Can doctors rise to the challenge of leadership?

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The NHS needs more clinicians to step up to leadership roles to improve outcomes for patients. But will doctors be able to endure the constant scrutiny and deliver what the service is asking of them, asks Mark Goldman

The race for the White House is a fascinating study of leadership. This year has been especially enthralling. Once the no-hopers have fallen by the wayside, the final runners and riders are laid bare in front of the electorate. Every gesture, every utterance past and present is scrutinised for meaning. Character is dredged and dissected on screen, in person and in print. Image, track record, congruence, values, integrity and behaviour are examined minutely. Even appearance and style will be sifted for coded messages. There is truly no hiding place.

For America, the biggest success story of modern times was the late Ronald Reagan. It is said he dealt only in principles and allowed others to embellish detail. His performance style and emotional engagement with the American people carried him through disasters that would have swept others from the Oval Office. It is an oft-repeated tale that his contribution to meetings would be laconic and brief. On economic policy he might drawl "fewer taxes" before retiring for his afternoon nap, leaving his team to sort it out. His essential leadership style was through his relationship with the American people and policy consistent with traditional "American" values. No one could accuse him of dither or micromanagement.

Barack Obama and Hillary Clinton have provided an interesting contrast. One was selling a big vision with an urbane style and a smooth fluency of language presented in a beautifully tailored dark suit. The other was all conceit and counter punch in multicoloured pant suits. Round one to the leader, Barack Obama. He lives on to test himself against the ageing warrior John McCain. I can't wait!

NHS leaders

Today's leaders, even at organisational level, are on stage at all times. Their every aspect is there to be scrutinised and judged by the people they lead. Risks must be taken. Failure is highly visible. However large or small the number of followers, the leader is important to them and they look up to them for reassurance. Leadership is not a comfortable place and not a place traditionally inhabited by doctors.

In the NHS, there is a notion that clinical leadership is the sword in the stone and that further and faster progress will be made if more doctors are leading from the front.

Clinicians are not trained for leadership and many find the explicit leadership role an uncomfortable one. The service in the UK has largely been interested clinicians who have made the move to clinical leadership roles. But if clinical leadership is to become a key transformational influence in the NHS, that will not be enough. Leadership skills will have to be exercised by all clinicians.

Clinicians will need to change the way they think about their leadership role if they are to fulfil the expectation the NHS is about to invest in them. This will not just happen. It needs a willing participant and a strong programme of support. Dragooning clinicians does not work. Under such circumstances, services stagnate, enthusiastic staff become disenchanted or leave and patients suffer.

Critical moment

This is the moment for clinicians to rise to this challenge with passion. In order to do that, they need help. Clinicians like to be trained and often feel compelled to be accredited before becoming confident in their skills. On leadership they have no teaching. For the most part, they do not understand or value it. They cannot describe it or deliver it. This is not a good starting place.

There is a message to be taken to doctors that leadership can have a dramatic effect on outcomes for patients and has a worth. They need to accept it is a learned skill and that they should want it and have it for that reason.

This is new territory for many doctors. The rewards of leadership are less explicit than the thanks of a grateful patient. Tough leadership decisions have to be made in the face of considerable concern and even hostility. Not all practising clinicians are able to cope with the changed dynamic of decision-making as a leader. Some can. It works for Kaiser Permanente in California and it has growing support in other countries, notably Denmark. Clinicians need to be enlightened by an understanding of the more slow-burning thrill of building a service that delights patients and is exemplary in clinical outcomes.

This is the moment for clinicians to recall the Arthurian legend. In the generally accepted version, only the true heir to the kingdom can extract the mighty Excalibur from the stone. As the NHS turns to clinicians to continue the transformation journey, it is the moment of truth for doctors. Will they rally to the cause of the health of the nation, accept the challenge and grasp the sword? And if they do, will the sword slide from the stone or will they be exposed as unworthy pretenders?