Why do clinicians and managers struggle to work together?

Martin Williams
‘Operations might get cancelled because somebody in the booking office has put together an operating list without knowing the details of the case.’ Photograph: Getty

With an army of more than 1.5 million staff, a £116bn budget and millions of patients to look after, it’s crucial that the NHS is well managed. But three years ago the landmark Francis report warned of serious problems. “Clinicians must be engaged to a far greater degree of engagement in leadership and management roles,” it said. “The gulf between clinicians and management needs to be closed.”

Has the relationship between clinical and managerial staff improved since then? Last year, research by the Nuffield Trust suggested financial pressure was compounding the problem, with many staff worried that “relationships are likely to deteriorate over the coming year”. The report concluded: “There is a long way to go.” We asked clinicians and managers to share their personal experiences of this fragile relationship.

Manager: ‘When I first started it was hard to get clinical staff to work with people like me, but things are changing’

I find it quite rare that clinicians and managers don’t get on. There’s not really a big difference. It’s just that they’re being pushed in very different ways.

National targets cause quite a lot of trouble, because you end up having a really tricky middle-management layer. They’re getting shouted at from above, from the senior director level, to meet their key performance indicators (KPIs). They’re also getting shouted at from clinicians, who see the KPIs as dehumanising.

For me, the sort of issue that I come up against is trying to release staff to do improvement work. I end up being the middle man; I want to get clinical staff out of their workplace for a few days, but I can also see from a management perspective that taking people out for that much time is not an option.

You get really weird setups, where consultants are managed by somebody who’s paid maybe half their salary. They think: “I know you’re my manager, but I also know you can’t tell me what to do, and I’ll do whatever the hell I want.” It becomes difficult for managers to change things and implement new ways of working. They’ve got to be skilled in the art of emotional intelligence. It’s almost manipulation – they need to impart ideas into people’s brains without a direct command.

When I first started, it was hard to get clinical staff to work with people like me – and to want to engage with change and improvement. But recently, we’re finding that staff are coming to us and saying: “We’re struggling, can you come and help us?”

My manager was about to risk my patient’s life for the sake of a government-inflicted target

A&E nurse: ‘One manager risked a patient’s life for the sake of a target’

We have managers who you rarely see in person. They are simply a barking voice on the other end of the phone. They harass you endlessly when a patient is coming close to breaching the four-hour target in A&E. I get relentless phone calls; if they actually let me get off the phone and do my job I could focus on managing and preventing breaches.

It’s rare that they ever come down as a supporting presence in the department. Some of them have a clinical background, but you rarely see them rolling their sleeves up and digging in to help us out. I feel alienated from managers.

Once, I was working with critically unwell people and a patient was coming up to a four-hour breach. We’re fined for each breach. Someone in a suit approached, took the brakes off the patient’s trolley, and started to push them out. He said: “This patient is about to breach, we need to get him to the ward.” The response was: “This man’s blood pressure is dangerously high. You won’t make it to the ward.” This manager was about to risk the patient’s life for the sake of a government-inflicted target.

Clinical manager: I’ve got a very responsive senior management team

I’m fairly lucky, I don’t have a heavy-handed senior management team and they’re very responsive. If I go along and say I have an issue, they listen. I didn’t set out to be a clinical manager, but managerial responsibilities come with the grade. The advantage is I know what the job is; I’ve had to do it.

I work in a small health board so it’s reasonably easy to communicate with each other. People are around and we’ve got good face-to-face relationships. I think when you’ve got a much bigger organisation, it’s harder to do that.

NHS manager: ‘The health service runs because managers and clinicians get on’

Running the NHS is an incredibly complicated operation, so I guess it’s not surprising if there’s a lack of understanding about what managers are doing all day. But most of the time, the NHS runs because managers and clinicians get on – not despite the fact that they don’t.

Sometimes it’s the managers who are seen as making the tough decisions and implementing the policies no one likes. But actually, in the parts of the NHS that are really succeeding, those decisions will always be made in partnership with clinical colleagues and leaders. And they’ll always have what’s right for patients and their families at the heart of it.

Managers share an awful lot of the same motivations as doctors, nurses, therapists and scientists. They have a lot more in common with clinical staff than we’re given credit for.

Junior doctor: ‘I don’t know who my manager is’

I’ve worked with some managers who are diabolically awful, and it makes it really hard to get your work done. As a junior doctor, it’s difficult to interact with senior management. We’re not invited to any of their meetings; we’re not consulted on anything.

Recently, I worked in a hospital where they sacked all the phlebotomists because they needed to save money, and said: “Well, the junior doctors can take those bloods anyway.” We can, but there’s only so many things you can do at a time. So they get done sporadically through the day, when you’ve got two minutes to spare. It means that if your results don’t get back until 8pm, then a lot of older people won’t be able to get home afterwards, so they’re stuck in hospital for another night, wasting money. If any junior doctor had been invited to the meeting where they decided that, we could have warned them. But there’s no relationship with management, and there’s no consequences if they get things wrong.

Consultant: ‘Managers see things from a very different angle: it’s all numbers and targets’

At the moment, it’s very much: “Here’s your list of patients, get on with it.” People start to resent that after a while. The fundamental change that needs to happen is that managers have more exposure to patients, and doctors have more exposure to management.

Managers see things from a very different angle: it’s all numbers and targets. Operations might get cancelled because somebody in the booking office has put together an operating list without knowing the details of the case, the complexities of it, and how fast or slow that particular surgeon is. It would make sense if doctors had a lot more input into how every day is run, what equipment is procured, and so on. People do try to engage, but it’s incredibly difficult to make those changes.

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