John Clark and colleagues report on a project that aims to break down bunker-like regimes and involve medical staff in trust leadership

Enhancing clinical engagement is a priority at every level in the NHS, and a joint project by the NHS Institute for Innovation and Improvement and the Academy of Medical Royal Colleges is looking to strengthen the contribution of doctors in a wide range of leadership roles.

Clinical engagement is not about the appointment of a small group of leaders to roles such as medical or clinical director. It is a recognition that leadership is a social function and not just defined by hierarchical reporting lines. Enhanced clinical engagement should work towards a model of diffused leadership, where influence is exercised across a complex set of relationships, systems and cultures. It is a set of behaviours that should apply to all rather than a few.

One output from the Enhancing Engagement in Medical Leadership project is an integrated framework for clinical leadership, designed to underpin the preparation of doctors for this enhanced role at each phase of their medical careers.

A key component of the project has been to address the issue of the link between medical engagement and organisational performance and better understand how the dynamics of this relationship may operate.

The level of medical engagement should not be thought of as a fixed point but as somewhere on a spectrum, with the organisation constantly evolving. It is important for chief executives to understand this so that they can develop appropriate strategies based on their current position rather than a general one-size-fits-all approach.

Formal ties

In order to explore the relationship between medical engagement and organisational performance, semi-structured interviews were conducted with chief executives and medical directors in a selection of the 15 highest and seven lowest-performing organisations (as defined by the Healthcare Commission in 2006).

When asked what percentage of doctors they felt were engaged, the top-performing organisations reported an average 44 per cent and the poorer performers 17 per cent. Similarly, when rating achieved level of engagement from 1-5, the top performers averaged 4, and the low performers 2.5, with chief executives in the latter group saying it would have been 1 when they arrived.

There was a tendency for most organisations to refer specifically to the top 20 or so medical leaders represented in formal positions. This underlines the earlier distinction about engagement being a process of strengthened contribution from all, rather than a potentially isolated few.

What can chief executives do to change the situation? In the interviews, several initiatives were identified but they were limited to one or two organisations and often varied according to the nature and size of the trust involved. For example, in the smaller trusts and in mental health trusts, there was a strong view that chief executives should always participate in consultant panel interviews and induction programmes. In large teaching trusts, this was seen as unmanageable as a result of their size and number of appointments. Virtually all trusts felt that current arrangements for consultant appointments were inadequate, but only two had taken steps to improve the situation with competency-based assessment frameworks.

All chief executives wanted to get to know their doctors better, and a number of formal and informal approaches were identified but nothing very systematic or comprehensive was proposed. In the poorer-performing trusts, the previous regimes were often described as "bunker-like", with few mechanisms for meeting doctors.

It is clear that engagement is not a one-way process. It is not about asking doctors to be more engaged. The organisation must develop reciprocal competencies to enable it to respond to opportunities, regardless of its position in the cycle of organisational growth and change.

A report for the Institute for Healthcare Improvement, Engaging Physicians in a Shared Quality Agenda, suggests some systems-based ways that clinical engagement can be promoted. In conjunction with the current project findings, several actions emerge as helpful behavioural practice in enhancing engagement:

  • Active listening. The highest performers exploit all opportunities for informal listening, such as groups at lunch, walkabouts to see innovations and improvements, and invitations for coffee/dinner. They ensure doctors are listened to all the way to the board.

  • Prioritising one-to-one meetings with medical staff. Top performers know 100 per cent of their doctors and are active in achieving this.

  • Setting fixed formal meetings with medical staff. These meetings are planned over the year, involve the senior management team and are a dialogue, not a one-way session.

  • Participation in all senior medical appointments. This may involve informal meetings, participation in panels and, in the best cases, developing more extended, perhaps competency-based, assessment frameworks that go beyond medical skills.

  • Involvement in induction programmes. The top performers clearly signal their interest in medical staff by seeing all newly appointed staff in the first two to three weeks of their appointment and again two to three months later.

  • Relentless adherence to quality and safety issues. These are key drivers for all clinicians. The highest performers know the difference between system and individual accountability. In high-performing organisations, doctors are system builders who encourage and facilitate change, recognising that the underlying values of the NHS must be visible and articulated.

  • Commitment to a third of total time in contact with medical staff. Chief executives in top organisations treat doctors as partners and move towards structures where doctors lead whole areas of the business.

  • Devoting resources to development. The highest performers ensure adequate resources and access to programmes that develop leaders. They actively pursue talent management and succession planning, and understand that organisational development is essential to effective organisations.

No single activity provides an answer; engagement is a cultural issue and these approaches may continue to help create context. The project is developing a good practice guide for NHS senior leaders and is piloting an index of medical engagement that will not only report current levels but suggest ways in which organisations can work to enhance engagement. Both the guide and medical engagement scale are expected to be available this year.