Clinical leadership is considered crucial for a successful health service but there is a lack of clinicians who are properly equipped to do the top jobs. Na’eem Ahmed suggests how the NHS can fill the skills gap
David Prior’s sentiments expressed in his HSJ article warrant further discussion.
‘Attitudes are changing; enthusiasm among clinicians for leadership and management is unwavering’
The chair of the Care Quality Commission acknowledges that effective clinical leadership can improve healthcare organisations and should therefore be encouraged. He also recognises that despite the NHS employing over 500,000 doctors and nursing staff, only a handful have made it to leading roles within the NHS. However, the depiction of clinicians being apathetic and disengaged towards leadership opportunities fails to highlight the underlying cause.
In the case of doctors, the problem starts as soon as a house officer arrives on the wards on the first day. Selected for a place at medical school on an ability to excel in multiple domains, these talents are suddenly considered superfluous due to the most pressing expectation of providing service on the wards.
Those square pegs that have a diverse repertoire feel stifled and are reminded “they won’t do well round here” or are challenged, as being “unfocused, not focusing on real work”. As members of the dark side they are left to negotiate rotas and complete improvement projects in their dwindling spare time.
‘Post-reform, surprisingly few people are au fait with the organisation in which they work’
The problem persists as the junior doctor continues training; leadership is still viewed by many as a perk, not essential to clinical care. Consultants are increasingly under pressure, having to do more for less, with little time for developing their junior staff, and report that doctors move on too quickly.
The status quo is akin to the philosophy at my university summer job: if the till isn’t ringing, the boss isn’t interested. Clinicians are employed only to treat patients.
Despite these circumstances, attitudes are changing; enthusiasm among clinicians for leadership and management is unwavering.
The growth of the Faculty of Medical Leadership and Management exemplifies this, while other programmes such as the Clinical Fellow Scheme, Prepare to Lead, Diagnosis and The Network have flourished, attempting to accommodate the growing desire among clinicians to become better leaders.
Sir Bruce Keogh, the NHS’s national medical director, recently said he support the creation of a talent management scheme for the NHS, in which aspiring clinical leaders could be fast-tracked to management positions through an integrated leadership and clinical training pathway. You could almost hear junior doctors rushing to sign up.
In creating a leadership pathway, perhaps in the mould of existing academic clinical fellowships, a few issues should be considered. These include the following but this list is not exhaustive:
Leadership is not for everyone. Publications and research remain the main currency for selection to top clinical jobs. Research is important for driving medicine forward but it is not for everyone. Leadership similarly shouldn’t be “one size fits all” and opportunities should be available to those who are interested. Tailored programmes are important, particularly for surgeons who are expected to acquire more complex and diverse surgical skills in less time than their predecessors.
Management skills are for everyone. Post-reform, surprisingly few people are au fait with the organisation in which they work. Clinical training could be underpinned by “understanding the machinery” early on. Clinicians should also understand processes such as planning, budgeting, staffing, measuring performance and problem solving. Management skills should become an integral part of undergraduate medicine and nursing.
Hierarchies will not work. Removing hierarchy is a necessary step towards improving patient safety and organisational culture. There is a growing realisation that, as a learning organisation, becoming a consultant cannot be seen as reaching the end point in personal development. Limiting leadership positions to senior clinicians ignores junior doctors and nurses with high potential and, as the undergraduate intake becomes increasingly diverse, those with existing management experience.
‘The Francis, Keogh and Berwick reviews have all reinforced the need for strong clinical leadership’
Do not be afraid of giving responsibility. The overwhelming success of placing junior doctors and student nurses on Keogh review panels highlights their ability to handle responsibility in demanding circumstances. Leadership development has focused on academic study, predominately courses, rather than experiential learning. Clinicians have near-perfected the “apprenticeship-learning” model in our day jobs, which should be harnessed and combined with management studies, to create younger associate medical directors, safety leads and improvement roles.
Look outside the healthcare bubble. Private sector experience continues to be viewed with suspicion − it shouldn’t. Clinicians could spend time in the consumer industry to learn about supply chain management and customer service. The airline and oil industry are frequently referred to as exemplars in safety. Clinicians will return with new ways of working and combine these ideas with their clinical knowledge to create a world-leading health service.
This is an important opportunity. We are at an important juncture for clinical leadership to move beyond rhetoric. The Francis, Keogh and Berwick reviews have all reinforced the need for strong clinical leadership.
This enthusiasm, coupled with support from NHS England leadership and, recently, the health secretary, provides the political impetus required to create a programme to produce a cadre of clinicians who are also excellent leaders and managers.
Dr Na’eem Ahmed is a clinical fellow at the Faculty of Medical Leadership and Management