The profile of NHS clinical leadership has risen considerably in recent times, but the concept is not a new one. Arguably, it rests at the heart of working as a doctor.

Whether you are leading a ward round as a foundation year two doctor or a royal college as president, it could be argued that every doctor plays a leadership role in their daily work.

Yet the knowledge, skills and attitudes required to perform this role well have historically been assumed or ignored rather than recognised, acknowledged and nurtured.

The question of whether leadership is innate, learned or earned has been debated for many years, and it is likely that within the breadth of the medical profession all three routes need to be addressed.

NHS hierarchy

Currently, there is little doubt that in the hierarchical world of the NHS and the medical profession, we are led by those who have earned their title through time and experience.

While this system clearly has its merits, we also need to be aware that those who shout the loudest or have the greatest conviction or gravitas may not be the voice of reason. We also need to be led by people who see medical leadership as a way into a career rather than a way out of one, so maybe it is time to seek a new paradigm.

Learning to lead

At entry to medical school, skills beyond pure academic success are assessed, including leadership attributes and achievement. Yet in undergraduate and postgraduate medical training there is little or no attention given to honing these skills.

If leadership is truly learned, then we are missing out on this head start. If every clinician is a leader - in some shape or form - then we must begin the process of training for this role at the earliest opportunity. The recent work of the NHS Institute for Innovation and Improvement and the Academy of Royal Colleges to address these issues is heartening, but it will be some time before their vision of a run-through leadership curriculum becomes a reality.

Outdated attitudes

For trainees whose potential to become clinical leaders is clear from an early stage of their careers, the propensity of the profession to quash enthusiasm through outdated "them and us" attitudes towards clinical and non-clinical leaders is depressing.

References to the "Dark Side" are still endemic at the front line of medicine, so it is unsurprising that our junior clinicians are reluctant to see clinical management and leadership as a viable career option. However, these are the clinical directors, medical directors and chief medical officers of the future, so any interest or enthusiasm towards "bigger picture" medicine in the early years of training needs to be captured and encouraged.

Darzi review

Health minister Lord Darzi's recognition that to provide a quality service you need quality clinical leadership has been and will be vital in raising the profile of this training need, but it is at a local level that this will need to be addressed.

Although they may lack experience, junior doctors are intelligent and logical people who are working at the coal face of the NHS. Yet their opinions and input are rarely sought on service improvement or clinical governance matters. If encouraged to tap into this resource of youthful enthusiasm, trusts may find that they not only gain insights into the true mechanics of their healthcare system, but also find solutions and - possibly more importantly - buy-in from those at the patient interface. A process of engagement and recognition would also go some way to breaking down historic barriers, even producing senior clinicians who have seen the light on the "Dark Side".

Ultimately, if the medical profession is to regain its leadership credibility, we need to enthuse, encourage and train exceptional leaders for the future. This will take time, investment and a seismic culture change, but if we are to see a truly clinically led, patient-centred service, there may be no other way.