An exploration of medical director identity
and performativity in the UK National
Health System
Megan Joffe
Kate Mackenzie Davey
Who/what are medical directors (MD)?
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Medical manager: Hybrid or boundary spanning role
MDs are senior most medical manager in the hospital
Has a seat on the hospital board
Strategic responsibility
Usually
– a 3/5 year tenure
– Remain practising clinicians although a few are full-time
managers
– Some have managerial training and most have some
management experience as Clinical Director (operational
responsibility for a medical specialty or division)
– No formal training/qualification available
Identity
• Who I am? = IDENTITY
• What I am? = ROLE
• How do I experience my identity when I have 2 powerful
identities (doctor and manager) supposedly integrated in to 1
hybrid identity?
Qualitative Research
Research Questions
1.
How do medical directors construct managerial identity in general?
2.
How do medical directors resist the negative implications of management?
3.
How do medical directors account for their own managerial identity?
Methodology
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Twenty, 90 minute interviews, with incumbent Acute Trust Medical Directors plus 5 ex Medical Directors
over the course of 2005 - 2008
Theoretical base
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Social Identity Theory (Tajfel & Turner, 1985)
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Performative identity (Butler, 1999)
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Power (Foucault, 1978, 1985)
The managerial context of health
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Management and medicine have been in a struggle for power almost since the
inception of the NHS
Much political and ideological capital is situated in the NHS
History:
• 1948 – 1980s: Management = Administration
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1979 onwards: Started engaging doctors in management
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Budget control/managers given legitimate power/consumer opinion
1989: Quasi market principles (Working for Patients)
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Managerial performance indicators/audit/resource management
1983: General Management (Griffiths Report)
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Consensus management/medical autonomy
Purchaser-provider split/Trust Hospitals with Executive Board incl Medical Directors
1997: New Public Management (The New NHS: Modern, Dependable)
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Scientific-bureaucratic model: targets
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Competitive tendering and accountability: efficiency and effectiveness
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Interdisciplinary and inter-agency working (e.g. MDTs, NICE, HCC etc)
2011: GP Commissioning
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(Equity and Excellence: Liberating the NHS)
Competition/patients and consultants decision making
Findings (1): The construction of management “in
general”
• Constructed from the perspective of doctors & their own perspective as a
doctor
• Negative construction of management mirroring that of doctors (and others of
managers in the NHS)
Specifically:
• Managers are constraining and controlling
• Managers are removed from the shop floor
• Managers are aligned against employees
• Managers are intellectually inferior and incapable of managing
doctors
• Management is a waste
• Management is risky
Findings (2): Clinical credibility
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Clinical credibility is the source of managerial credibility
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Clinical credibility is key to understanding doctors and operational problems
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Clinical credibility is core to my relationships with my clinical colleagues
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Clinical credibility is a reliable source of feedback
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Clinical credibility means I remain a member of the ‘medical tribe’
BUT IT IS CONTESTED
• Idiosyncratic contracts with varying amounts of clinical work
• Some do no clinical work
• No actual evidence – “you are a black sheep anyway”
• Some evidence that you simply need to be a people person
Findings (3): Medical Directors’ construction of their
own managerial identity
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Constructed from their own perspective (my view is ..)
Positive construction except for collegial relationships
Specifically:
• Management is stimulating and creative
• Management is challenging and fulfilling
• Management is influencing and improving
• Collegial relationships
– Relationships with colleagues in difficulty
– The medical director as headmaster
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“I am always a doctor”
Conclusions
1. Medical identity is robust and magnetic
2. MDs use medical identity to resist being seen as managerial and assert their difference from
other managers
3. Managerial credibility is predicated on clinical credibility rather than on managerial
experience and expertise
4. Clinical credibility is a source of resistance to being fully ‘colonised’ by management and is
central to doctors retaining control over their work and their separation from management
5. The ambiguity of the role of MD makes it difficult
6. Medical management is seen as difficult compared to clinical work
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“It’s downtime ... It’s really relaxing”
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“ ... Easy! Work hard. Do your best. Be nice to people”
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“... And actually when I’m doing a day in ICU I think: Actually this is a doddle compared to what I’m doing in the other bit of the job”
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“... like walking into a Jacuzzi. It’s relaxing. This is my environment. I am very happy to be here”
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“Whereas clinical work is rather more stereotyped, so typically my speciality which is clinic based, it would be back to doing repeated large numbers
of clinics probably. And, I do think even now what that would feel like to go back to after such a rich experience as medical director”