By empowering trainee doctors to undertake service improvement projects they can share their broad hospital experience and learn about leadership in the process, say Patrick Marshall and Clare Penlington
Junior doctors leading innovation
The new NHS change model has at its apex leadership for change and the spread of innovation. For all the rhetoric of shared and distributed leadership, the group often held as responsible for making this kind of innovation happen has been the formal leaders in the NHS − the chief executives, managers, clinical and medical directors. An often underused resource for change and spreading innovation to improve services for patients in the NHS is trainee doctors.
‘With the right kind of guidance, trainee doctors are well placed and suited to catalysing and sharing innovation across the NHS’
Because of the way postgraduate medical education works, rotating doctors through different hospitals, trainee doctors often develop a sharp insight into different practices, across trusts, and have excellent ideas about how services could be improved for patients, carers and staff in the NHS. Yet, this same group often feel disempowered and disinclined to make these changes because of the way they are regarded as temporary members of NHS organisations.
In Health Education England Kent, Surrey and Sussex (HEKSS), we have developed programmes that empower trainee doctors to undertake service improvement projects that make a real difference to patient care.
In response to the 2008 Darzi report, HEKSS developed a variety of programmes in leadership in clinical settings to fulfill the requirements of the Medical Leadership Competency Framework that are now incorporated into all medical curricula.
At the heart of these programmes is the principle that doctors learn about leadership by planning and undertaking projects − all of which are aimed at improving services for patients and staff in the NHS. This approach has the benefit of doctors linking the theories of leadership with developing skills in their practice setting and improving services in their local trusts.
Our experience shows that with the right kind of guidance, trainee doctors are well placed and suited to catalysing and sharing innovation across the NHS in a way that engages other professional groups in change agency. This reaps real rewards in improving the quality of patient care, as well as affording developments of working conditions for staff in the NHS (an often undervalued aspect of service improvement).
Champions for change
Two key programmes that we have developed to support doctors engaging in service improvement projects are a pairing scheme in which we partner foundation doctors with graduate trainee managers and a postgraduate module in leadership.
In both programmes, we provide support through teaching and action-learning sets, as well as guidance and support in the doctors’ and managers’ NHS trusts. For doctors this is in the form of leadership tutors and mentors, so that trainee doctors can take on service improvement projects that effect actual change in practice and improvements in patient care.
For managers they have a “champion” who will help the trainee navigate their project through to completion. The best way of describing the success of these schemes is to outline two service improvement projects that trainee doctors have undertaken through the programmes we run.
Easing the pain
The first example is from a specialty registrar in anaesthesia and intensive care at a hospital in south of England. In this service improvement project, the registrar attempted to introduce a policy of routine premedication of all day surgery patients with oral paracetamol. The reasons for this were twofold; to provide effective pain relief after surgery and to reduce expensive use of intravenous paracetamol in theatres.
The change was designed to ensure consistency and address patient safety issues (such as the danger of double dosing). Although this was largely a change in anaesthetic and nursing practice, this project, like all important changes, was systemic in character. It had to go through rigorous consultations with different hospital directorates and to overcome opposition from special interest groups before it was finally approved and put into operation.
‘The benefits of engaging trainee doctors in leading change and spreading innovation should not be underestimated’
The effect of this simple change in clinical practice was profound and has saved time, money and improved the experience for patients. It is, however, worth considering what the trainee doctor learned about the process of introducing this change in a NHS trust and leading this change from his position as someone with authority but not with a formal leadership role.
The trainee doctors who undertook this project learned valuable lessons about how to negotiate with multidisciplinary teams as well as how to build relationships with key players in the formal leadership structure in order to ensure the change did not just stay on paper, but actually translated into a robust change in clinical practice.
The second example of a service improvement project comes from our leadership pairing scheme where a graduate trainee manager and two foundation doctors worked together to reduce the carbon footprint of their hospital.
This project came from their joint interest in the dangers of climate change and resulted in them engaging with large swathes of the hospital organisation from facilities to finance. They succeeded in changing their hospital’s culture around energy, persuading staff to engage in reducing consumption and comparing levels across wards and theatres. This group gained access to their hospital’s clinical governance group as well as sharing their results with neighbouring hospitals.
‘Understanding how to take on the role of change agency must become part of doctors’ identity’
The benefits of engaging trainee doctors in leading change and spreading innovation should not be underestimated. Trainee doctors are able to spread innovation across trusts in unique ways because they understand the structure from the bottom up and are often very keen to make a difference to services before they move on.
Understanding how to take on the role of change agency must become part of doctors’ identity, early in their training, in order for them to be open to change when they reach more senior positions.
We have found that more measurable changes happen when these doctors and managers lead the initiatives and their voice and experience must be remembered when thinking about how to develop leadership and spread innovation in the NHS.
Patrick Marshall is academic head of the School of Leadership and assistant dean, education, at Health Education England Kent Surrey and Sussex; Dr Clare Penlington is deputy head, education, at Health Education England Kent Surrey and Sussex, and academic head of the School of Clinical Leadership