‘Buddying’ clinicians with managers could help both groups collectively create an environment where clinical excellence is inevitable. Bob Klaber and colleagues report.

A paired learning initiative at Imperial College Healthcare Trust has improved outcomes and helped mobilise the quality, innovation, productivity and prevention drive through increasing communication and collaboration between clinicians and managers.

There is increasing evidence linking engagement between clinicians and managers with improved patient outcomes. The NHS leadership framework acknowledges the move to shared leadership by having one framework for all staff groups. With the current reforms placing a strong emphasis on clinical leadership, clinicians and managers will need to bridge the gap between their respective professions and collectively create an environment in which clinical excellence is inevitable.

The announcement that a new leadership academy will be formed as part of the NHS Commissioning Board provides an opportunity to consider new approaches to leadership development that focus on enhanced collaboration between clinicians and managers and improved outcomes for patients.

Imperial pilot

Clinicians and managers can operate in very different ways and often have little opportunity to understand each other’s roles and the challenges they face. Paired learning is an innovative approach to leadership development, designed and piloted within Imperial College Healthcare Trust during 2010-11.

Specialist registrar doctors, many of whom had never spoken to a manager as junior doctors, were paired up with band 7 or band 8 managers. The aim of the “buddy” approach was to learn from each other’s experiences and harness expertise and different perspectives on improving services for patients.

The initiative was developed by a team of experienced clinicians, managers and educationalists. They recognised the need to support the strong clinical leadership structure at Imperial through building a pipeline of clinical and managerial leaders who could collaborate effectively.

Similar pilot programmes were run on a smaller scale in North Middlesex University Hospital Trust and King’s College Hospital Foundation Trust, and were all supported by NHS London and the NHS Institute for Innovation and Improvement.

The initiative was based on four key elements:

  • informal pair meetings;
  • work shadowing;
  • workshops on leadership and improvement;
  • quality and service improvement projects.

Through the opportunity to observe and learn about each other’s role, 75 per cent of participants were able to identify an opportunity for improvement of a service and to jointly design and implement a solution. Both managers and doctors felt significantly more prepared for leadership roles after paired learning, as measured through a five point preparedness scale based on the leadership framework.

All participants reported that paired learning had not only improved their understanding of each other but that the first hand experience of the benefits of collaboration was a driver to seek out each other’s input in the future. Participants reflected that the peer learning relationships they had developed had the potential to drive forward long term cultural change across the NHS.

Planning a scheme

Leadership: Strong and adaptive leadership, with active role modelling of partnership working, is critical to the success of paired learning. Ideally this should come from senior managers and clinicians, who together can provide ready access to networks of potential participants and suitable improvement projects.

Organisational support: Support from the leadership, education or development teams within the organisation is important and may lead to further opportunities or support for the initiative. Depending on the size of the cohort and the time available from project leads, dedicated administrative support may be useful.

Recruitment: Participants should be recruited in an open and inclusive way with clear communication about the targeted participants for the programme. There is a strong case for co-development of managers and doctors early in their training so that they can build on this collaborative approach throughout their careers.

The paired learning pilot worked well with doctors at specialist registrar level (ST3-8) who are starting to think about the leadership responsibilities they will encounter as a consultant. The managers in the pilot were all at bands 7 and 8, and a significant number of them had come through the NHS graduate management training scheme. There are many pathways into management and managers of all backgrounds and functional areas should be encouraged to participate.

Time: Participants should be supported in attending as many of the learning events as possible, and to put aside some time for informal pair meetings and project work. Also, seeking engagement from the consultants, educational supervisors and line managers who are releasing their staff for paired learning can be important.

Evaluating outcomes: Too few leadership development initiatives are results focused and fully evaluated. The need for robust measurement of the outcomes that come out of leadership programmes is crucial if time and resources are to be justified. It is worth building an evaluation strategy into the programme during the planning stages.

The pilot programme used an online application form to capture reasons for applying and perceived learning needs (see box 1). Applicants were also asked to benchmark, on a five point scale, how prepared they felt for different leadership roles. Neither group felt fully prepared for a more senior role. Working together and learning from each other they could provide an opportunity to support each other’s development.

Pairs can be established in various ways. Some participants stated a preference for getting to know colleagues informally before choosing to work together, while others would have preferred to have been placed in a pair before the start of the programme. Pairs should be based at the same site where possible. Pairings within a department worked well for those who wanted to focus on a work based project or specialist area, but is also a powerful tool for sharing knowledge across divisions and specialties.

Designing the programme

The success of the pilot was built on five different learning components.

Conversation: Learning from each other’s training, experience and perspective on healthcare issues through pair conversations was identified by doctors and managers as the most valuable learning component overall.

Shadowing: Pairs were also encouraged to pursue opportunities to shadow each other. Clinicians gained opportunities to contribute to strategic and operational meetings, while managers joined ward rounds, theatre sessions and even clinical night shifts. The person doing the shadowing was often able to give a fresh perspective, enabling the duos to develop solutions together.

Improvement projects and design surgeries: The pairs were also encouraged to either work together on an improvement project or to provide a different perspective on each other’s project. These projects can be self-led, allocated, or chosen from a “menu” of projects the organisation is keen to run. Regular access to project leads or coaching support is important for enabling barriers to be overcome.

Workshops: The pilot also demonstrated the benefit of facilitated workshops for managers and clinicians. Although there were differences in their learning needs, an emphasis on developing the skills and behaviours to lead change was a useful approach to help participants to drive real improvements across many different contexts. The pilot provided six workshops:

  • developing self-awareness and a shared purpose;
  • exploring the NHS context: quality, safety, finance and policy;
  • developing skills and tools for change;
  • designing services for quality and safety;
  • a powerlab simulation: working within systems;
  • sharing learning through project presentations.

While paired learning has provided real improvements in services and quick wins for pairs, the real challenge comes with making collaboration and change sustainable.

The most successful pairs developed a personal connection and shared trust such that they can call each other for advice or direction in the future. We think that these pairs will influence the culture within our organisations and go on to change the way we lead and deliver healthcare. 

Next year we intend to build on the success of the pilot. There is a strong case for paired learning to also involve nurses, therapists, pharmacists, scientists and professionals working across organisational boundaries. The aim is to bring these professionals alongside clinician-manager pairs to make threes and fours in shared learning groups.

There is also scope for paired learning to support a more integrated approach to health and social care, through helping to bridge primary-secondary care boundaries and to link with professionals from education and social care.

View from participants: ‘we both care’

  • “We implemented a pre-surgery assessment clinic through paired learning. Cancellations on the day have gone down and the length of stay compared with last year has gone down from 7.4 days to 4.1 days for elective surgery.”
  • “I tried to implement a patient transfer form last year that will ultimately improve patient safety andit just didn’t work. This year I worked with my manager buddy who had an insight into the admin and managerial side of things. She told me who I needed to approach so I wasn’t just pushing it through myself and how to get the communications out effectively. We successfully started using the form a month ago.”
  • “I was asked to ring a manager to sort out a long standing service issue and after about a minute we realised we had already met through paired learning. I felt that because we knew each other we actually wanted to sort it out. It has been much more straightforward to organise admissions since we have worked together. The patients go straight to a surgical ward on Friday night and stay overnight.”
  • “We are aiming to reduce unnecessary admissions through jointly reviewing cases. We have already identified one patient who breached when they should not have been admitted. Doctors are quick to say ‘it should not be about finance, it should be about patient care’, but I have realised we both actually care about both.”

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