Be careful what you wish for, warns Dr Shikha Pitalia, as clinicians are burdened with expectation that their new decision making powers can right all the wrongs in the NHS.

The gatekeepers, arguably the only true generalists left in the NHS, are now being asked to don that ultimate mantle and organisationally develop themselves as leaders. Since Andrew Lansley, announced the health and social care reforms, he has told us repeatedly of innumerable clinicians telling him, “if only someone would let us take the decisions in the NHS”.

Be careful what you wish for colleagues! Because here we are with clinically-led commissioning.

Many clinicians have embraced this offer and already possess valuable skills and experience required to adapt quickly to influence the direction of local health economies to meet this unprecedented challenge to the NHS of doing more for less.

Far too many others, unfortunately, have been overwhelmed by the same offer and are at risk of losing this most extraordinary opportunity. The apparent burden of leadership can seem formidable, but if these reforms are to realise the unparalleled results which are needed and eminently possible, then this overpowering trepidation must be quelled.

Leadership, many would assert, is apparent in each contact with the patient. Every doctor, regardless of how junior, has an inherent degree of this powerful skill to lead patients safely through the maze of the NHS.

Some traditionalists adopt an autocratic style. “Stop smoking, take more exercise and I will see you in a month” Scroll this forward to: “Don’t prescribe this statin anymore. Stop referring for this condition unless you have prior approval and I’ll see you in a month with your balanced scorecard.”

Achieving transient impact this approach may work for some people some of the time but surely there must be a better way to engage professional colleagues.

Worryingly, a prevalent trend in some leaders recently has been to bow down to the establishment. Here the clinician leads the patient into a decision dictated by the system. “You don’t need a referral for this because it’s what is classed a procedure of lower clinical priority.” An uncomfortable clinical conscience may nag but the non-clinical and financial pressure pervades.

It is imperative to moderate this intense and considerable influence on the emerging clinical leadership of some historically risk-averse senior managers and colleagues. The real danger is destructive leadership. Based on the legitimate interests of the finances of the NHS, this sadly simultaneously sabotages the objectives of the health reforms, undermining the enthusiastic reformists, demotivating the innovators and disempowering clinical colleagues.

Let’s stop and review the objectives.

Effective clinical leaders should regularly ask about any service:

  • Is it value for money?
  • Is it expedient?

But must always ask:

  • Is this right for our patients?

What is desperately needed is transformational clinical leadership galvanising the new CCGs to trailblaze into a realistic yet optimistic new health care organisation.

Constraints, real or perceived, by government targets and initiatives, have perhaps impeded the ability for such transformational leadership to succeed to date. Or is it possible that for the most effective transformation the leaders need a shared purpose with their followers, empathy based on common experiences and a long term commitment to the organisation.

Who better than clinicians, with similar training and backgrounds, experiencing similar challenges in their attempts to access the best services and care for their patients, to provide such leadership?

Effective clinical leaders will inspire their colleagues most successfully if they lead by example. Challenging the status quo, empowering the individual to voice an opinion, being receptive to ideas and innovative solutions from grassroots will be fundamental.

So who and where are these unique brands of clinical leaders? How do we develop these outstanding qualities so that many more of us play a pivotal role in the transformation of the NHS?

“Clinical leadership is needed at all levels.” Olsen and Neale’s observation in 2005 seems even more pertinent today. Have our medical schools and Deaneries done enough to incorporate medical leadership into their curricula? If so, is it constantly reviewed to keep pace with the ever changing landscape of the NHS?

Most clinicians want to remain just that. The leaders amongst them are eager and enthusiastic to raise their awareness and understanding of all things relevant to commissioning from IT to procurement and from finance to contracting and all that goes in between. What most clinicians don’t want is to become managers. There are already highly skilled individuals in all these areas who have spent much time, effort and resource perfecting that craft to be excellent non-clinical leaders.

An effective transformational clinical leader needs to gain the trust of his followers. A shared bond, empathy and commitment must be qualified with respect and confidence in your leader’s knowledge and expertise. Without this mutual trust even the most proficient and accomplished leaders with impressive and imposing CVs will fail to influence their followers to change the habits of a clinical lifetime.

If it were so simple to influence the issue of each prescription, the dictation of each referral letter and the admission of each hospital emergency then we would not be in the grave financial situation we face today.

Emergent clinical leaders and aspirant CCGs need education to fill the gaps in their knowledge to better understand the complexities and implications of some of the very difficult commissioning and de-commissioning decisions for which they will be held accountable. External expertise from savvy business leaders and managers is desperately needed and should be welcomed.

There is much to be learned about their proficient methods from the private sector without compromising the values of the NHS. Let’s harness the energy and spread the ideas from primary care entrepreneurs learning from, rather than stifling, their enthusiasm and feeling threatened. Let’s also explore the lessons from successful acute trusts or PCTs, but heed the warning that it is only the surplus generated by investing-to-save services optimising innovation which are worth replicating.

The clear and present danger is that the system has created a potentially huge adversarial atmosphere. Sadly the discussions around shape, size, mosaic and potentially anything which fails to comply with co-terminosity and co-tigousity have already disillusioned many clinicians and risk disengaging many more. Let us do all we can to avoid sleep-walking into another PCT-look-alike structure, whether by coercion, bullying, frustration or apathy.

As we invest more scarce and valuable resources at this critical time into leadership development, it is crucial to remember that skills can be taught but only with the right attitude will future clinical leaders achieve the influence they need in their general practice followers.

Management is about doing things right but the purpose of clinical leadership must be to do the right things.