Whichever way you look at it, ensuring a supply of high quality clinical leaders is a top priority.
Frontline clinical staff possess a high degree of control over their work, what Marxists might term the “means of production”. As a result, managers have only a limited ability to influence their decisions. Moreover, clinicians make decisions together, so if change is to take place it is essential to have clinicians in a leadership role. If this does not happen, little or no progress can be made on quality improvement or patient safety.
Clinical leadership - and this usually means doctor leadership - is increasingly in the policy spotlight as the go-to remedy for a wide range of ills besetting the NHS. The white paperEquality and Excellence: Liberating the NHS puts power firmly in doctors’ hands, setting out plans to “devolve power and responsibility for commissioning services” to GPs in consortia so that “clinicians are in the driving seat”.
The 2008 Darzi report promoted clinically-driven change with a quality focus “at the heart of everything we do”. It concluded: “Leadership has been the neglected element of the reforms of recent years. That must now change”.
Over the past two years there has been increasing investment in management development for doctors, for example the Darzi Fellows Leadership Development Programme. Although curiously some hospitals are still novices when it comes to doctor management, for many years GPs have had professional executive committee roles and consultants have been clinical directors in hospitals.
CIHM has now launched a post-graduate certificate for doctors as managers. This isdesigned for practicing doctors who already have general management responsibilities or who are planning to enter management roles in the future.
The background for this programme is the wide research CIHM has carried out on clinical management in the UK. We also lead an international network looking at the best ways of engaging doctors in management to secure innovation and quality. We draw expertise from our work on the London Darzi Fellows programme, with practice-based commissioning groups, and our tailored leadership programmes for individual trusts.
We have found that many senior clinicians have masses of real, practical experience of change, and may know a lot about change processes. They are experts in understanding the context and content of their work, but they know very little about organisations. Our experience is that when doctors first participate in management, they firmly see it as a frustrating but simple layer of their organisation, which can be improved with a bit of evidence and persuasion. Over time, they move to a more sophisticated understanding of how to intervene for effective change.
We have identified a number of tensions that play out in the development of doctors as managers. The first is “where power lies”. Clinicians see power in terms of patient and specialty. For them, leadership is based on ‘personal power’ – credibility, respect, trust, plus the ability to influence, persuade, debate and negotiate – combined with “expert power” – knowledge of the clinical condition. Managerial leadership, by contrast, always takes the corporate or organisational viewpoint, and is largely based upon “position power” or place in the managerial hierarchy. To clinicians, it seems to ape the medical model of expert power, for example becoming a board level director usually requires expertise in a managerial speciality. Unfortunately, these ways of working have come to be seen as competing ideologies rather than necessary tensions in the system.
The second tension is “professionalisation versus professionalism”, a distinction based on the work of sociologist Celia Davies. Professionalisation is characterised by mastery of knowledge, unilateral decision-making, autonomy, and individual accountability. Practitioners are more or less interchangeable. Professionalism on the other hand is characterised by reflection, interdependent decision-making, and collective responsibility. Practitioners are not interchangeable - the particular qualities of the individual are very important. The challenge is to integrate these two approaches.
The third tension is around the “illusion of expertise and evidence”. Clinical leaders have a preference for an incremental, evidence-based, planned and evaluated approach to change which involves clarification, a choice of options and consultation. However, in our experience how they actually behave is different - often their frustration leads to them ‘just doing something’ which in their view is obvious.
CIHM’s task has been clear - to develop a wide range of skills for working with communities, users, co-clinicians, and the wider organisation. Personal skills around working with diverse teams, for example how to have difficult conversations, feedback, negotiation, are also vital. However, any programme must make the most of doctors’ intellectual capability and tolerance and hunger for high challenge, as well as developing more effective personal relationships between clinician leaders as managerial peers.
Finally, there is an inevitable tension between individual versus collective working. Doctors tend to see things in terms of their specialisation, patient need and the best option for that particular patient. They are less concerned with the community of patients. Moving doctors to a “we are in it together” perspective for the good of the whole requires a profound culture shift.
The Darzi report called for undergraduate studies for all health care professions to be reviewed to ensure that they provided appropriate leadership skills. Postgraduate curricula and appraisal processes also needed to change according to the report, and it anticipated the development of postgraduate clinical leadership programmes at certificate, diploma and masters levels.
As a result of this work the Academy of Medical Royal Colleges and the NHS Institute for Innovation and Improvement undertook work to develop a Medical Leadership Competency Framework.
One early manifestation of this clinical leadership development has been the clinical leadership fellows scheme, the Darzi Fellows, run by SHAs and postgraduate deaneries. This began with a purely medical focus but is increasingly becoming multi-professional. Although each scheme is tailored to local circumstances, there are certain identifiable common features:
- The use of an underlying competency framework for assessment purposes. Typically this is the NHS Leadership Qualities Framework or the Medical Leadership Competency Framework, and uses a 360° tool.
- A personal development focus. Psychometric tools are used for diagnostic purposes, personal development plans are devised, one-to-one coaching and mentoring is provided and programme participants are subject to the support and challenge which comes from membership of action learning sets.
- A service improvement focus. Participants work on a service improvement project or projects across the duration of the programme.
- Academic input. Participants are introduced to theories and skills and techniques through workshops and master classes. In some instances participants also work towards a relevant Masters qualification.
CIHM believes effective programmes must be designed to address the tensions that obstruct clinical leadership. They must also develop a real understanding of systems change, and provide opportunities for participants to learn more about it by experimenting in their organisations.
“Learning through doing” on a practical project is a critical part of our approach to developing doctors as managers. First, clinicians need identify a complex problem area. Then we ask them to provide a rationale for their proposed intervention based on theories of change they have worked on with us, and their own understanding of their personal leadership capabilities. Next they must devise a way to engage key actors and identify metrics for measuring success. After implementation, we ask them to share the impact locally.
What kind of results do such courses give? We found clinicians developed more rigorous and coherent thinking around strategy. They got better at improving services, for example by workforce engagement, managing services and nurturing capable teams. They acquired enhanced skills around relationships across health, local government and the voluntary sector. They also got better at establishing consistent management practices across the organisation in order to secure better patient outcomes - for example ensuring clinical practice is evidence-based, or spreading recognition that quality and value for money go hand in hand.
Evaluation shows the impact of our programmes is far reaching and, in many cases, profound. Participants generally came out with greater self-knowledge and personal skills, as well as greater insight and adroitness when working with others. They had better understanding of the organisation and system to be changed, along with better skills in change management, service improvement and capacity-building. Their values and beliefs changed and they often had new career goals.
A significant “mind shift” was clear in the way most clinical leaders viewed their role in service change. They had been equipped with knowledge and understanding of the NHS, complex organisations and themselves. They had also acquired personal, interpersonal, quality improvement and change skills. This put them in a position to support and sometimes lead on service change, improvement and leadership capacity-building.
Our findings are backed up by a letter to the London Deanery written by the London Darzi Fellows as a group. The group said CIHM has “fostered a culture shift and succeeded in having a huge impact in shaping our attitudes, beliefs, approaches and ultimately, we believe, our behaviour and impact. Their enthusiasm, dedicated effort and approachability, alongside their credibility from vast experience … [has] earned them considerable trust amongst our group”.
A number of factors beyond the programme itself have also been identified which influence the success of clinical leadership development. A committed and learning-oriented medical director is important, as is a supportive organisational culture with high quality mentoring. Work should be done on ambitious but appropriate live projects. Learning programmes should target transformational change, and there should be a combination of workplace and external learning.
Where might the current interest in clinical leadership take us in the long term? NHS chief executive Sir David Nicholson has said he wants to see a clinician on the short-list for all chief executive vacancies. If this were to happen, the expectation might well grow that all senior positions in health care should often be filled by people with a clinical background.
As clinical leadership develops, NHS managers will have to adjust to changes in organisational priorities which will reflect clinical concerns more than they do now. It is also true that clinicians are not as likely to be influenced by government and political directives as career managers. As clinicians “step up to the plate” there will also need to be recognition that they do not have all the basic managerial skills acquired by career managers and will need significant support, in terms of both training and support staff. We hope our postgraduate certificate for doctors as managers will contribute to this.
The other side of the coin is that clinicians will need to see the broader health picture beyond their specialist areas. They must align their professional priorities more towards service and organisational goals and accept financial responsibility for clinical decisions. They will need to change their perception of risk management from wanting to do the very best for each individual patient to accepting that prioritisation and compromise are necessary. They will find this challenging, but the prize is an NHS increasingly run by clinicians.
Becky Malby is director, Duncan Ross is director of international programmes and John Edmonstone is an associate at the Centre for Innovation in Health Management, University of Leeds