Wanted: doctors to help redesign services

Clinical leadership can come in many shapes and sizes - from a doctor running a clinical unit, leading a multi-disciplinary or commissioning team, to a nurse working as a chief executive.

While there are a large number of nurses in senior management and in leadership roles across the NHS, there are relatively few doctors in such roles. It is almost 20 years since resource management was introduced in the NHS. We are moving towards a stronger focus on clinical productivity, so it is important to examine why we are still discussing the challenges of the entry and support of doctors to leadership roles.

The Cambridge Health Network met in late April to discuss whether more doctors should take on senior managerial and leadership roles in the NHS, and, if so, how they should be encouraged and supported.

The consensus of the group was that there should be more doctors involved in the management and leadership of healthcare services, accepting that there is a critical difference between leadership and management and that management involves teachable skills.

Experience from the US, South Africa and other countries suggests it is much more common to find doctors running services or hospitals overseas and that greater clinical involvement in senior management can improve the quality of care and make service provision more efficient. So, how to bring this about?

One approach would be to imbue in medical students a greater sense of the importance of good management of services - they could be encouraged to consider the wider aspects of patient care at the same time as learning to take a medical history, examine a patient and make a diagnosis.

Clinicians and managers could be educated and developed alongside each other to bridge the historical gap between the professions and 'administration'. However, medical schools are already finding the curriculum difficult to manage and time is in short supply.

Knowledge deficit

Many doctors in management have never had training in basic management principles. Compounding this problem is the plethora of leadership programmes that are high-level, reflective and philosophical but do not teach fundamentals such as the basic financial workings of the NHS. Gaps in knowledge include how to read a balance sheet or profit and loss account; how to hire, fire and motivate staff and teams; how to redesign core processes; and how to manage a project.

All these areas are becoming critical as we move into an NHS measured on the basis of clinical and financial effectiveness.

Another approach would be to encourage doctors to take leadership roles, by recognising and rewarding those who take on the challenge. We need to pay attention to the context in which individuals work and ensure senior clinicians are properly recognised and remunerated for managerial roles.

The structure of the organisations in which we work would have to be significantly revised and redesigned so jobs, incentives and rewards were aligned to harness clinical energy. It is demonstrated in organisations such as Kaiser Permanente and the Mayo Clinic in the US, and must surely be possible in the NHS.

But there are significant barriers to overcome. There is often a perception among doctors that a move into a management or leadership role signifies failure to excel in clinical practice. While there are signs this is changing with regard to medical directors, some doctors in management are still treated with suspicion by colleagues.

There needs to be a wider recognition in the medical community of the value of medical leaders, and the skills and capabilities required to be effective in such a role. Developing role models of highly successful clinical leaders will encourage others.

Flexible solutions

Doctors will want to spend different proportions of their time on management and this may change over their career. There needs to be greater flexibility to allow them to change their level of involvement. For example a senior medical director may decide after a few years in post that he or she would like to continue in a management role rather than return to a clinical post.

Some clinicians may want to be reassured that after a period of time in a leadership role they will have retained enough of their clinical skills to be able to return to a purely clinical role. The more intelligent construction of managerial and leadership jobs will encourage younger members of the medical profession to give it a go.

There are currently few opportunities for doctors to acquire skills and experience to help them become more effective managers and leaders.

Doctors should be encouraged to take time out from a clinical career to study for an MBA, or to work in a management role. This could be within healthcare services, or doctors could be supported and encouraged to spend time working in a different environment, such as a consulting company, pharmaceutical company, start-up organisation or multinational corporation.

Weak rewards

Finally, there are weak incentives to encourage doctors into management or leadership roles and potentially an even weaker reward system once they are in these roles. For some doctors, a move into management or leadership in the NHS can mean a pay cut and exclusion from the Clinical Excellence Award scheme. For others the potential negative impact on their reputation will be a powerful reason not to consider a change.

For most, the difficulties in bringing about meaningful change and improvement within the NHS will be frustrating. Do politicians and those at the top of the NHS really want doctors in serious leadership and management roles? History and experience suggest otherwise.

Perhaps the greatest levers for change are to open up the market for healthcare provision at the same time as measuring the outcomes and quality of care. Both of these trends are beginning to bite and perhaps we should wait to see if clinicians lead the move to greater transparency on performance and quality measures.

Allowing different organisations to compete in healthcare provision could lead to the emergence of new players in the leadership role.

If medical leadership can deliver improved patient care - measured by clinical outcomes and efficiency - then these organisations should emerge as successful future providers and provide abundant examples to inspire and lead a new generation of doctors.

Opportunity knocks

There are early signs that doctors are beginning to sense opportunities in developing their leadership potential. Organisations such as Alliance Surgical and Centres of Clinical Excellence are now competing with established private providers to win business in the private market - and have aspirations to participate in the extended choice network.

In primary care, many new corporate providers bidding for GP contracts include doctor-led companies, such as Concordia Health and Chilvers McCrea. Foundation trusts are also beginning to explore measuring and improving the financial and clinical performance of individual service lines.

The next few years will be critical in demonstrating whether or not clinical leadership can fulfil its potential.

The authors would like to thank members of the Cambridge Health Network for their contributions to the thinking expressed in this piece. Penny Dash and Pam Garside are independent consultants and senior associates at the Judge Business School, University of Cambridge. They co-chair the Cambridge Health Network. For more information, e-mail pg@pamgarside.com or pennydash@aol.com