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- Introduction
- A Brief Historical Perspective
- Stages of the Clinician Leader Role Model in the NHS
- The Role of the Clinician Leader
- Increasing Leadership Capacity Within the NHS
- References
Introduction
Clinical leadership – the rallying cry is heard in health systems across the world today. Governments want more of it, doctors, nurses and others are trying to understand what opportunities it offers them and patients are led to believe that it will change the nature of services. As with all such terms its meaning ultimately lies in its context – as Humpty Dumpty said "words mean what I want them to mean". This paper sets out to examine what clinical leadership currently means in the context of the National Health Service (NHS) in England, what people hope it may achieve, what we know about leadership and leaders and some thoughts on how a national health care system might deliver this magic ingredient.
A Brief Historical Perspective
There have always been ill and sick people, and doctors, nurses and others trying to treat them. Whatever health care system exists, formally organised and publicly run or fragmented and driven by market forces, clinical professionals as individuals and as members of groups and teams will always find opportunities to seek to transform the very nature of the system itself. With cholera victims all around needing help Dr John Snow traced the source of the outbreak to the public water pump and became the founding father of epidemiology in public health and medicine. George Bernard Shaw reminds us that the world is transformed by unreasonable men – and the history of medicine and nursing is full of unreasonable men and women who changed the nature of health care. Florence Nightingale may be remembered as the lady with the lamp, but her insistence on statistics, numbers and evidence transformed health care at the time. Dr AE Codman may have been ejected from the American Medical Association but left a lasting legacy of farsighted vision into clinical audit and other aspects of what we now see as governance.
To define these outstanding characters as "leaders" is perhaps simplistic. Leadership seems to be much more about becoming the focus for change and taking responsibility for change, working with and acknowledging the efforts of others in that change.
What is the relevance of this for the NHS today – and tomorrow? Why is the rhetoric of clinical leadership so persistent at every level in the system? A First Class Service, the government White Paper, first outlined the need for clinical governance, highlighting the need for the NHS to systematically develop clinical leaders within teams. The national rhetoric, picking up from initiatives by the British Association of Medical Managers (BAMM) and others, is clearly focused on leadership. Why should this be? What is this leadership intended to deliver?
Ultimately, of course, to have any validity at all, health care must be about improvements in patient care. The Prime Minister and others are convinced of the urgent need to "modernise" the NHS. This is often described as a NHS that would provide services with the same level of customer service as the best examples of the hotel, banking and other service industries. And so our politicians and our public seek transformation in the way that services are delivered to them. They also seek, to some extent at least, a transformation in the services themselves. In particular there is a growing unease that the evidence base for much clinical practice is lacking. The continued need for assessment and accreditation of clinical professional skills gives cause for concern and continues to be a distinct agenda for health care systems worldwide to tackle. However, clinical leadership is not seen as being essentially about this. It is perceived to be the strength and ability to transform the delivery of service.
Stages of the Clinician Leader Role Model in the NHS
The clinician leader role model of the UK’s NHS has been through a number of stages in its evolution over the last 10–12 years. An understanding of these stages – and the attitudes and cultures that underpinned them at the time – gives a valuable insight into the challenges now faced by those seeking to educate and develop future generations of medical leaders.
In the early days of medical management in the NHS, doctors arrived in their management roles through a number of different routes. The building blocks for today’s concepts of doctors as leaders were laid down by Sir Roy Griffiths 1 in 1983 who, in his report to the Government on NHS management, said that "the nearer the management processes get to the patient, the more important it is for doctors to be seen as the natural managers.1
What was happening on the ground, however, amounted to guerrilla warfare, with the managers undermining what clinicians were trying to do and the clinicians vetoing – largely by table-thumping and digging-in of heels – what the managers were seeking to achieve.
Then, as now, the managers in the system were accountable through various levels of hierarchy to the politicians, ultimately the Secretary of State for Health. The clinical profession, however, was – and still is – a flat, collegial body governed by professional standards, codes of practice and ethics. The degree of antagonism and conflict between the two sides at that time had rendered the system unworkable. Yet both sides could see that doctors and managers should be aiming at precisely the same goals – efficient, effective health care, delivered to the highest quality possible, given a finite pool of resources.
The early doctors in leadership positions were risk takers and revolutionaries – some of whom found that they thrived on the challenge and others who found they did not. At best these early pioneers were regarded as eccentric, although many faced accusations of being "traitors to the profession" with questions about their commitment to – and even competence in – patient care.
After the introduction of the White Paper "Working for Patients" in 1991, 2 with the establishment of the medical director as a statutory position on the Trust Board, the role of the doctor as leader became less of an oddity. Indeed, many made a deliberate move in to the role – although the motives varied from a true interest and set of skills – to "its my turn", "it will look good on my CV" and "I really don’t want so and so to get it". Over recent years this stage has passed and medical management is now an accepted and respected career choice. The doctor/leader population now emerges as a cadre of strong, effective clinicians, with finely honed leadership and management skills. They have gained these largely by painful – and often time consuming – experience. It is recognised that this is not, however, the way to enthuse and develop the leaders of tomorrow, who unlike the early pioneers in the field, will not be inspired by the motivating drive of breaking new ground, of being first on the scene. The NHS Executive, the managerial arm of the UK’s Department of Health, has recognised this for some time as, in addition to supporting the work of professional associations promoting clinical leadership.
The Role of the Clinician Leader
In understanding the role of the clinician leader, first consider the environment in which health care is delivered. It is an environment of change. It is one in which the advance of technology means that more can always be done – but the pool of resources remains finite. It is an environment in which the public has increasingly raised expectations of what the service can provide and people are far better informed in matters of health than has ever been the case before. This means that an already stretched service is still further stretched and that clinical leaders are faced with many difficult dilemmas.
The medical leader sits, often very uncomfortably, between two systems. In the collegial, professional world, he or she sits as a peer, a colleague, a team player with a set of specific clinical skills. As a leader, he or she sits also within the managerial world of health care, taking a corporate view of the organisation, plotting its future course and direction in the light of clinical knowledge and experience. Simultaneously, the medical leader troubleshoots and anticipates problems, scanning the horizon, both for opportunities and for potential difficulties.
Doctors in hospitals and community trusts in the NHS have been working in this way for a number of years. Those in primary care, however, face the challenge of developing new organisations and a new culture on top of these roles.
This then represents some aspects of the current position of doctors within the overall management system in the NHS. How have such doctors tackled the issue of gaining some management development, insights and experience to equip them to take on such roles? There have been a number of programmes run by universities, NHS regional offices, professional bodies and associations such as the BAMM, the King’s Fund and others. It has been a patchwork quilt lacking coherence and often by run in a competitive way. Of course such programmes represent only a small element of the development of such medical leaders. Far more important has been the establishment of what Lave & Wenger 3 call a community of practice. The ability to share with other practitioners and establish a body of variously skilled individuals with some sense of a "centre" and by extension and proliferation has helped move medical leadership towards an apprenticeship model with which doctors are already familiar. Increasingly we are seeing more coherent attempts within trusts to think through succession planning and establish developmental organisational positions for doctors moving into leadership roles.
It is helpful at this stage also to consider the distinction between management and leadership. Bennis and Nanus 4 suggest that "leadership is pathfinding, management is path following. Management is about doing things right, leadership is about doing the right things". Kotter 5 on the other hand believes that management is concerned with activities that are to do with consistency and order, whilst leadership is concerned with constructive or adaptive change.
Increasing Leadership Capacity Within the NHS
Given these disparate views, the wide and varied nature of initiatives and the continuing battleground that is the NHS, what is going on now to increase the leadership capacity within the NHS?
In the first place, it is clear that what is needed is more than simply developing individuals to be leaders. This will form one component of a complex programme to ensure that the opportunity for transformational leadership is available throughout the system. Transformational leaders will not emerge and seize opportunities, as John Snow did in London in the 1860s, in an environment that is risk averse and seeks above all conformity to standards. Leadership will always involve some questioning of current patterns and some discontinuity. The constant series of small improvements suggested with the philosophies of continuous quality improvement may not be the way to transform services. Indeed systematic approaches that reduce creativity and innovation and attempt to control such forces are paradoxically doomed to fail.
The development of leadership capacity in the NHS goes hand in glove with a shift away from processes and solutions in either the individual or the organisation. There have been a number of change initiatives in the NHS focused on trusts as the organisational body to deliver change or on individuals through discussion, for example, on revalidation for doctors – whereby an individual’s fitness to practise is assessed on a regular basis. The area that requires support but that is currently neglected is that of services. Services for any patient group, for example diabetics, cut right across the functional streams of NHS trusts and organisations. Where significant change has been achieved in services, for example, the delivery of diabetic services in Salford, it has been as a consequence of bringing together a number of organisations, creating partnership.
Many of the embryonic learning mechanisms within the NHS focus on learning between trusts and between organisations. There need to be mechanisms for learning across and between services. For example, how does an exemplar service such as Salford provide a learning focus for other diabetic services and their components in other parts of the country? Work currently being undertaken by the BAMM in association with Cranfield University attempts to explore this issue.
A number of key points can perhaps be made.
- Clinical staff learn much of the world from the example of their peers. In that sense increasing leadership capacity within the NHS is a "catch 22" situation. We need to work on both ends of the puzzle at once and try to introduce concepts and opportunities into the undergraduate curriculum whilst acknowledging that they will need reinforcement through positive examples from role models.
- Whilst there exists a reasonable – if loosely co-ordinated – network of understanding amongst higher education organisations working in and with the NHS, there remains an interesting network of freelancers and less formally accredited organisations delivering management development. Much of this work is excellent but there needs to be a greater engagement between the NHS and this fragmented grass-roots cottage industry.
- Just as clinical care is moving towards national guidelines and national strategic frameworks, so the development of leadership understanding in clinical staff within the NHS needs to be supported by national frameworks. Seeking to harmonise the continuing professional development requirements of the professional bodies concerned and to ensure a recognition of the leadership issue would be an important component of this.
- The NHS needs to be clear about what is required to create a climate in which individuals and teams can lead. This will require an investment in management and time support to innovation, change and to those who challenge the current systems.
The NHS is a hugely complex, hugely diverse organisation. It has recognised both its need for clinical leadership and its vast wealth of talent, enthusiasm, determination and skill amongst its staff.
The next few years will see a much more active approach to developing its hidden talent, to run and develop its clinical services and create the future’s health service.
References
- Griffiths R. Letter to Secretary of State re NHS management inquiry, October 1983. Official submission - Sir Roy Griffiths led the Inquiry into NHS Management in 1983, appointed by Mrs Thatcher, Prime Minister
- Department of Health. Working for patients. White Paper 1990
- Lave J, Wenger E. Situated learning: legitimate peripheral participation. Cambridge, UK: Cambridge University Press; 1991
- Bennis WG, Nanus B. Leaders: The strategies for taking charge. New York: Harper and Row; 1985
- Kotter VP. What effective general managers really do. Harvard Business Review 1982
