A trifle of management

Health services across the world have been marked (some might say scarred) by regular and overt conflicts typically seen between clinicians and managers. Hardly news, I suppose, but what factors underlie these conflicts, and how might we understand them better? While the literature on this issue is large (to say the least), and, undoubtedly, there are a range of complex and multi-faceted factors at play, there is one important aspect of the conflict that tends to have been underemphasized within these debates. Namely, not enough attention has been paid to the negative way in which managers (both in health care and more generally) typically get portrayed in the wider culture – in novels, films and so on. Picking up on some of the literature concerned with the relationship between fiction and management,^1–5 the negativity inherent within these cultural portrayals may well be an important factor that gives clinicians’ attacks on managers extra salience and bite – as well as adversely affecting the way in which health care managers themselves see their own identity and the legitimacy of what they do.

The negative portrayal, indeed the satirical caricature, of the figure of the manager enjoys a long history within literature. ⁵ And the reason that Charles Dickens's Dombey and Son is worth a second look is because it is the first major English novel in which the managerial class was represented in a sustained way. ⁶ So let's meet James Carker, manager of the firm of Dombey and Son:

From passages like these, it is easy to assume that Dickens intended Carker to be a melodramatic, stagey villain – who's every appearance should be greeted (metaphorically) with a hiss. Indeed he is far from unique in Victorian fiction in the nature of his death – he ends up being killed by a railway train – like all the best villains of the time should. But taking the novel as a whole, Dickens represented Carker with a degree of subtlety, complexity and ambivalence. Such subtlety means that Carker can be read, in part at least, as a victim of the corporate world that had emerged by Dickens's time. This was a world which, Dickens thought, had already come to institutionalize and reward petty hypocrisies – there are examples of corporate double-speak, cruel humiliations, and pointless bureaucratic procedures within the novel. But, for Dickens, while the reward for complicity in the corporate world's hypocrisies was the promise of money and a certain kind power, its price was the inevitable corrosion of character – the sort of cruelty of heart that he ascribes to Carker in the excerpt above. Indeed, both Carker and Dombey, his boss, seemed unable to relate to people as people; others, for them, were mere instruments, whom they valued only in as much as these others could further their business interests or their wider pursuit of power. (At the very end of the novel, however, Dombey is redeemed through the love of his daughter – but only after his firm had gone bankrupt.) I think it's pretty clear, then, that Dickens meant us to see Carker's primary motivation as the selfish quest for power. Furthermore, he was widely feared by his staff (and many of the others with whom he came into contact), and though initially obsequious in his dealings with Mr. Dombey, he really despised him: scandalously, Carker ran off to France with Dombey's wife – and bankrupted the firm.

In representing the manager in these sorts of ways, Dickens seems to have established a (minor) literary convention. This convention has been followed in the past by authors as diverse as PG Wodehouse ⁷ and Sinclair Lewis, ⁸ as well as by successful contemporary novelists, including Tom Wolfe, ⁹ Bret Easton Ellis, ¹⁰ and Sebastian Faulks. ¹¹ And the same sort of caricatures can be widely seen in some of today's popular films, TV shows and journalism – think of Mr Burns in The Simpsons. Indeed, it is hard to find many positive portrayals at all of a manager – in any form of fiction. ¹²

OK, but so what? I certainly don't want to give the impression that the literary caricature contained in Dombey and Son and other more recent fiction is, in any way, a reflection of what today's individual managers are really like. (I've no reason to believe that there aren't as many nice health services managers as there are nice people in the population as a whole.) On the other hand, the dominance and persistence of their negative image within the wider culture may be one reason (among others) for managers having to fight uphill battles in establishing the legitimacy of their views and their actions: often, the archetypal anonymous manager is assumed to be a money-obsessed, emotionally illiterate bureaucrat. This sort of assumption seems especially prominent in health care, where managers are generally pitted against people like doctors and nurses, whose cultural caricatures are overwhelmingly positive – at least by comparison with that of managers! One might even speculate that the recent trend in health policy to represent organizational issues as leadership (rather than management) could be a trend that is reinforced by managers’ negative image. After all, talk of leadership represents a way in which the negative cultural valences that adhere to the term management can be played down if not, perhaps, eradicated entirely. ¹³ In any event, this brief foray into nineteenth century literature has hopefully wetted your appetite for the potential benefits in making imaginative links between today's health policy and other sources; especially sources which seem, at first glance, to be entirely unconnected to the politics of health care policy and delivery.