The Manager/ Clinician Divide

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Why - the Manager/ Clinician divide

There seems to be an enormous gulf, in healthcare, between those that care for patients, and those that administer. Neither side seems to trust the other – clinicians accuse managers of thinking only of costs, and in return managers complain of a refusal to recognise limited resources. This applies in other environments, eg social care, where care professionals and management also seem to struggle to bridge the communication gulf.

I was at a NAPC dinner the other evening, and met a person who was amazed I believed that it was possible to forecast. I asked the question “what is the likelihood that someone will win the lottery this week?” Of course the answer is “anybody – pretty much certain. A specific ticket – 14million to one.”

Having spent time helping teams to work together in contentious areas such as service redesign, I present my conclusions on the differences (I’m going to use the term ‘administrator’ throughout, as I believe the problem set in when administrators took on the title Manager and thought they were important):

They think differently

Administrators and clinicians have different views on the world. This reflects the kinds of people that gravitate towards each role.

Doctors, nurses and AHPs like working face to face. They have endless patience to address each individual need, but it makes it difficult to then take a helicopter view and say “how many next year?”, “what skills will be needed?”, and “what do I prioritise and what do I do with the ones who aren’t prioritised?”. Administrators provide the complementary function.

Care vs statistics

This focussed ‘one by one’ approach can lead to different responses when each looks out into a full waiting room. A natural reaction from the clinician is “I’m so busy, how will I manage?”, whereas the administrator should take the view “I need to plan to manage” – but then that is what the manager has prioritised their time for, planning ahead.

Similarly the clinician looks at the patient presenting and says “what condition do they have?”. Statistics play a relatively minor role in this process. The administrator looks at the demographics and disease prevalence, and says “what resources do I need in place to meet the likely requirements, and to provide a response in the event of something serious but rare?”. The Administrator has the phenomenally difficult task of deciding how to prioritise limited resources, and who to say “no” to. Mind you, the clinician has to look the person in the face!

Planning ahead

There is, there will always be, more need than there are resources. Demographics change over multi-year periods, eg the number of people living with long-term conditions, the numbers alive in different age decades and their changing needs. Two studies illustrate that quality care is not dependent on the amount of money spent – one done by me on World Health Organisation data shows that within a limited range more money spent = longer life, but USA spends much more than anyone else (both as % of GPD, and also because GDP is so high per head) without getting better results:

after Porter & Teisberg who quoted Friedman, Milton in "How to Cure Healthcare" pg 20

And the one below quoted in Porter & Teisberg pg 29 showing that the UK model of GPs to see all patients and refer those who need further treatment to a specialist not only gives higher quality care than the patient self-referring from one specialist to the next, but is also cheaper:

(incidentally, why are we in UK trying to imitate USA when they are trying to imitate us?)

The administrator’s task

To set the strategy, or if it is already set, to plan how to comply with the strategy in a specific situation. This means taking advice, gaining understanding of the clinical requirement, understanding the resource requirement, whether different skills or a multi-disciplinary team is required, and how.

It applies today, and it applies in short, medium and long terms.

Bridging the divide

We’re going to present specific techniques for getting working groups that work together, and illustrate with some successes (both mine and ones I’ve studied). The first step is to acknowledge the difference.