Duncan Bland looks at the findings from nine leadership focus groups that reveal doctors’ definitions of clinical leadership, the skills they believed were important and the potential barriers to and enablers of leadership they perceived in the health system.

Clinical or medical leadership continues to be under the spotlight. Intense scrutiny of the Health and Social Care Bill and the establishment of new commissioning arrangements have led some to ask: what will this mean for doctors as leaders in a reformed NHS? 

But the leadership agenda for doctors had already advanced steadily over several years. So much so, that the prominence of clinical leadership in new NHS structures was a relatively unsurprising feature of the Health White Paper when it was first published. 

But how does understanding of leadership at the top of the health service relate to attitudes to leadership among “grass roots” doctors, and is the concept of “shared leadership” getting through? 

At the BMA during 2011, we undertook a series of nine leadership focus groups across the UK with around 70 doctors from general practice and secondary care, a few of whom had experience of leadership but the vast majority had not. 

We asked doctors about their definitions of clinical leadership, the skills they believed were important to clinical leaders and the potential barriers and enablers of leadership they perceived in the health system. The research took place prior to the Health and Social Care Bill becoming an act. Its findings serve as a useful benchmark of medical attitudes to leadership. 

Skills and attributes for clinical leaders

Our groups identified some of the same skills and behaviours as reported in the Seven habits of emerging leaders by Oliver Warren and Emma Stanton in their article about discussions with emerging young medical leaders in the NHS London Prepare to Lead Programme. Doctors identified being able to develop and articulate a vision, networking and communication skills, the ability to listen, empathise and act upon the informed opinion of others and, crucially, “clinical credibility”. 

Clinical credibility, through retaining some clinical practice, was considered paramount to be an effective leader and to engender peer respect. Our findings were encouraging not merely because they replicated the results of another study group, but precisely because they suggest that the views of ordinary doctors mirrored those of young prospective clinical leaders.  

Barriers to clinical leadership

When our doctors later discussed perceived barriers to leadership, many cited the inherent autonomy of fellow medics as creating a challenging leadership environment, thus demonstrating the age-old expression of medical leadership as like “herding cats”. We can therefore add resilience and a positive outlook to our credentials for aspiring leaders, whatever their age. 

Many of the doctors in our discussions felt they were not sufficiently aware of leadership opportunities; often because of a perceived lack of transparency in recruitment to leadership posts or a career structure poorly defined for leadership. These findings give rise to two further inferences: the ability of doctors to identify leadership opportunities continues to be highly varied and; many doctors still perceive leadership opportunities as being limited to those with designated leadership responsibility. This seems to be a clear difference from more confident identified clinical leaders. 

How can potential leaders be supported?

Our discussions did not suggest a paucity of potential clinical leaders. Unknowingly, doctors did provide many examples of where they had shown leadership through, for example, taking responsibility for redesigning services. Our findings imply that this ability to “self-identify” leadership skills and behaviours, to know “when you are leading”, is just as variable among doctors as it we might expect it to be in any professional group. 

The ability to self-identify leadership skills is very relevant to the leadership barrier most often identified by our doctors – a shortage of time. It is harder for the time-poor doctor to reflect on behaviours which reinforce effective leadership and drive improvements in patient care. Being unable to do so may stifle leadership for many and ultimately limit service change. 

If time for leadership is perceived as scarce this places further emphasis on the competing demands which the NHS must face for the foreseeable future. Clinical pressures and the clamour for increased productivity are greater than ever. The NHS cannot afford not to make system wide improvements to clinical services, changes which require the expertise and leadership of doctors. Yet at the same time, NHS managers, practices, hospitals, and perhaps even the most confident clinical leaders, may naturally be concerned at the potential effect of protecting time for leadership upon their short term clinical pressures. They may also be daunted at the prospect of justifying their allocation of resources to fellow colleagues. Long term improvements to services may be inhibited by a catch 22. 

The ability to self-identify and practise leadership behaviours should therefore continue to be supported through training and continuing professional development for the broadest range of doctors even though this presents a further challenge among many others affecting the NHS. 

Peer support was unequivocally the most consistent enabler of clinical leadership to emerge from our discussions. Established clinical leaders in particular, within secondary care and general practice, have a major role to play in encouraging their colleagues. Encouragingly, participants in our discussions recognised that all doctors can benefit from being more supportive of another colleague who tries to provide new ideas. There was recognition that too often keen leaders are met by a suspicious audience. 

The future for clinical leadership

That so many participants in our discussions perceived of more barriers than enablers of leadership suggests there remains an inclination among some to conceive of leadership in relatively heroic and hierarchical terms or as a designated rather than shared responsibility. Many members of our discussion were keen to differentiate management from leadership and, in showing a preference for leading by example, most doctors placed their emphasis on skills, knowledge and innovation.  To achieve a sustainable shift in the NHS culture, knowledge and expertise must be recognised and lauded as valuable leadership commodities to avoid leaders being defined in such narrow terms as those who hold power or designated responsibility. 

Taken together, the results of our discussions with grass roots doctors suggest a slow but gradual shift in the leadership culture.  Lasting change will require greater effort by all health stakeholders from the BMA to the newly formed National Leadership Academy, NHS trusts and clinical commissioning groups to ensure that an improved climate for leadership survives the stormy financial weather affecting the NHS.