Aidan Halligan on why Darzi needs clinical leadership

Aidan Halligan

• Increase image
• View all images

The NHS must do more to develop clinical leadership if it is to achieve the aims set out in health minister Lord Darzi's review of the service

Clinical leadership is at the heart of the Darzi review.

The engine of the review is built around two major cogs: expectations (of patients and staff) and information. However, expectations and information without effective clinical leadership will not deliver on the review's promises.

Healthcare strategy cannot move forward one millimetre unless there is a willingness among those who deliver the service to move towards a new way of working. That willingness needs to be enabled and empowered. You will not persuade people through command and control, but by giving them an insight that allows them to understand, beyond doubt, that it is time to change their behaviour. Clinical leadership is the tool that can give these insights and influence behaviours.

Past and present 

For most of its history, the NHS was built on the trust and sacrifice of its workers, at a time when vocational commitment meant long hours for relatively little reward. These workers' trust and sacrifice were easy to feel but hard to measure. Their vocation and passion were built by generations of extraordinary clinical leaders. Patients remembered the care they received. They remembered the trust they placed, willingly, in those caring for them. They remembered the dedication, the commitment and, above all, the many, many small unprompted moments of kindness that exceeded all expectations.

Clinical leadership provided the fabric and grit of that culture. That clinical leadership needs renewal. The crucial issue is culture. The obstacles to transforming the NHS are not financial, structural or technical. The biggest single obstacle is the lack of clinical leadership in transforming culture and overcoming custom, tradition and convention. Trying to influence an organisational culture without realistically dealing with clinical leadership is like trying to take a core from an apple without breaking the skin.

Doctors as navigators

No-one should underestimate how stressful it is for a patient to be left to steer their own patient journey. Doctors cannot guarantee a good outcome, but they can and should help patients navigate their way as safely as possible through our complex and fragmented health systems.

The profession does not need people with formal or informal authority, but those with "real" authority. More than ever before, the medical profession needs clinical leadership - leadership that is more concerned with augmenting professional standards than with protecting professional status. Doctors want this leadership and want to strengthen their professional morale because they understand that a more robust and motivated profession will mean better outcomes for patients. All of these emerging truths should be hammer blows against the sleeping conscience of the profession.

Changing culture

I have worked across seven different trusts in the last six months, each of which is dealing with the increasingly alarming consequences of a prolonged lack of effective clinical leadership. In every service, I noticed underlying themes of poor leadership, professional isolation, ineffective systems and processes, disempowerment and poor communication. The underlying team issues I saw included an "everyone knows" culture, active covering up, indecision, a disconnect between management and clinicians and a culture of fear.

At the heart of all was a denial around the need for effective clinical leadership. Morale and motivation are the lifeblood of an organisation. Assumptions, principles and beliefs are often informed by the reaction of the clinical leadership within a trust to what "everyone knows, but nobody says". There is no shortage of leadership talent among frontline doctors and nurses. It is just difficult to see if you are not looking for it.

Future gazing

The thing about progress is that it tends to creep up on you. People feel they know what the future will be like and they are often right - it is just that when you arrive there, because it has crept up on you, and although it is dramatically different, it just does not look it! Even as you read this, we are living in the future and just do not see it. I believe the medical profession retains a great power for good and that doctors are as impressive and ethical as their idealised images. The danger is not, ironically, from hubris, but that the medical profession will believe the myth that they are condemned to mistrust and powerlessness.

Leaders in the health service need to lose their fear of being disliked. Unless that fear is overcome, the cultural transformation needed will not succeed. Providing you give people a mechanism to put things right, speaking your mind is appropriate for a leader.

Cultural change will happen - and soon. There is no choice. At the heart of that cultural change will be a new-found clinical leadership, and that leadership will use the springboard of rediscovering lost values to take them where they need to go. As Martin Luther King Jr said: "Our lives begin to end the day we become silent about things that matter."