The samples of managers consisted of very diverse groups of managers with a wide range of educational
qualifications and diverse personal experiences. Capturing and analysing the often lengthy career
narratives of those managers through interviews gave us a clear sense of where critical sources of variation and difference were to be found. Nevertheless, those experiences did tend to converge around one of a
small number of well-established professional or occupational career trajectories, as reflected in the model.
Clinical managers
Clinical managers placed a lot of emphasis on the clinical aspect of their professional identity, which was
forged through their educational and professional qualification and associated continued professional
development. Among clinical managers, there was quite a sharp distinction between the‘accidental’
managers– those whose clinical career path had led them (usually unexpectedly, not by design or
inclination) into management positions, found more among medics and at the acute and specialist
trusts– and the ‘reluctant but resourceful managers’20– those for whom management responsibilities
were an inevitable (and often not desirable) next step in the development of their career, found more amongst those with nursing backgrounds and, in particular, at the care trust.
For both of these groups, the clinical frame of reference was still a very strong one. For the accidental managers, receptivity towards management responsibilities and ideas was much more of an exception than the rule. Although there were some clinicians whose orientations were more towards management processes (e.g. the psychologists at the care trust) and some who saw themselves in a hybrid, bridging or translational role (e.g. particular clinical directors at the specialist or acute trusts), management activity still tended to be seen as an adjunct to a largely clinical professional role.
For the reluctant managers, although clinical experience was still important in shaping views about managing, there was a greater degree of acceptance, if not necessarily internalisation, of management
practices and management thinking. Managers of this type (often with nursing backgrounds) would typically draw upon and value the more experiential learning they had experienced as clinicians and proto-managers in charge of wards and were also well attuned to the challenges faced in bridging the
clinical–managerial divide. As such, the analysis appeared to offer some support for the idea that
management knowledge, albeit quite localised and informally developed, could offer some support for those from clinical backgrounds attempting to harness managerial knowledge to further a
professionalisation project based on a mixture of clinical and managerial knowledge and experience.113
There were a few, notably exceptional, cases of clinical managers who were rather less accidental and reluctant than their counterparts and who were not only more receptive to management thinking
generally, but also more enthusiastic than many in accessing and using more imported, commodified
forms of management knowledge in pursuit of their management aspirations (e.g. Nina at the specialist trust, who had become a manager via the Athena programme, and Nancy at the acute trust, who had a MBA).
However, these exceptions aside, for the most part, neither group of clinical managers was receptive or
responsive to more abstract and commodified managerial knowledge and practices (or in turn willing
and able to transmit them to others). These knowledge bases generally neither matched the clinical
requirements of managers with a strong clinical/scientific frame of reference nor met the requirements of
those managers from a clinical background steeped in experiential learning and for whom translation into management practice they could relate to and use immediately was a sine qua non. In general, a historical and often continuing reluctance to take part in formal management or leadership development was evident, in part owing to scepticism regarding their value and in part because their legitimacy in their role depended primarily on their clinical experience and expertise and not their management knowledge.
General managers
General managers had reached their positions through a varied set of routes. The most common denominator
was some level of clinical experience, combined with some level of qualification related to health care or
health-care management, although many did have some formal management postgraduate qualifications
and training (especially at the acute and care trusts) as well as plenty of direct managerial experience. Management experience was, however, still quite varied although what was fairly consistent was the comparative absence of wider (i.e. outside the sector) management experience and pure general
management qualifications. Fewer than half of the general managers had some experience of working in
the private sector and, in several of these cases, they had rather limited experience. Only in a very few cases did this appear to consciously shape thinking about the nature of management and management challenges in health care. Most often, the distinctiveness of managing in a health-care environment was emphasised. Experience in the NHS (especially clinical experience) was what characterised how managers in this group had developed their skills, particularly among the sizeable group of hybrid managers found among those who had entered management from a nursing background (these were particularly prevalent at the care trust). The diversity of managerial circumstances and challenges this group faced was highly reminiscent of the
sorts of differences in management practice that have traditionally made it very difficult for general
managers anywhere to forge a strong professional identity around a distinct body of knowledge. Managerial responsibilities were not only diverse but also lacked any real commonality across the trusts. This was particularly the case given the wide disparity in organisational characteristics not only between, but also within, each trust and the very different pressures and trajectories for change that they faced. So, although there was certainly a good deal of consensus around the nature of general management responsibilities (the challenges of dealing with clinicians, the intensity of work in terms of volume and speed) and associated key management skills (especially the emphasis on generic interpersonal skills), the practical contexts in which these general managerial skills were developed and applied and the managerial challenges they needed to meet were very different.
DISCUSSION
92
Moreover, as noted in Chapter 3, there were also significant differences between the trusts in terms of
their perceptions offinancial and other pressures, structural and organisational divisions faced, patterns
of interprofessional conflict negotiated and experiences of stability or change, etc. Thus, for general
managers in the acute trust, the principal challenge was frequently the need to bridge the entrenched divide between management and clinicians, whereas for general managers in the care trust, all of whom
shared a clinical background, concerns focused on the difficulty of integrating practice across a diverse and
fragmented organisation.
This emphasis on the more home-grown development of management knowledge and skills was reinforced by the strongly held perception that experience was the most important way of developing the expertise and learning required to perform managerial work. Consequently, the development of managerial careers in situ and in very particular localised clinical and organisational domains could tend to reinforce a reproduction of managerial knowledge and practice that was driven rather more by immediate organisational needs and management challenges than by attempts to access and apply more abstract management knowledge and learning or to generalise learning from experiences elsewhere in the
organisation. This could, in some circumstances, lead to difficulties in spreading knowledge and learning
from certain parts of the organisation to others. On the other hand, it did create conditions in which a
form of professionalisation could develop that was based on‘responsibilisation’, or the status conferred
on particular individuals and groups by virtue of their expertise in dealing with key local problems in their local situation.116
The comparative absence of wider networks for general managers to access readily and to draw upon different forms of knowledge also reinforced the likelihood that the existing ways of operating and managing would become self-reinforcing. In other words, managers were not only focused on responding to local managerial challenges but were also more isolated than the other two groups from sources of knowledge and learning potentially accessed through networks of peers, not only outside the organisation (where competitive conditions could constrain open dialogue anyway) but also within the organisation (where operational conditions were likely to be quite different).
Functional managers
These were the groups that varied most widely in their professional orientation and status, depending, of course, on their particular occupational specialism. For these managers, career development depended on the nature and extent of professionalisation (in institutional terms) of the professional development pathway associated with their discipline. For some, this was quite established and formalised and involved
expected levels of intense formal education and training leading to recognised professional qualifications
(e.g.finance managers and also some specialists in HR and estates). For others, whose discipline was less
professionally institutionalised, the nature and intensity of formal education and training was clearly less
formal and intense and career pathways were sometimes more diffuse or ill-defined (e.g. specialists in
marketing and IT).
By the same token, functional managers were the group most predisposed and receptive to formalised
and generic management knowledge, albeit knowledge that was likely to reflect the particular nature and
requirements of their specific role, rather than general management practice (such as Chartered Institute
for Personnel Development courses on aspects of people management in the case of HR managers). In turn, their knowledge base often directly constituted the knowledge and expertise deemed essential
by general managers, as was the case forfinance and HR. General managers’ work was often explicitly
focused onfinancial aspects and they commonly relied heavily on HR support and saw implicit HR activity
as an important aspect of their role and responsibilities. Other forms of knowledge either generally underpinned the activities of general managers (e.g. the contributions of IT and marketing specialists), or represented a more distinct and separate knowledge and practice domain (as was the case, for example, with estates management). What was interesting about this group was the extent to which certain knowledge bases of functional managers constituted some of the important aspects of managerial work (and was recognised as such by general managers).
As a group, functional managers also tended to be more highly networked and made much wider professional networks, which allowed them to interact with colleagues elsewhere more regularly. Most belonged to formal professional associations, as did a number of the clinical managers, although they varied greatly in their activity, ranging from regular and proactive participation in formal events and other
activities to merely remaining on a mailing list. At one level, this reflected the wider range of professional
connections they depended on to develop their careers, knowledge base and learning. At another level, it was perhaps necessary for those managers to avoid becoming too enveloped by immediate trust conditions and concerns. This does not mean that the occupational mobility of functional managers was such as to make them look beyond the health-care sector for future career development opportunities, although there were one or two exceptions who did talk about other possibilities beyond health care. However, there were some differences between organisations suggesting some within-sector occupational mobility. For instance, although there was a much greater degree of longevity and commitment at the specialist trust (owing to its prestige) and the care trust (owing to the strength of local ties), there was much less evidence of this at the acute trust.