The NHS’s strange divide between clinical leaders and management must be closed to meet the service’s challenges.

As a generation of senior NHS managers begins to leave the service, we may be seeing the passing of the peak of NHS managerialism. As the graduates of the 1970s leadership programmes head for pastures new, the conventional wisdom is that the leadership baton now falls to the clinicians.

Across the NHS, no decision is possible, no reform proposed and no organisation complete, without the central involvement of clinicians, even if in practice this is too often short-hand for “doctors”. 

Yet the concept of clinical leadership is perhaps paradoxical; is it possible to be a clinician without being a leader? The nature of the professional relationship between clinician and patient and the working of clinical teams requires all clinicians to have at least some leadership skills.

But in any healthy and successful organisation, all the staff, whether porters or paediatricians, accountants or anaesthetists, need to have leadership skills. In the most effective organisations, leadership is neither optional nor hierarchical, but dynamic and shared. In such organisations, people are encouraged to take on leadership responsibility as circumstances require and their skills and experience allow.

Within all professions, leadership is a vital factor in creating and sustaining standards of quality, safety and behaviour. Nowhere is this more important than in the clinical professions where any failure in clinical quality could perhaps be seen as a failure in clinical leadership.

Leadership is a fundamental component of organisational success. However, the NHS’s concentration on leadership may also reveal a continuing and underlying discomfort with the notion and status of management. And leadership and management are different.

Out of step

Our healthcare system, particularly its political leaders and the clinicians, have never have quite come to terms with the translation, nearly 40 years ago, of NHS administrators into managers and their subsequent accretion of power. Certainly the public has never been convinced.

As a result, the English NHS has sustained a strong presumption and distinction between the role of the clinician and the manager. In doing so, while it is not unique, it is certainly out of step with most other health systems. 

Many of our doctors seem to view management as a necessary trade rather than a desirable profession. As a result, remarkably few senior management positions are filled by clinicians, with striking and honourable exceptions. The resulting schism, between the key professionals and the “management”, looks to any outsider remarkably strange. 

It is difficult to think of any other industry which exhibits a similar pattern; it would be very odd if engineers did not lead and manage engineering companies; and accountants, accounting firms. It is also notable how effective and enthusiastic some doctors can be as managers of businesses, invariably outside the NHS.

One interpretation of the NHS’s enthusiasm for clinical leadership is that it is an attempt to bridge this schism; a way of involving clinicians in management without them having to be managers. As a result, considerable resources are being devoted to helping clinicians acquire leadership skills, not least in the clinical commissioning groups. A key element of this approach is the current push for the professionalism of NHS leadership, in part as a proactive response to the presumed outcome of the Francis Report on Mid-Staffordshire.

Requiring all NHS leaders to have appropriate qualifications may appeal to clinicians, providing them with a legitimised route to leadership roles. But by focusing on leadership, clearly crucial in providing reassurance to public and patients, this approach may also reinforce the divide between clinicians and management.

Giving credence to a view that it is possible to assume clinical leadership without taking on the consequential corporate or managerial responsibility reinforces clinicians in the comfort of their professional silo. 

While strengthening clinical leadership in the face of major failures in clinical quality and safety is crucial, it is not enough. Most observers would agree that the NHS is facing two unavoidable forces: financial reality and consumer demand. These challenges are so significant that it may only be possible to preserve an NHS “free at the point of need” if the productivity of health professionals, in terms of both cost and quality, is improved dramatically, which in turn will depend on renegotiating both the role of the patient and the clinician.

Structural changes to services and organisations will not be sufficient. No industrial transformation of the scale required for the NHS to survive has ever been achieved without a fundamental redesign of the workforce and of the form and function of the constituent organisations.

The challenge is to redefine what a hospital is, to reinvent primary care and to redesign our clinical professions; simply changing existing organisational boundaries and administrative structures will not be enough.

This is an unprecedented management challenge and one that has to be led by clinicians. But leading the NHS means running it and that means we need some of our best and brightest clinicians to take on the management mantle; “clinical leadership” is not enough.

Kingsley Manning is a director of Newchurch.