Knowing me knowing you
. . . interpersonal relationships between managers and hospital consultants . . .
Cranfield Healthcare Management Group
Research Briefing
11
How do they manage?
a study of the realities of middle and front line management work in healthcare
Cíara Moore: June 2011
‘At the end of the day you are just trying to do the same thing’ (Consultant)
Interpersonal relationships between hospital consultants and managers can be frustrating
when things go wrong, and rewarding when things go well. The perception of ‘them and us’
has been the norm for many years (McCarthy 1993). Is this still the case today? Do doctors
and managers really face different pressures? How can these two groups support and learn
from each other in the challenging environment of the NHS?
During a focus group discussion at Clearview Hospital, a manager said that consultants see
them as ‘bean counters’. Consultants are being asked to shoulder more management
responsibility, and with cuts in funding looming, it is easy to assume that an organization can
cope with fewer managers. Many managers thus feel undervalued and insecure, and in this
study have told us that they have difficulty managing human resource issues, high workloads,
conflicting priorities, and a lack of influence and authority. Are these pressures experienced
by consultants? How important is the manager’s role to them, now and into the future?
The Johari Window is a tool for understanding interpersonal relationships, based on what we
know and what we don’t know about ourselves and others. Using our interviews and focus
groups, we can fill the following version of the window with our understanding of managers
and consultants, based on their perceptions of themselves, and of each other.
Open
Blind
How managers see themselves
How consultants view managers
As managers, we recognize that the job
comes with bureaucracy.
I remember as a registrar someone saying, ‘Get
this person out - they are about to breach’.
There are more targets than ever, and
less money.
You don’t come across management until you
are a consultant and someone appears in your
office and says, ‘I want you to do this’.
Hidden
Unknown
How managers view consultants
How consultants see themselves
Managers are the jam in the sandwich;
they do not like the negative stereotype.
Doctors assimilate and learn in a different way.
There is a role for people who are non-medical.
Even in Holby City, the manager is the
bad guy.
Support from the consultant is needed.
I am not one to get rid of management; we need
their skills, and we need them to be embedded in
the unit.
We interviewed consultants at Clearview Hospital and found that the pressures and problems
that they experienced were similar to those faced by frontline and middle managers. There is
a sense of ‘we’re all in the same boat’. And perhaps surprisingly, consultants supported the
value of managers who bring different skills and perspectives to problem solving and change.
Reinforcing the value of medical-managerial collaboration, one senior consultant said, ‘As
clinical director responsible for managing the service, I want a very confident, expert manager
with a good business accountancy and finance background, who understands that side of it’.
But he was also critical of the ‘pettyfogging nonsense’ of inappropriate targets and layers of
bureaucracy generated by government policy.
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What we found - the same pressures
managers
consultants
I’m always fire fighting, always trying
to meet another deadline
Targets, such as breaches happening right left and centre in
the emergency department - there’s no space, you work as
hard as you can and there are people waiting five to six
hours and that’s not good. You do feel pressure, and think, I
have got to do something, and often the answer you come up
with is just working yourself harder
My management responsibilities just
seem to keep expanding
You start out with a job plan and job description and quite
quickly extra things get added to it. Or you are asked to take
on extra things without getting the opportunity to say no
I mentor, train, and act as a role model
for less experienced staff
Junior doctors for the last two years have not been the same
calibre. That puts pressure on you to get them through
things and improve them and work with them more
I regularly arrive early and leave late 10 to 12 hour days are normal for me
It’s about managing your day job and taking responsibility
for all these extra things and keeping them running at the
same time. Some of them you have control over, like the
things you decide to develop
I am expected to improve the service we
provide, but resources are being cut
I think pressure from above to do more with less, and you
feel - I am already working pretty hard and I don’t know
how to improve things further
It doesn’t matter what I do,
It’s never good enough.
You could see the obvious problems but you could not do
anything in spite of all the efforts we made. Talking to
everyone in sight you couldn’t really affect anything
How important is the management role?
Back in the 1990s, clinicians said that ‘managers huddle together and talk incomprehensible
shop. They are aloof and supercilious. Friendliness may be displayed but it’s a front’. Our
findings present a different view. The consultants we interviewed saw the management role
as critical, bringing different skills, vital to achieving objectives and implementing service
improvements. They recognized that managers were overworked and one said that, ‘there is a
lack of appreciation of what a manager does’.
Negative views were directed more toward senior management, perhaps because front line
and middle managers are closer to the day-to-day business. When changes are due, middle
managers are often the messengers; and as Huy (2001) notes, this involves using translation
skills to sell a change initiative. Close working between managers and consultants ensures
that good relationships are maintained, and that managers are seen as key to the service.
Strengthening the relationship
SWEAT the small stuff: Consultants often turn to the manager for support and operational
assistance. So, if you agree to sort an issue, then deliver. The consultants to whom we spoke
said that anger towards management was fuelled by the small issues that were never fixed.
For example, one consultant waited eight months for a printer connection. He recognized that
this was not a management priority, ‘but I was reminded every day and that just annoys you’.
The big stuff, such as developing business cases, and responding to serious incidents, are of
course important. But if as a manager you put the small issues to one side, you risk losing
credibility, and losing the support of a current and future ally.
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MEET your consultants: Consultants have many demands on their time. But they want
‘more dialogue’, ‘to know what’s going on’, and to be involved in decisions. One said that
she had management contact when setting up new services, but once running, there were only
‘snatched conversations in the corridor’. Consider having regular ‘I’m okay, you’re okay’
meetings with your consultants. Keep actions realistic, agree timescales, and report back if
you can’t deliver on target. Consultants know that managers are busy; keep them informed.
REMEMBER the doctors of the future: Some of our consultants never met managers until
they became a consultant. Invite them to ‘management only’ meetings so they can understand
your role. Junior doctors may also have bright service improvement ideas.
. . . and back to the future?
The consultants who we interviewed said that they would like to see:
¾
¾
¾
¾
more doctors engaged and given the support to manage their services
management demystified
more integration, working closely with managers embedded in their services
better consultation on issues that matter to them
If you have a view on any these issues, please let us know.
Sources
McCarthy, S., Berman, R. and Bell, L. (1993) ‘Professionals in healthcare: perceptions of managers’
Journal of Management in Medicine, 7(5), pp.48-55.
Huy, Q.N., (2001), ‘In praise of middle managers’, Harvard Business Review,79(8), pp.72-9.
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The research
This study is based on interviews and focus groups with middle and senior managers at six acute trusts and one
primary care trust. The next stages of the project include a management survey, debriefing groups, and case
studies exploring how changes are managed in the aftermath of serious incidents.
Participating trusts
Bedford Hospital NHS Trust
NHS Bedfordshire Primary Care Trust
Cambridge University Hospitals NHS Foundation Trust
Gloucestershire Hospitals NHS Foundation Trust
Northampton General Hospital NHS Trust
North Bristol NHS Trust
Whipps Cross University Hospital NHS Trust
Project team
Prof David A. Buchanan (PI)
Dr Charles Wainwright
Prof David Denyer
Dr Clare Kelliher
Ms Cíara Moore
Dr Emma Parry
Dr Colin Pilbeam
Dr Janet Price
Prof Kim Turnbull James
Dr Catherine Bailey
Dr Janice Osbourne
Acknowledgements: The research on which this briefing is based was funded by the National Institute for Health
Research Service Delivery and Organization programme, award number SDO/08/1808/238, ‘How do they
manage?: a study of the realities of middle and front line management work in healthcare’.
Disclaimer: This briefing is based on independent research commissioned by the National Institute for Health
Research. The views expressed are those of the author(s), and not necessarily those of the NHS, the National
Institute for Health Research or the Department of Health.
For further information about this project, contact Jayne Ashley, Project Administrator
T:
E:
01234 751122
J.Ashley@Cranfield.ac.uk
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