The background of the management problem
Health care management has been the preserve of qualified and trained managers since time immemorial. The advent of specialization in health care has opened doors for the incorporation of professional health workers in management. Although little achievement has happened in this direction, the debate is gathering momentum on the role professionals ought to play in the running of health care particularly in the United Kingdom.
The United Kingdom is among the most developed economy in the world in terms of its gross domestic product. Health care is mainly provided by the government-funded by the National Health Service (NHS) that is supplemented by efforts from the private sector. The National Health Service runs all the public hospitals and serves slightly more than 90% of the population. Since its inception by an act of parliament in 1946, the NHS has continued providing primary care and inpatient treatment care. With a workforce estimated at more than 1.3 million, the NHS spends a large portion of its funds on the remuneration of managers who are not professional health workers. This came into effect in the late 1980s when the government introduced policy changes that underscore the need for general managers to boost efficiency and accountability in the hospitals. The policy also recommended the active involvement of clinicians in the overall running of health, although to a lesser extent. Despite many years of policy changes on management and service delivery, the NHS has continued to experience financial pressures due to changing dynamics of health care such as insurance, aging population and improved technology (National Health Service n.d., para. 1).
Introduction to the management problem
Management entails aspects of getting activities done efficiently and effectively by engaging the services of other people in an organization. Health care management involves the integration of leadership abilities, management prowess, and aspects of administration in health care facilities. Health care management is imperative in the determination of the overall health status of a country’s population. Furthermore, health has been closely linked with economic development owing to the destabilization of workers’ productivity that may result in ill health. Management entails many intertwined roles that enhance the achievement of positive benefits. According to Mintzberg (1973), the roles of a manager have surpassed those advocated by the classical literature. In addition to the planning, coordination and financial management, the managers are supposed to play interpersonal and decisional roles as well as act as information agents of their organizations (Mintzberg, 1973).
Health care management refers to the overall running of activities related to the prevention and treatment of illness and diseases as well as the maintenance of physical and mental well-being (National Health Service n.d., para.2). The health care services are offered through the concerted efforts of nurses, doctors and another specialized and unskilled workforce. Management in all areas including health care entail encompasses the planning, staffing and organizing supplemented by leadership and control (Whittington 1994, p.12). Taking into consideration the level of investments made in health care, there is a need to have very competent individuals mandated to manage the resources. Effective application of managerial skills will result in the development of solid health institutions with the ability to provide quality services to the citizens. Management also endeavors to follow laid-down policies that are vital in guiding the institutions in the achievement of specific objectives and goals. It is, therefore, an integral aspect of any organization since it links up the various actors and factors of production. This is evident in hospitals where the first line managers shoulder much of the responsibilities of linking up the patients, staff and senior managers (Duffield, 1992, p.42). The possession of managerial skills comes in handy in the exercise of daily routines that require a wide variety of competencies.
Management in healthcare organizations has taken different twists in the last few decades owing to various policy changes aimed at addressing the problems plaguing the health sector. The understanding of the functioning of the healthcare system is imperative in the achievement of efficacy and effectiveness in the overall running of the institutions. The linkage of technicalities from the first line to the top brass of management has greatly improved thereby resulting in timely action on pertinent issues. Moreover, the involvement of professionals from different cadres of the health workforce helps bring synergy that is crucial in coordination and communication. The application of laid down guidelines respects the various regulations governing professional performance (Duffield, 1992, p.42).
The National Health Service has continued to experience budget deficits despite investing in the hiring of trained managers (Witz 1994, p. 10). The over-dependence on managers has been criticized thereby making the hospitals start embracing the clinicians as a core component of their management. Recently, the Labor government led by Gordon Brown has increasingly advocated for the scaling down on managerial jobs thereby giving the doctors more leeway in the management of the institutions.
The overdependence on this cadre of workers to deliver change in the health care institutions has received criticism from previous studies. The embracement of clinicians in the management is not new to the United Kingdom since the last decade has seen its slow implementation. Leatt (1994, p. 171) asserted that an ever-increasing number of physicians were expected to involve themselves in managerial work, in addition to their professional activities. However, discontent has occurred with several analysts arguing that conflicting roles will ensue. Their argument pegs on whether there will be effective delivery of teaching, clinical care or even research in line with the newly acquired managerial duties. The excellent performance of the clinicians and physicians in junior levels of management has endeared the physicians to policymakers who are continuously pushing for the downscaling of managers in favor of the clinicians. Despite putting in place several policy measures in terms of hospital management, severe problems in the management and service delivery persist.
Research work has continuously delved into the variations witnessed in managerial work while paying scant attention to how the evidence can be utilized to impart on the managerial practices. The mere description of the features that depict managerial work and theories that fail to link the relations between managerial works with the research findings serves to justify the need to undertake a study on this topic. This worsens due to the lack of adequate information that depicts how the reasons managers are able to reaffirm the norms and to a smaller extent the meanings that enhance the interaction of the managerial practices (Hales, 1999, p.372-373). This study is therefore imperative in the determination of the degree to which the clinicians are involved in management while also checking their impact on service delivery.
Statement of the Management Problem
The United Kingdom cannot continue relying largely on trained managers in the overall running of health care who have failed to achieve the desired expectations in terms of accountability and governance. The exorbitant fees paid to the managers as remuneration have continued influencing negatively on the budgetary allocation to NHS thus the need to embrace the clinicians as an integral component of the management. Minimal research has occurred on the factors and implications of the switch to managerial duties by the clinicians. Of particular importance, are the policy implications needed in place in order to achieve maximum productivity of the professionals and health care organizations while minimizing the role conflicts among the various stakeholders.
The role and competencies of managers
Managers have become an integral part of any organization and business because of their ability to link up the factors of production and the various actors. Hales noted that managers have a propensity of indulging much in the daily activities that involve supervision of the workforce and ascertaining everything is in order at the workplace (2001, p.52). The most common features of this work include involvement in fragmented activities, usually interrupted, and the propensity to address the urgent rather than the planned activities. The irresistible obligation to provide solutions to problems affecting the work processes. More importantly, is the increasing indulgence in all types of communication (Hales, 1999, p. 338). Communication plays a big role, especially when dealing with the internal and external environment. In this regard, the managers have to display impeccable communication skills, especially when dealing with situations concerning the welfare of the workforce or the reputation of the organization.
In order to understand the specific roles of managers, it is imperative to list the purely managerial duties and separate them from the normal duties. Avoidance of the assumption that everyone knows what managerial work entails is paramount while substantive linkages between who and what they are need explanations in terms of positive or negative impacts on effective management (Hales, 1999, p.336). This is imperative since it helps remove the ambiguities and controversies that surround the role played by the management.
There has been much debate on the role of managers because of several factors. In their course of action, the managers need to observe guidelines and take into consideration the objectives of the organization before embarking on a certain course of action. According to Mintzberg (1973), managerial work is greatly informed by several schools of thought. The classical school is reliant on the five basic functions expected of all managers. Apart from planning, coordinating and organizing, the managers are also expected to command and control the functioning of the institution and the workforce (Hales, 2001, p.50-53). Today, managers have to offer motivation to the workforce while at the same time exerting their influence on the overall staffing of the institutions. In fact, innovation is the single most activity that distinguishes a successful manager from the rest. Management requires a lot of courage, effective communication skills, determination and a combination of the right skills for success to be achieved in the negotiations or in the achievement of the long-term goals of the organization (Mintzberg, 1998, p.142-144)
Mintzberg (1973) noted that managers indulge in several roles while executing their responsibilities. Interpersonal roles play a major role in ensuring the togetherness of the workforce (Mintzberg 1973). The manager acts as a figurehead and a leader upon whom others seek direction or help. Communication roles help the manager to interact with various stakeholders and effectively deal with the workforce. More importantly, the manager must have the ability to monitor and disseminate information while at the same time acting as a spokesman of the organization in different forums. The informational roles are important in the health care setting since the working environment requires accuracy when making decisions particularly on the course of action to take when dealing with a patient. The exposure of the organizations to the harsh work environment requires the managers to make strategic decisions regarding the operations. In this case, the health care manager must be at the forefront in the initiation and development of change management. Monitoring and evaluation capabilities assist in the analysis of the situation before corrective measures are applied especially when there is a deviation from the initial plan. Problem-solving is another unavoidable role that the manager must struggle to execute diligently. Problem-solving may involve the internal conflicts witnessed within or those pitting the organization with others. Resources form the foundation of any organization and as such, the manager must be ready to allocate the resources appropriately while keeping in mind the time, program and formalities involved in the process (Hales, 2001, p.50-53).
Effective management requires the managers to have a combination of skills. Proper utilization of communication and decision-making skills have continuously propelled their careers while helping the organization build its image. Moreover, information gathering has proved instrumental particularly when the institutions are planning to initiate change management. For the managers to perform the above roles efficiently, they must have the following competencies. The managers must be progressive and results focussed by directing the team towards the right path of prosperity. According to Hales (2001, p. 50-58), managers must be competent in planning the financial and human resources and be willing to develop a cohesive and focussed team that will push forward the desired change. Possession of powerful decision-making and communication skills also affects change management. Health care managers must listen to their juniors and patients in order to effectively address their concerns Hales (2001, p. 50-58). Managers must embrace and act on the positive feedbacks and criticisms from the stakeholders since this will greatly inform the final decisions on paramount issues in the organization.
Professional as managers in health care settings
For many years, managerial positions were the preserve of professionally trained managers. However, following the dismal performance of the health care units, several government regimes embarked on a restructuring plan that resulted in the development and implementation of policy papers in the last two decades of the 20th century. The integration of managerial and clinical practice received mixed reactions from various stakeholders. This ushered the integration referred to as the ‘two windows’ in reference to the two roles assigned to the professional. The metaphor represented a great interchange that embraced transparency and openness in the running of health care. The introduction of this concept served to bridge the gap that existed in the earlier years.
Bolton noted that since early 1990, the government has embraced the role played by the nurse in the delivery of quality patient care and organization of NHS (2005, p.6). Although the first-line managers existed before this directive, they actually received a major boost since they could progress to the middle-level management (Duffield 1994, p. 49). International evidence provides interesting insights. Canada is experiencing the same problem of health professionals taking up managerial jobs (Duffield 1994, p.50). However, the change is due to a constellation of internal and external factors in the health care system. The ever-rising costs of health care buoyed by advancements in technology and insurance premiums have worried the government making it institute policies to regulate the medical practice. Furthermore, increased pressure particularly from the medical fraternity and the decline in demand for medical professionals has resulted in the diversification into other areas. Likewise, nurses are lured into managerial positions as part of the normative device that is aimed at regulating the work pool by reducing competition through diversification of roles (Bolton, 2005, p.7). Canada thus has experienced a surge in the number of physicians holding top managerial positions with health care providers and learning institutions. The Canadian hospitals have increasingly tapped the potential by offering them high-level positions as administrators, board members and trustees. This has propelled into decision-making organs where they delve into strategic planning and financial management (Leatt, 1994, p.171-173). Australia has also embarked on change management where the nurses are assigned several roles to maximize their productivity. According to Duffield (1994, p.49), the nurses, who act as first-line managers, are assigned triple roles aimed at promoting and maintaining clinical excellence in the institutions. More importantly, the nurses are burdened by the workload combined with the high standards of accountability required of them. The situation is complicated by the changes in patients, organizational and nursing dynamics (Duffield, 1994, p. 50).
The opening up of managerial positions has resulted in conflict in the workplace by advocating a performance culture. The nurses are pushed to deliver care at the lowest cost possible thereby bringing into fore the probability of poor quality care for patients (Bolton, 2005, p.6). Furthermore, the switch aims at realigning the medical profession from their normal duties where the administrators supervised them. The sense of autonomy and empowerment that comes with the positions is construed to be a part of a wider scheme of normative control aimed at silencing the professionals, eventually endearing them to managerial positions. The two-window system is detrimental to career advancements since the professionals lose their focus, thereby concentrating more on managerial roles. The nurses become overly frustrated by the system on realizing they are overburdened with responsibilities. This worsens due to the tight budgetary controls and ambitious measures and targets aimed at improving their performance. This system has posed ethical dilemmas to the professionals since they feel compromised by accepting to offer poor quality care while the institution reap considerable profits (Bolton, 2005, p.7).
The physicians also face conflict in the execution of their roles. The physicians not only oversee activities in the health care organizations but also protect the patients from any harm or harassment when accessing medical services. Ethical dilemma results in case of an eventuality where the patient and the employer are involved. Furthermore, the physicians act as part of a convoluted network of professionals who uphold some standards and values as part of their broad mandate. The network also called the role set comprises the patients together with the other members of the professional fraternity. A role conflict may ensue particularly when there is a disagreement or failure to satisfy the expectations of one or all of the members. Such instances are very critical to the professional since they may lead to a negative eventuality. Role conflict is believed to take the following forms; instances when the professional association is convinced that the physician manager has deserted the profession by spending the lengthy duration of his/her time in managerial duties; and involvement in teaching or research ventures may be against the expectations of the employer. Role conflict occurs when organizational decisions touching on programs targeting patients have negative implications in their life and health (Leatt, 1994, p.173-174). Role conflict is a dilemma that faces healthcare professionals thereby forcing them to strike the right balance between their professional conduct and managerial duties.
Physician managers have to become accustomed to the notion that they must account for others’ actions in addition to theirs. The physicians take up many roles depending on hospitals or departments. Most of them take up managerial roles were overseeing the activities of their junior staff is part of their mandate. Staff roles that involve the formulation of policies and collateral role that ensures collaboration between two persons are also favorites for the physicians. They are also absorbed as monitors and representatives whereby they represent the interests of a particular group. Other roles may include secondment for a short duration and coordination of a certain group of people (Leatt, 1994, p.172-173). Involvement in one or more of the above roles may have a strain on the performance of the professionals although it opens other career advancement avenues.
The issue of clinicians taking up employment will only become a policy issue when the government exerts undue pressure on the health care system aimed at minimization of costs. The medical fraternity realized that their existence is challenged hence should involve themselves in policy formulation at all levels of governance. At this point, the physicians feel compelled to intervene as part of wider efforts of fostering participation in the governance. Leatt asserted that the physicians need to acquaint themselves with the policy and largely the political processes that give birth to the policies (1994, p.174-175). This is imperative in understanding the implications of funding to the clinical practice and health care system. The need to focus on client-oriented programs and decisions informed by evidence-based practice is crucial in the achievement of the intended policy changes. The understanding of strategic building and quality improvement particularly in the healthcare systems are among areas that need close attention by the physicians. Initiation and development of performance improvement plans in the organization are imperative in the achievement of quality improvement (Leatt, 1994, p.174-175).
Following the changes in management in the recent past, what remains to be seen is the tenability of the paradigm shift. Considering the practice is gaining root in many healthcare organizations, it will not be long before notable changes occur especially regarding the quality of patient care and the improvement in the financial outlook of the organizations.
Specific research questions
The main aim of this study is to analyze the extent to which clinicians engage in health care management. To explore the above aims, a number of research questions have been developed.
- What is the meaning of management and how does it differ in the context of health care?
- How does professional bureaucracy in health care impact on physicians and other health care workers taking up managerial duties?
- What are the main predisposing factors that make clinicians take up managerial duties?
- What are the major roles taken by the physician managers in health care organizations?
- What policy measures are put in place or are needed to safeguard the interests of all stakeholders affected by the switch?
Significance of the study
The study will focus on deducing the factors that influence the clinicians to engage in health care management. The study in particular will be interested in addressing the knowledge and research gap between the reasons behind the engagement of clinicians in managerial duties particularly in the United Kingdom. The study will also look into the various roles embraced by the clinicians after joining the health care institutions as managers. More importantly, the study will try to explain the factors that lead the physicians to switch to managerial duties and in particular look into depth, the role played by professional bureaucracy in perpetuating the switch. Outlining and discussion of the resultant implications due to this switch will occur in order to get the real impact on the professionals and the health care organizations. The factors that influence the formulation of policies aimed at managing the engagement of clinicians in management will receive considerable attention. The policies in place or needed will also be discussed in depth.
Who is this study of interest?
As concerted efforts get underway to integrate health professionals in management aspects and as issues related to roles embraced by clinicians on assuming health management duties, achievement of quality care to patients will get immense attention. As more questions surface about what motivates clinicians into taking up management positions in health care providing organizations, at the receiving end will be the patients who will be enjoying better service delivery.
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