Embedding leadership in medical training

The need to improve clinical leadership skills has been gathering momentum in recent years. Strengthening and embedding leadership in postgraduate medical education and training is part of this drive and was a recurring theme in the Postgraduate Medical Education and Training Board's Future Doctors review.

Leadership is one of many important issues the review is looking to address in examining the future requirements for the content and outcomes of postgraduate medical education and training in the UK.

The review is taking into account changes in society, medicine, patient expectations, workforce and service delivery - all factors that affect the requirements for training and how training is delivered. In this context, the review will have particular regard to the needs of trainees, patients and the service.

PMETB head of policy Mark Dexter, who is co-ordinating the review, says: "We have been talking directly to a wide range of stakeholders, including trainees, and it is clear that coverage of leadership training in postgraduate education varies considerably across the UK."

Key skills

This is underlined by our national survey of trainees for 2007, which showed that of the 33,000 postgraduate trainees who responded, only 23 per cent reported having had any formal teaching in leadership since leaving medical school.

Also, as part of the service strand of the Future Doctors review, PMETB recently surveyed senior NHS managers. The majority of respondents - 117 of 154 - cited the development of leadership skills in particular as being vital in preparing trainees for their future roles as managers and leaders in the service.

Underpinning the Future Doctors review has been the advice provided to PMETB by a number of expert working groups. One of these is the Educating Tomorrow's Doctors working group.

Its chair, Dr Charles Swainson, says: "The majority of these doctors occupy leadership positions, inside or outside their own organisations, within the context of continuing to be a valuable member of a multidisciplinary clinical team. The Educating Tomorrow's Doctors working group identified leadership skills as essential for future doctors.

"We believe that doctors need to understand the close relationship between good clinical leadership and high-quality clinical care, and hence understand their own place within a team. Most doctors will occupy leadership roles during their career and we thought it was important that their postgraduate training and development prepared them properly for that role. Leadership, however, is fragile, and needs to be sustained if it is to flourish."

Central drive

Dr Swainson welcomes the proposed NHS leadership council, which he says will provide focus and a structure for ensuring leadership development is available and well used across the NHS. "Doctors as a profession need to embrace the concept of medical leadership, and that leadership is a set of skills and behaviours that can be recognised and developed further, in parallel with the enhanced clinical skills that develop over a career."

PMETB has given advice to the Academy of Medical Royal Colleges and the NHS Institute for Innovation and Improvement, which have been leading the development of the medical leadership competency framework. The framework will define the leadership competencies to be acquired in undergraduate training and postgraduate programmes, through to the first years after entry to the specialist register.

Dr Patricia Hamilton, chair of the joint academy/institute steering group, Enhancing Engagement in Medical Leadership, says: "Newly appointed consultants feel more confident about their clinical skills than their leadership skills. They recognise the latter will be needed in the roles they are expected to take on - and expect to be trained to do so.

"The medical leadership competency framework aims to instil in all doctors the concept that management and leadership skills are just as necessary for good outcomes and the safety of their patients as having the requisite clinical skills.

"Not all doctors take on higher leadership roles and not all clinical leaders are doctors - but every doctor will need some of these skills within their own team. Through learning about leadership they will be more effective in running their own service and better able to be leaders or good 'engagers' at higher levels."

Workplace learning

The competencies will be taught in the workplace by clinicians who are positive role models as leaders, and will be part of workplace-based assessment. The framework has been piloted in undergraduate, postgraduate, general practice and hospital settings.

PMETB and the General Medical Council are being asked to support the curricula so colleges and medical schools can demonstrate that their programmes deliver the competencies defined in the leadership framework. Medical directors will be expected to include it in the revalidation process, which will affect all doctors. The E-Learning for Healthcare initiative has been approached to develop resources to ease the burden on tutors and trainees.

Dr Hamilton says: "This programme is unique in medicine - no other national medical training programme provides this training from undergraduate years. Research shows that the better the clinical engagement with senior management, the better the organisation performs - which is good for the health service and good for patients."

Mark Dexter says PMETB looks forward to proposals from the medical royal colleges indicating how they intend to integrate the leadership curriculum into specialty training curricula - which must be approved by PMETB - and therefore clinical practice.

He says: "There is clear evidence and a consensus for action supported by the national policy direction set out in Lord Darzi's next stage review. The challenge now is for all who have a stake in postgraduate medical education and training to make the theory a reality."