The past years have witnessed the introduction and implementation of strict macro and micro economical principles in the planning and delivery of health care. The change is a consequence of the limitation of resources and the obligation to optimize their utilization in the delivery of health care to those in need. This has led to the birth of a new domain of management science dealing with hard choices and with the selection of priorities in the delivery of health care.⁽¹⁾ Even Western European countries, where a tradition of equity presides over health care and developing countries, with a tradition of care based on welfare system are adopting strategies built upon managed care principles. Of course, the private health care present in many forms in the different countries has been a driving force in this movement.

The new management perspective is based on the standards of management discipline but has to adapt to the main ethical concerns of delivery of care to suffering human beings. Because management has oftentimes been imposed as an ‘external’ mandate to the clinical community, clinicians, lacking understanding for the basics behind management, are reluctant to accept it; they often feel degraded by managers and develop negative attitudes towards them.

The objective of the present chapter is to provide clinicians with some input on how to manage the resources at hand and how to understand and communicate with managers in order to reach priorities closer to the needs of patients.

Health professionals and managers differ in many aspects. They belong to two different cultures which are summarized in Table 1.6.1.

However, many managerial skills are extremely useful to deal with psychiatric diseases, because they are chronic, they are accompanied by high degrees of disability, they require an interdisciplinary perspective, and they have important interactions with the social environment. Nowadays, most psychiatrists work as members of a multidisciplinary team, need to develop collaborative working relationships with other professionals, should have an understanding of the roles and the limits and extent of involvement of other agencies, and lastly, of the lines of accountability. Furthermore, the concerns about the competence of psychiatrists that is the framework for training programmes include some such as: the psychiatrist is a medical expert, a communicator, a collaborator, a manager, a health promoter, a professional and somebody able to tolerate ambiguity and uncertainty. In most of those, managerial skills are essential. Unfortunately, those skills are not taught in most medical schools.

There are three levels at which there is a parallel between a manager and a psychiatrist: a) the psychiatrist as a manager of the interventions needed to implement an individualized treatment plan for his patient, b) the psychiatrist as a manager of the involvement of other professionals in clinical settings, and c) the psychiatrist as a manager of health care resources available to his practice.

The psychiatrist as a manager of his patient’s needs is a consequence of the introduction of processes of disease and patient management by most health care organizations. These play an increasing emphasis on prioritizing health care provision on the basis of limited resources and increased sensitivity to specialized patient needs. Therefore, the clinician has to keep a delicate balance between cost containment principles and quality in care provided. It is crucial for the psychiatrist to be able to identify and implement practices that assure quality of care without sacrificing this to any external pressures for containment of cost within his clinical practice. The Madrid Declaration of the World Psychiatric Association (WPA)⁽²⁾ has one item on the rights of psychiatrists that in essence
declares that the first right of the psychiatrist is to be able to practice the profession without external constraints of any kind.

The psychiatrist as a manager of other professionals in clinical settings is consequently working as an element of a multidisciplinary team. Everybody in a team should at least possess an understanding of the essence, the extent and the limitations of cooperation and accountability. Managing other professional also largely refers to managing other psychiatrists within the same clinical settings. Management goes beyond the simple ‘coordination’ of various roles and steps in the process of providing health care, in the professional education of colleagues, the training of young professionals and the sharing of experience.

The psychiatrist as a manager of health care services has to struggle to reach a satisfactory degree of equity and in order to do so, the clinician has to become familiar with issues such as human resource management, customer satisfaction and change, crisis and conflict management.

The word management derives from the Italian maneggiare ‘to handle’ (i.e., a horse), from mano ‘hand’, from Latin manus. Management is ‘the art of getting things done through people’;⁽³⁾ it is the act (sometimes the art) of conducting or supervizing something (initially a business) and the thoughtful use of means to accomplish an end. Management needs to direct and to control a group of people or entities for the purpose of coordinating and harmonizing that group towards accomplishing a goal and it often encompasses the deployment and handling of human, financial, technological, and other resources.

Management in health care is not new. Physicians have a long tradition of being supervisors or conductors of a team. The simplest form of management is the partnership, an essential model for the doctor-patient relationship.

Management can also refer to the person or people who perform the acts of management; in this sense management has to do with power by position, whereas leadership involves power by influence.

From a functional perspective, management consists of measuring a quantity on a regular basis and of adjusting some initial plan in order to reach an intended goal. This applies even in situations where planning does not take place.

Management has several functions, which are summarized as following:

Although in the following paragraphs we will, as often as possible, replace managerial jargon by one more pleasant to clinicians, there some basic concepts which need a definition.

Efficacy is the ability to produce a desired effect and it is measured by the closeness to an achievable goal.

In clinical settings, efficacy is the degree of the benefit for patients, induced by an intervention (treatment, procedure or service) in ideal research conditions (i.e., in a controlled trial). It indicates that the therapeutic effect is acceptable. ‘Acceptable’ refers to a consensus that it is at least as good as other available interventions to which it will have ideally been compared to in a clinical trial.

Effectiveness, on the contrary, refers to the impact in real world situations.

Efficiency is the achieved results or effects related to the effort invested in terms of money, time and other resources. It is the maximization of some desired output or effect for the least amount of input, means or effort. Usually, the larger the ratio, the greater the efficiency.

Efficiency is not a pure scientific concept as it carries a value judgement. Efficiency is achieved through design, the process by which intelligence is substituted for matter and energy in technological systems.

Productivity is a measure of efficiency; it is the amount of output created (in terms of goods produced or services rendered) per unit input used. For instance, labour productivity is measured as output per worker or output per labour-hour.

Equity is social justice, the way of providing services according to the needs of each individual in a defined population. It is not an equalitarian principle because each individual should not get the same, but what he or she would need in a specific situation.

The light bulb example: the efficacy is the amount of visible light measured in lumens; the efficiency is the ratio of lumens to the amount of energy consumed to produce them, measured in Watts. Equity will measure the reach of the lumens to the needs of, let’s say, the passers by on a street.

Health care and economic management are two different cultures. Cultures are defined by their values and peculiarities, among them ethics. Specific values are part of the property of a culture and belong to the identity of every social group.

There are three stages in the development of medical ethics,⁽⁴⁾ each one adding value to the previous one without replacing it totally. In each one of them particular managerial skills are helpful.

The ethics of welfare is the traditional medical ethics, first appeared in Hippocratic writings. According to it, the doctor’s primary goal and duty are the well-being of the patient and as much as possible, harm avoidance. The doctor is perceived and behaves as a good father, to be fully trusted, convinced that the physician will act adequately to the benefit of the patient. To meet this obligation, the doctor has to increase to the maximum his own medical knowledge and to assume a series of obligations. The scientific advances increase the paternalism of the professional who has to learn how to manage information. The Madrid Declaration
of the WPA expressed this notion in the following way: Psychiatry is a medical discipline concerned with the provision of the best treatment for mental disorders. Psychiatrists serve patients by providing the best therapy available consistent with accepted scientific knowledge and ethical principles. It is the duty of psychiatrists to keep abreast scientific developments of the specialty.

The USA influence, with its strong emphasis on autonomy and individualism, has lead to the ethics of autonomy. The ethics of autonomy considers the patient as an autonomous human being, adult and free and consequently, able to take his/her own decisions. The values and beliefs of the patient are the background for the moral responsibilities of the doctor. As a consequence, doctors have to truly inform patients about all possible diagnoses and treatments so that patients are able to decide. The basic element of this new way of establishing the doctor-patient relationship is the informed consent.⁽⁵⁾ From this perspective, patient-doctor relationship is defined in new terms: The patient should be accepted as a partner by right in therapeutic process. The therapist-patient relationship must be based on mutual trust and respect to allow the patient to make free and informed decisions. It is the duty of psychiatrists to provide the patient with relevant information so as to empower the patient to come to a rational decision according to his or her personal values and preferences (WPA Madrid Declaration).

The ethics of equity is a consequence of the impact of economic factors in medicine. The need of equal access to health care resources for all patients, including those suffering from mental illnesses and the principle of equity in a period of intrinsic and extrinsic limitations to health care cost, is leading to a third stage of bioethics which has also been called the ethics of management. The main reasons for the increase or imbalance of the costs are partially due to the successful developments of modern medicine: health care by itself is increasingly expensive (implementation of new and expensive technologies, incorporation of new professions into medicine, financing research in biomedical sciences, and applying resources for the training of physicians and specialists); the better control of acute diseases which increases the proportion of chronic illness requiring care; the increased demand due to ageing of the population and in social security systems, the change in the population pyramid, decreases the population of those paying compared to those making the expenses.

Resources to be invested in health care are limited. The first one to ask for limits was President Carter in the USA, during his first public speech after assuming the presidency, when he claimed for a ceiling of the 7 per cent of the GNP to be devoted to health care. This was in 1977. But, why such a limit? Why could it not be possible for an enlightened society to decide to devote 10, 20 or even 50 per cent of its GNP to health care and less, for instance, to defence? President Carter expressed it very well: too much spending in this area would decrease investments in education and care of the environment, which would lead to a deterioration of health.⁽⁸⁾ In Europe, the cost of brain disorders (to be precise brain diseases and mental disorders) is more than the double of the cost of all cancers and diabetes together.⁽⁷⁾