Within the context of the creation of the internal market for health care, the paper examines the role of clinical directors, that is doctors who have retained their professional clinical positions whilst at the same time assumed roles as managers within increasingly well-defined corporate organizations providing health care. This represents considerable change from previous contexts in which doctors could always contract out of difficult managerial decisions. The role of clinical director is examined in terms of its own directorate and its involvement in contracting, co-operation and competition both within its own corporate organization and within the wider market place for health. Key issues are raised for the individuals and organization by these changes, they are discussed in terms of time, succession, managing colleagues, financial and human resources, market behaviour , support and terms of reference. These changes occasion wider discussion in terms of the challenge of coping with future demands for innovation, changes in the distribution of power within an emerging market for health care and the relationship among health care organizations, professionals and lay clients.The National Health Service (NHS) has entered a period of far reaching change since the publication of the White Paper Working for Patients (DHSS, 1989) and the creation of the internal market in April 1991. Change is not new to those who work in the health service. The difference between this and previous creations, however, is that rather than concentrating attention on specifying how operating institutions are to be restructured -these reforms have concentrated attention on the creation of an environment in which health care is to be provided. That environment is the internal market in which purchasers (district health authorities, general practitioner (GP) fund holders) now receive money from the state in proportion to their population figures, weighted for certain indices of disadvantage. Their remit is to assess local needs, determine the acute, community and priority services required and accordingly place annual contracts for an expected level of activity at an agreed price with selected providers. There are procedures for handling emergency requirements falling outside these contractual arrangements.The focus of this paper is on the position of medical doctors in NHS trusts who have become engaged in management, usually on a part-time basis. The context is described in terms of an evolving relationship between medicine and management and the emergence of a 'doctor cum manager' role. The paper is in three parts. The first deals with the context of change. The second looks at the implications of the changes for the role of doctors cum managers within NHS trusts. It pays particular attention to those who are now known as clinical directors and examines their increasing involvement in management and competition. The final section identifies issues for discussion and places this case of doctors in management within a wider context.

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