Review

Herding cats in the NHS

CONTROLLING HEALTH PROFESSIONALS: THE FUTURE OF WORK AND ORGANIZATION IN THE NHS
Stephen Harrison and Christopher Pollitt
Open University Press, 1994, £12.99

The medical profession has become used to facing challenges to its power and autonomy, and adept at surviving them unchanged. Nursing, in contrast, has — along with other less powerful health care professions — progressed paradoxically, at the same time attempting to build a professional status yet handing power and control to non-nursing managers.

But never before have the health care professions had to brave such a steady barrage of policies and initiatives in such an uncertain environment, which may ultimately wrest all residues of professional autonomy from their grasp, and even see the end of the idea of professionalism itself.

Or so we might think. Harrison and Pollitt bring their usual clarity, slightly amused style and easy readability to this complex area. They begin by outlining the scope for conflict between professionals and managers which runs as the constant theme through the book. Essentially, managers are those people whose job it is to tell others what to do. Professionals are those whose job it is to act on their own judgement, frequently ignoring the wishes of non-professionals. As Alain Enthoven memorably put the crux of the issue: ‘Managing doctors is like herding cats.’

The authors begin by painting briefly the financial backdrop — one of ever more constrained resources yet unrestrained demands — against which managers, politicians and professionals will play out their parts. The drama which follows is in three acts, three ways in which politicians — through their managers — have tried to extend their control over resources and the professionals who use them.

The first is through direct attempts to extend managerial control over professional groups, most notably through the Griffiths general management reforms of the early 1980s. Management information, health service performance indicators and challenges to the health service unions are also discussed here.

In act two the theme is ‘incorporating the professionals’ through the development devices such as the resource management initiative, clinical management and quality assurance. The analysis of the quality bandwagon gets the hype into perspective and is one of the most valuable sections of the book.

Act three examines the impact on professional autonomy of the purchaser-provider split and the rise of consumerism within the health service. Both of these developments pose direct challenges to the traditional paternalistic judgements of health professionals.

Finally, Harrison and Pollitt allow themselves some speculation on how such strategies might progress in the future. Ultimately, as they point out, managers will find it convenient to allow professionals to continue to exercise their ‘clinical judgement’ in politically difficult areas — such as rationing. Thus there may be a limit beyond which managers do not wish to go.