Service improvements and organisational change in the NHS are more effective when led by clinicians with management responsibilities than by full-time managers, according to research by Professor Louise Fitzgerald, Saïd Business School, University of Oxford. However, these ‘hybrid’ managers are currently struggling without support and training in management, which they need to help them succeed.
“The popular image that the NHS is overrun by managers with no medical expertise is inaccurate,” said Prof Fitzgerald, visiting professor (organisational change). “Hybrid managers, who combine managerial responsibilities with clinical or medical duties, outnumber the full-time managers by four to one. But many find the role a tough challenge, partly because of a historic conflict between how medical professionals view themselves and their roles and their perception of management, and partly because they have not been taught how to manage.
“Although our research has suggested that it may be more important to learn how to be a hybrid than to do management, even the most proactive hybrid managers can be slowed down by a lack of knowledge of basic issues – which can be taught,” she said. “Better management training alongside professional training, as well as improved financial rewards for those taking on a hybrid management role, would have the benefits both of encouraging more professionals to become hybrids, and making them more effective when they do.”
Prof Fitzgerald has identified two key issues that have an impact on the effectiveness of hybrid managers in the NHS: Medical professionals in all fields identify themselves as medics first and foremost. If they take on a management role, they often see it as something of a sideline – either they have been asked to ‘take a turn’ (defined by Fitzgerald and her colleagues as ‘passive professional obligation’), or they feel that they need to ‘protect’ the profession from encroaching managerialism (‘reactive professional obligation’).
“These ‘incidental’ hybrid managers typically use their roles to keep medical professional work separate from the demands of politics and management and to protect it from change,” explained Prof Fitzgerald. “They are not really interested in service improvement, seeing it as a ‘box-ticking’ exercise. To effect real change, the NHS will have to identify these incidental hybrids and find ways of either engaging them in genuine service improvement or encouraging them to vacate the role for others who wish to achieve this – those we have called ‘willing hybrids’.”
Willing hybrids often have to endure accusations from their fellow professionals of “going over to the dark side”, of becoming “a poacher turned gamekeeper… fraternising with the enemy”. Nevertheless, they were proactive in seeking service improvements and used their roles to disrupt and challenge unrealistic and out-dated professionalism.
“Our research showed that these hybrids were interested in inter-professional teamwork, focused on delivering ‘the best service’ for patients collectively, in contrast to the institutionalised lone professional who focuses on individual patients,” said Prof Fitzgerald. “They were willing to challenge professionals who ignored resource limitations and were willing to work with government targets as a means of providing good patient care.”
Hybrid managers tend to learn the management side of their roles on the job. This has an advantage in that they are not seen to distance themselves too much from clinical or medical practice. However, some do not feel supported in their roles. Others are hampered by a lack of knowledge about management, particularly in specialised areas such as change management.
