Darzi drives doctors to scale the dizzy heights

"Leadership has been the neglected element of the reforms of recent years. That must now change."

Lord Darzi's battle cry for leadership - in particular clinical leadership - to drive improved quality of services in the NHS is likely to strike a chord.

NHS Employers acting director Sian Thomas welcomed it as heralding probably the biggest ever investment in NHS leadership development through a systematic approach.

But despite the big ideas, the health minister's report is short on details - in public at least - of how they will be implemented across such a diverse employer as the NHS.

Even organisations that have been involved in the working parties underpinning the leadership section of the report do not know what their future involvement in delivering the programme will be.

NHS Institute for Innovation and Improvement leadership director Paul Allen says that remits and accountability, as well as what is to be done at national, regional and local level, are still to be clarified.

Lord Darzi promised to establish an NHS leadership council, to be chaired by the NHS chief executive, "responsible for overseeing all matters of leadership across healthcare". This will be crucial in making decisions about how leadership is fostered in the service, but its membership is not clear.

Ms Thomas suggests that the council will have a central role in "describing the narrative" around leadership. But she questions whether it might be trying to do too much if it also gets into the details of commissioning programmes.

Doctors take centre stage in this vision of the future; however much Lord Darzi may have enraged the profession over polyclinics, he has made many friends with his promises on clinical leadership. The British Medical Association, the Academy of Medical Royal Colleges and the British Association of Medical Managers are all enthused.

However, substitute doctor leadership for clinical leadership and the report does not read radically differently: there are a few references to nurses but far more about doctors - and virtually nothing about the myriad other professions that contribute to care or to the non-professional roles where there will still be a need for inspirational and committed leaders.

Managers as a separate profession get a look-in where regulation is discussed or the need to prevent them moving on to other jobs when they have performed poorly.

Doctors, in contrast, get leadership embedded in their undergraduate and postgraduate training, and more closely linked to their clinical excellence awards. Institute of Healthcare Management chair Andrew Corbett-Nolan says: "I suspect what Lord Darzi means is not bringing in more clinicians [into management] but bringing in more doctors" - although some people feel Lord Darzi is committed to a wider view of clinical engagement.

Putting patients first

BMA consultants committee chair Jonathan Fielden argues that doctors are in the right place to take on leadership roles: "The difference that doctors bring is that we do put our patients and high quality care first. We understand that there is a financial aspect to high quality care. But that is a different mindset to the accountancy mindset we have suffered from for so long.

"Medical leadership is the best model for this. We have the skill set, the education, the knowledge and the drive for our patients. But the report has used the word clinicians to recognise that it's not just doctors who have this skill set."

The report draws comparison between the low levels of clinical leadership in the UK and the higher levels in the US - specifically in Kaiser Permanente. But the clinical leadership in Kaiser is very much doctor-based and there are not the equivalent high level nursing roles that are found in the UK (although skilled nursing is a key part of its system). Kaiser's watchword is "every physician a leader" with 25-30 per cent of its physicians having some management responsibility.

But managers from different backgrounds should not be forgotten. Andrew Corbett-Nolan points to the importance of good leadership of other healthcare workers - such as cleaners - to delivering quality care. And he challenges the idea that managers are divorced from patient care: they nearly always end up carrying their own caseload of people's problems.

He welcomes the greater involvement of clinicians but appreciates that this is an area where managers may be sensitive. "I do understand that some people might feel that their nose is being put out of joint but I hope they could see the bigger picture."

Many of the details of the schemes suggested in the report will determine how successful they are. The NHS 250 - the leaders who will be picked out for additional support and mentoring - is seen by many as just a start. Mr Corbett-Nolan says he welcomes it but looks forward to the NHS 25,000.

Peter Reader, the NHS Alliance's spokesman for professional executive committee chairs, points out that leadership development needs to be more embedded in organisations than simply selecting a small number of people and "taking them off somewhere".

But who will these people be? Mr Corbett-Nolan suggests they need to be "respected by their peers, genuinely enthusiastic about fulfilling this role, excellent communicators and with a little bit of humility".

Dr Reader points out the value of clinical leaders being allowed to be challenging and aberrant at times.

But 250 will be less than one per trust so it is likely many will be established leaders already. Many people feel the list will need to allow people to move onto the scheme (and presumably off it as their career progresses). Mr Corbett-Nolan says: "Let's not create another exclusive club... it's a seed corn that we may need to nurture and grow over the next decade."

He points to London with its strong ethnic minority population, large gay community and high percentage of people born overseas as an example: "We want to see these groups properly represented in leading the health service."

There is similar uncertainty on some of the qualifications suggested in the report, such as the Leadership for Quality certificate and the Clinical Management for Quality programme - let alone masters qualifications for board members. Who will be selected and how the schemes interact is not yet clear.

At the moment leadership programmes are spread over many different organisations - the NHS Institute is a major player, for example, but strategic health authorities and the Appointments Committee are involved in board development, while many professional organisations are also developing leadership courses. Unless the leadership council takes an accreditation or kitemarking approach, some could lose out.

Mr Fielden cautions against making certificates a prerequisite for doing or getting a job: "You would have to say just because you have a certificate does not mean you are a good leader, just because you don't [have the certificate] does not mean that you aren't," he says.

Two to tango

The British Association of Medical Managers is delighted by these moves and what it sees as the primacy given to quality in the final report. Chief executive Jenny Simpson envisages a future with "a lot of clinicians at the top - in different jobs such as planning and human resources, and not doctors involved in a tokenistic way".

But Mr Corbett-Nolan points out that there is a need for other managers to be helped to understand the clinical side as well. "I would put it as a challenge to many managers in the health service to write down on one side of A4 what a histopathologist does," he says. "We need to develop clinicians into managers and develop managers to understand clinical processes."

If Lord Darzi manages to pull more doctors into leadership roles he will have overturned a history of doctors feeling that some of these roles are not high status, are too risky for them to take on and that they are inferior to top academic or clinical appointments.

Mr Fielden suggests there has already been a change of ethos in some trusts, with much more planning around leading doctors' roles and enhanced support for them. "It's seen as going over to the dark side. We would prefer it if clinicians see it as the force being with you!" he says.

But Dr Reader sounds a note of caution. He welcomes the moves but says good intentions can be hard to move into practice.

Professional executive committee chairs, for example, sometimes end up out of pocket for taking on this important role. This is despite high level support for their position. He warns of good schemes "withering on the vine" without "a real change in ethos, approach and acceptance".

Some problems may be more pressing in primary care where many potential clinical leaders are independent contractors in a culture different from acute trusts: the system has to support clinical leaders at different levels, not all willing to move to a full-time role.

Royal College of Nursing director of nursing and service delivery Janet Davies points to the need for support around clinical leaders - especially at ward or community team level. Some of this can be as simple as clerical and administrative staff to free them for a leadership role. They may also need support to keep up a clinical role and hands-on work.

But national workforce director Dame Carol Black points out that leadership means making hard decisions: "You have to learn to take leadership in a financial sense - you have to be responsible with managers for the budget. That would be a new role for many doctors but that's part of being a leader."

Clinical leaders online

This week hsj.co.uk launches a new section for clinical leaders.

It gives clinical leaders a forum to debate important clinical challenges in policy. It will focus on the evolving relationship between management and clinical professionals, innovations and best practice - major areas in Lord Darzi's next stage review.

This week, look out for:

• Can doctors rise to the challenge of leadership?

• Aidan Halligan on why Darzi needs clinical leadership

Forthcoming content will focus on clinical outcomes, technology, service transformation, patient safety, regulation of healthcare professionals, modernising careers and pharmaceutical innovation.

Visit www.hsj.co.uk/clinical_leaders for more.

If you want to get involved in shaping this new resource, please email anamika.rath@emap.com

HSJ's sister title Nursing Times is holding a Nursing Workforce Forum on 18 September