Clinicians have been given new leadership roles in the post-reform NHS, but many organisations are still working out what medical leadership means for them in practice, writes Kate Wilson

Man looking through microscope

Clinical leadership in focus

Many would agree that clinical leadership is important, but as new structures bed down across the UK it is not clear what effective clinical leadership looks like in practice

This is thrown into the sharpest focus for the new medical leadership roles that position doctors as the key driver for change. Hay Group draws on work with hundreds of medical leaders to highlight what can be done to embed clinical leadership and deliver the step change this will require.

Clinical commissioning groups and provider organisations alike are creating new medical leadership roles that are bigger and broader than ever before. However, many organisations are still working out what medical leadership means for them in practice. For many organisations, this means a lack of clarity about the distinct value of medical leadership roles and what is needed from them, resulting in roles which are ill defined, too broad and lack focus or recognition of the time that medical leaders need to fulfil them properly.  

Leadership transition

This lack of clarity is not surprising given the size of the shift in these roles. In fact, medical leadership roles are changing more strongly than ever before, with an increasingly overt emphasis on their role in setting direction, leading, engaging and managing others. In summary, this shift can be articulated as:

Transforming from:

  • leading on pathway design or clinical networks within their area of clinical expertise;
  • setting standards or defining projects;
  • assuring clinical quality and safety and operating within budget constraints;
  • influencing and engaging colleagues; and
  • managing projects or governance processes.

Transforming to:

  • leading on service transformation, often beyond their own area of clinical expertise;
  • creating direction and/or aligning others around it;
  • assuring performance and effective resource management;
  • influencing and engaging colleagues across a broader range of stakeholders, as well as line managing colleagues directly and leading teams;
  • managing services, teams or organisations (in the case of CCGs); and
  • systematically assuring that patients’ views and needs are driving decision making.

This does not just have implications for medical leaders, but also for the other clinical and managerial leaders they work with. Understanding the focus of new roles, what they look like in practice and how they interrelate is an important starting point to making them work. Not only does this mean some careful thinking about how they are designed, but also the time and space for leaders – medical, clinical and managerial – to work through how they will work together. Role clarity is the fundamental building block for turning new structures into new ways of working.

‘New roles require fundamentally different ways of working for medics’

Not investing the time now to help clinical and non-clinical leaders work through what new roles means in practice, seems particularly risky for this generation of medical leaders. Potential successors will be watching with a keen interest to see if these roles are worth investing their careers in or whether to keep their heads down.

New ways of working

New roles require fundamentally different ways of working for medics. CCG chairs, for example, cannot deliver without developing the influencing, engaging and participative leadership skills these challenging roles require: simply providing the medical perspective on safety, quality and change is no longer an option.

At the same time, many medical leaders are stepping into leadership roles for the first time. One medical leader we worked with described being “catapulted into a senior clinical leadership role at a time of crisis and substantial change… while experiential learning might be a brutally effective way to learn lessons, it is not an approach I would wish to continue with in the longer term”.

‘Few medical leaders are comfortable with the directive style − or telling others what to do’

As for most professional groups, the shift from individual professional to leader is a significant one that also requires a shift in self-image and values, alongside new skills and behaviour. Not surprisingly, our analysis of competencies has shown us that medical leaders have intellectual strength, resilience and patient focus. This now needs to be supplemented by the ability to set direction, engage others, influence and understand how to work through the processes and practices by which organisations get things done.  

This is reflected in our analysis of the leadership styles used by medical leaders. The most common is leading by example, which involves pace setting and focusing on getting the job done themselves to a high standard.  

But the best do something different. They still lead by example, but are also more likely to demonstrate the leadership styles that allow them to engage, align and influence an educated and independent peer group over which they often lack formal authority (the visionary, participative and affiliative styles).

The six leadership styles that have the biggest impact on engagement of the team

  • Directive “Directives not directions”
  • Visionary “Selling ideas”
  • Affiliative “People first, task second”
  • Participative “Involving others”
  • Pace setting “Follow me; do what I do”
  • Coaching  “Long term development”

The transition from a single general focus on pace setting begins with a greater focus on creating a common vision to align others (visionary). As medical leaders add more strings to their bow they then begin to consider the people side of leadership − either through building personal relationships (affiliative) and/or facilitating others input (participative). The next transition should be the development of a coaching approach, as they begin to focus more clearly on developing the next generation of medical leaders.

Finally, few medical leaders are comfortable with the directive style − or telling others what to do. This reflects some real discomfort in managing the performance of peers and colleagues. They are likely to need support in thinking about how they challenge and manage difficult behaviour or performance issues.

So when developing medical leaders, it is important to focus on helping them to explore what good leadership looks like for them, building interpersonal behaviour that will support success and an understanding of the processes and practice by which organisations get things done, from finance, to chairing meetings, to governance structures.

How to embed clinical leadership

  • View as an organisational change and development process, not a leadership development programme
  • Define roles and structures clearly − working back from what you need clinical leaders to deliver
  • Help leaders to work through what the interrelationship between leadership roles looks like in practice and what this means for their role
  • Support medical leaders to build a picture of what good medical leadership looks like
  • Build medical leaders skills in leading through others and negotiating organisational processes and practices
  • Revisit governance structures and ensure you model the change in authority from the top
  • Support medical leaders to challenge and make change happen − support their authority with peers and colleagues
  • Consider changes in behaviour and ways of working needed in existing leaders from the top down

Effective clinical leadership does not just mean that the clinical community has to develop new ways of working − it requires a more fundamental shift in how organisations do business.

Medical leaders do not just need to take up accountability; non-clinical leaders need to also let go. Given the dominant pace setting style noted to exist in the NHS, this is a significant challenge.

‘There is no one right answer. It is important to provide the space and time for leaders to explore and agree a collective solution’

Leadership behaviours need to be reworked from the top down, and changes made to the formal and informal governance practices by which the organisation gets work done. It means aligning organisational culture, processes and ways of working behind the formal commitment to clinical leadership. This can range from supporting medical leaders to tackle difficult colleagues to realigning decision making structures.

There is no one right answer. But it is important to provide the space and time for leaders to explore and agree a collective solution. A good starting point might be asking the question − what does clinical leadership mean in this organisation?

Therefore programmes to up-skill medical leads are not enough to truly develop clinically led organisations. Rather, organisations must see this as organisational development which helps their leaders to work through the change, define what it means in practice and develop new skills and ways of working from top to bottom.

Kate Wilson is clinical leadership practice lead at Hay Group