Becky Malby explains how a prototype clinical senate in Leeds explored the issues that the real organisations will face

Clinical leadership is at the heart of the emerging health system. But for it to succeed, doctors need broad leadership skills and strong relationships with each other. Neither of these things will happen by themselves.

‘To unleash the potential of senate-level leadership, support for senior doctors is required’

To address this, NHS Leeds commissioned a development programme for 26 “senate level” doctors, delivered by the Centre for Innovation in Health Management. The programme created a prototype medical senate for Leeds and allowed the city’s senior doctors to develop working relationships that had not been possible before.

Formal clinical senates will be regional and have a membership drawn from social care, patients and the public as well as doctors. The senate in Leeds is narrower, consisting exclusively of medical director, medical leads, associate medical directors and clinical chairs from the city’s clinical commissioning groups and provider organisations.

But it shares something of the objective of the regional senates to provide strategic, system-wide collaboration and guidance which can help CCGs, trusts, transformation boards and health and wellbeing boards make better decisions.

Workshop programme

The premise of the medical senate development programme, which ran from March to December 2012, was that doctors do not automatically have the skills to provide that strategic, collective guidance. To unleash the potential of senate-level leadership, support is required.

For example, doctors have very different views depending on where they work and need facilitation to understand each other. Moreover, unlike nurses, even the most senior clinicians receive little leadership and management development.

To address this, participants took five one- or two-day workshops, including:

  • analysing the context – complex problems, and the limitations of solving these problems from the top;
  • leading as peers – the relationships medical leaders need to have with each other to undertake collective decision-making;
  • strategic decision-making – this workshop took a key strategic challenge for Leeds and participants co-designed a response;
  • leading complex change through partnership – system management and how to work across boundaries.

All these workshops were active and participative. Leaders were asked to bring in real challenges to work on, and to test their discoveries and ideas in their work together across Leeds.

How the Leeds senate will do business

The 26 clinicians have drawn up a working statement, which sets out how they see their role. It describes its values as follows:

“An increase in investment in the NHS over the last 10 years has not led to an equal increase in clinical effectiveness. Ineffectiveness needs to be addressed to make better use of the money invested. A fully informed and empowered collaborative clinical leaders group will add significant value to overcoming these challenges.

“As clinical leaders across Leeds, we will ensure an integrated system of health and social care, based on the principles that all organisations and professionals will only be doing things that add value to patients and the system. All organisations will be mutually supportive, cooperate and be both respectful and open to challenge.

“We will ensure a consistent set of values, aims and outcomes across all organisations that focus on patient and community need, and ensure people get the right response from the system in the right place, wherever they access it.”

It sets out its goals and how it will achieve them as follows. The senate will:

  • Enable each member to work in his or her own organisation in a way that is coherent across the city
  • Take a leadership role only where it can make a difference
  • Connect managers and clinicians across Leeds
  • Help decisions to be made across organisations, services and groups

It will support commissioners and providers to:

  • Stop what does not work
  • Modify what is ineffective
  • Appropriately introduce new pathways
  • Encourage innovation

It will achieve these goals by:

  • Asking powerful questions
  • Focusing on critical issues
  • Sharing information – and working through it – to make better decisions for the whole system, not just each member’s individual part of it
  • Focusing on the causes rather than the symptoms of problems
  • Generating feedback at multiple levels
  • Mobilising colleagues

Joining the dots

The doctors also spent time working on skills they felt would be most useful, for example dealing with conflict or patient engagement.

Some chose to take CIHM’s narrative 360-degree feedback tool. For those who took part, the benefits were felt in better relationships within their organisation and greater ease in giving and receiving feedback.

The senior doctors we worked with are immensely bright and quick to learn. They are used to analysing and diagnosing a problem, then working out a solution. They have phenomenal strategic capability and are passionate about innovation. But when we began the programme they lacked understanding of the wider system, and assumed they knew a lot more about each other than they actually did.

‘People in the system have a much greater understanding of what others in the system are trying to achieve’

Our sense as facilitators is that the single biggest impact of the development programme was to generate the relationships and mutual understanding which make possible collective action. Leeds’ clinical leaders now really know each other, know each other’s circumstances, and have a common language to discuss difficult topics.

When they encounter each other in meetings, each can see how and why the other takes up a particular role. Rather than getting exasperated, they can comprehend each other’s perspective and begin to work in a joined up, supportive way.

These interpersonal advances are enhanced by greater theoretical understanding of systems and complexity. Doctors learn how to deal with things as experts. But the big, expensive health problems do not respond to such approaches because they are dynamic and multidimensional. The programme focused on exactly these kinds of intractable, wicked issues.

Solving complex problems

Leeds’ senate-level doctors are now much better placed to contribute to complex problem solutions by working with and influencing the whole system, rather than just their patch.

Feedback from participants bears this out. When asked which aspect of the course had the greatest impact, one doctor said: “Developing networks between medical leaders… more understanding about theories of management and how to use this knowledge to navigate and use the present system to improve outcomes… realising the influence we can have on the system.”

‘Projects have been unblocked because relationships have developed between people who didn’t know each other before’

Another spoke of “better communication and more trust” between medical leaders.

Leeds Community Healthcare Trust executive medical director Dr Amanda Thomas says: “The senate has enabled us to look at healthcare across Leeds as opposed to just within our own organisations. This has allowed us to understand how changes made at a single organisation level affect other organisations – for example, bed closures in one trust, and the impact on community services. We are now trying a whole systems, integration and partnership approach. There is a real willingness to work together.”

Greater understanding

Another participant, Dr Simon Stockill, clinical director for service transformation across the city’s three CCGs, adds:  “Instead of seeing things as simple – and believing there’s a simple solution to problems if only we could find it and persuade others to do it – I now know that I work in a complex ecosystem.

“There are some projects that have been unblocked because good working relationships have developed between people who didn’t know each other before. People in the system have a much greater understanding of what others in the system are trying to achieve, so things that previously took an age to resolve are now easier.

“For example a new, transformed evidence-based self-harm pathway for the A&E department will actually launch in February 2013. All the appropriate contractual arrangements have been made; the only thing holding it up now is an HR process. That came directly out of discussions over a cup of coffee at the senate development programme. This is a concrete example and I believe there will be many more.”

‘We hope what we have learned will strike a chord with other parts of the country seeking to make the most of their clinical leaders’

He hopes similar progress can be made with the much larger Leeds Care Record project: “This involves huge changes in the IT infrastructure and sharing of information. Many of the key players have got to know each other through the development programme.”

Dr Stockill believes the developmental status of the programme allowed it to quietly get on with things. Whereas a body with decision making powers and a budget would have created bureaucracy and an impression that doctors were getting preferential powers.

One implication of the programme is that regional senates may be too big to achieve the kind of network we now see developing in Leeds. It might therefore be useful to have smaller sub-groups where strong connections between senior clinicians can develop.

We hope that what has been learned in Leeds will strike a chord with other parts of the country seeking to make the most of their clinical leaders. Dr Stockill adds: “What we’ve done in Leeds could be applied wherever you’ve got medical leaders coming together from across the system, with very different perspectives, to solve complex problems.”

 Becky Malby is director of the Centre for Innovation in Health Management, email: