between doctors and organisations.

The first paper outlines some of the political, philosophical and cultural differences that exist between managers, as organisational agents, and doctors as professional ones. It charts the rise of managerialism and the fall of professionalism as an organising principle. In hospital settings particularly, the trend has been for doctors to become more alienated from organisational management. Debate ensues about whether doctors have been marginalised or whether they have distanced themselves.

Despite the distance between doctors and organisations, the paper argues that a range of drivers are changing the traditional organisational environment – more competition, providing more services in community settings, a new financial system – and necessitating a fundamentally different relationship between managers and doctors. To survive in a more competitive environment, each department within an NHS hospital will need a clear clinical strategy, formulated and implemented by managers and clinicians together. PCTs will likewise work with doctors to develop new clinical pathways and strengthen commissioning. Clinical leadership becomes ever more important.

Across health economies, redesigning and reorganising services will require close collaboration, common strategy and clinical leadership: a different kind of management is required in this new environment, one that affords a greater role for the clinical vision. It may be that reform will spawn new kinds of organisations that are more clinically led.

In different ways, and from different perspectives, the common conclusion of the papers focusing on this theme is the need for clinical strategy and clinical leadership to be at the forefront of what is clearly going to be a complex and uncertain period of change. It is interesting to contrast the experience of secondary doctors who are employed with GPs, many of whom are independent contractors. Thomas Frusher examines changes in primary care and the agency of general practice in changing health services and shaping their development. From the early 1990s, as hospital doctors have become more remote from organisational management, GPs have moved closer to it. This may be because GPs have a clearer constitutional position within healthcare: they provide premises, are a managerial, an employing unit, an organiser and provider of care.

In the current programme of reform the centrality of general practice is further reinforced. GPs will drive commissioning forward, making key changes in services and many are likely to work in new collaborations with other practices. Frusher shows that unlike the secondary sector, in primary care there has been a development of management by professionals, in contrast to secondary care which has been characterised by the management of professionals.

One of the more recent levers employed in their management is a greater use of incentives. Jonita Jabbal notes a tendency within health policy towards seeing doctors less as ‘knights’, with a professional compass that guides them to do the right thing, and more as ‘knaves’, or self-interested agents who need to be incentivised to do the right thing. Drawing on studies of the use of incentives in changing medical behaviour, Jabbal asks: ‘what drives hospital doctors?’ She shows that incentives can make a difference to medical behaviour. She also shows that doctors are not purely economic agents and that there is a clear and sizeable ‘x-factor’ that economic studies fail to capture. This relates directly to the professional ethics of doctors and their clinical ambitions.

The implications for policy are two-fold. First, there is scope for alignment between payment by results (PbR) and specific departments, which will go some way to facing professionals towards organisational performance, and a greater emphasis on departmental strategy may focus managers more on organisational development. Second, organisations should seek to harness professional incentives rather than ignore them.

Jon Ford’s economic piece on the development of PbR and tariffs suggests that it is still difficult to develop the system to reward and reinforce collaborative efforts. Ford is concerned by the lack of emphasis on quality in the payment structure or commissioning framework. He suggests that the full development of PbR should, focus on results whereas the current structure places the emphasis on activity. He is also concerned about the effects on acute trusts of greater financial volatility, when more coordinated and managed change is needed across health economies. He suggests that the financial climate will point commissioners towards lower tariffs in primary care, which will be developed locally.

Newspapers are already beginning to report the effects of service change. There have been protests in many towns across the country. MPs in areas where services are threatened are becoming nervous that the direction of health policy might make their lives more difficult.

Given the recognition that services will change and that any discussion of changing services is politically tense, it is perhaps understandable that there has been an increasing call to ‘take the politics out of the NHS’. It is argued that difficult decisions need to be made and these should be protected from political influence.

While it seems everyone is agreed on what they want to move away from – centralised control and political interference in healthcare – there is less clarity on what they want to move towards. This issue sees the first of a new regular feature, Health Policy Debate, which will explore and analyse discussion around different aspects. In examining calls for an independent body, it is noted that though they use similar language individuals are talking about quite different things. Four different models have so far emerged – a management agency model, a regulatory one, a proposal for a constitution/charter and suggestions that power should be devolved right down to the local level with the aim of strengthening local democracy.

While aspects of the models proposed may improve the management of the NHS, none will take politics out of the NHS. Nor should they; while suggestions to do so are understandable, they are perhaps not realistic because there will inevitably be different views on how services should develop and these should be discussed. Given the degree to which current reforms are contested and the feeling of many that they have not been adequately involved, it could be argued there should be more politics in the NHS not less. More mechanisms are needed to frame discussions between different perspectives.

When it comes to critical issues – such as service changes or what services are and are not available – it is essential to discuss their implications and to take account of different perspectives. A process is needed to scrutinise decisions. For these reasons, politics cannot be taken out of the NHS, though, of course, they can be much better managed. Politics are important and cannot be ignored or dismissed as unhelpful. This is as true at the organisational level as the national level.

Contributors
Eleanor Babbington, Research Analyst, Health Policy and Economic Research Unit
Tania Fisher, Research Analyst, Health Policy and Economic Research Unit
Jon Ford, Head, Health Policy and Economic Research Unit
Thomas Frusher, Policy Analyst, Health Policy and Economic Research Unit
Jonita Jabbal, Senior Policy Executive, Staff and Associate Specialists Committee
Tom Smith, Senior Policy Analyst, Health Policy and Economic Research Unit