To make patient care truly effective, all doctors need to develop the skills of transformational leadership, as Graham Neale explains

Before the turn of the century, there was little emphasis on the need for doctors to develop leadership skills. In 1983, as a result of the Griffiths report, the present-day managerial structure for hospitals became universal. As a result, consultants lost their powers of veto and retreated behind the barriers of clinical autonomy and self-regulation.

In the 1990s, defects in hospital care surfaced as an important issue. The problems of paediatric cardiac surgery in Bristol lit the touch paper. The investigation of the underlying issues by Sir Ian Kennedy prompted Richard Smith to write a BMJ editorial quoting WB Yeats: "All is changed, changed utterly". The hierarchical and autocratic structure of medical leadership uncovered in Bristol could no longer be tolerated.

But there were bright spots. In the 1980s, John Lunn (in Cardiff) and Brendan Devlin (in Stockton-on-Tees) organised a confidential and anonymous inquiry, in five NHS regions, into mortality associated with surgery. This must have required huge dedication and leadership and it had a profound effect on surgical and anaesthetic practice. This initiative continues today in the work of the National Confidential Enquiry into Patient Outcome and Death.

Bristol and the national confidential enquiry involve big issues - the one showing the adverse effects of unrestrained hierarchical leadership in a high-profile endeavour, the other showing how visionary leaders can achieve profound organisational change.

The road ahead

Lord Darzi's document High Quality Care for All stresses the importance of clinical leadership in achieving the ambitions of the NHS next stage review. However, the nature of such leadership and how it may be nurtured remain to be determined. The difficulties are considerable. The increasing specialisation of hospital practice, the fragmentation of clinical experience in the foundation years and the need for shift-working to satisfy the European working hours directive appear not to encourage development of holistic leadership.

For optimal performance of surgical procedures, there is good evidence that quality and safety can be improved by working to a checklist. In each phase, a co-ordinator confirms that the surgical team has completed the listed tasks before it proceeds. This is fine for task-oriented leadership.

But most hospital medicine does not follow pre-ordained lines. With an ageing population, it is usual for most patients admitted to hospital to have multiple problems. For optimal care, close teamwork is essential and for this to work well all doctors need to develop the skills of transformational leadership. This form of practice allows members of the group to raise standards. From their first days of taking clinical responsibility, all doctors need to work with everyone directly involved in patient care, recognising and linking with their experience and skills.

Leadership is ultimately a social function in an organisation or group. Regrettably, hierarchical leadership remains the predominant culture in hospital practice and change will take time. The way forward requires dynamic leadership that addresses the unconscious concerns of all members of staff and, indeed, of patients. It needs regular joint meetings of frontline staff to address issues of quality and safety and to elicit improvements; involvement of members of hospital boards and management; and a determined approach from the Healthcare Commission.