Clinical Leadership in Practice - Wearing Many Hats

• Introduction
• Clinicians as Leaders
• Clinical Directors
• The Medical Director
• An Alternative Arrangement
• The Acute Trust Organisation
• Competencies
• Conclusions

  Introduction

Unlike their managerial and clinical colleagues, doctors involved in health services management have two jobs to do, and to do well. Not only do they have a clinical service to manage, but they will also be providers of service themselves. They may well be leaders in their clinical field and have educational responsibilities as well. This article will explain some of the practical issues for senior clinicians involved in the management process in an acute trust and the conflicts that they face. An acute trust in the United Kingdom is a hospital or hospitals providing the acute medical care for its catchment population. The prime requirement of any doctor involved in management, certainly in an acute hospital, has been the need to maintain "street credibility" by continued involvement in delivering a clinical service.

  Clinicians as Leaders

In the UK there have always been doctors who were leaders. This leadership was generally exercised through participation in the activities of Royal Colleges and other professional associations such as the British Medical Association. Such activity has been regarded as meritorious by the profession and by managers, who have supported this judgement explicitly through the Distinction Award process. This system rewards consultants who are deemed meritorious by giving substantial supplements to salary.

Doctors have also exercised a leadership role in the development of their clinical speciality. Indeed it could be claimed that the National Health Service (NHS) would not have "developed" in the two decades after its formation without the drive and ambition of consultants who wanted to see their unit, hospital or specialty excel. The development of many units is associated with the "name" of a clinician who promoted it and often raised funds for the required facilities either through their own efforts or by forming an organisation that would do the same. Such developments were often in the face of either indifference from local/regional administrators or overt hostility because of the resource consequences. However, they resulted in "centres of excellence" within the NHS that became world-renowned.

  Clinical Directors

It was only in the mid to late 1980s that there evolved a new requirement for clinicians to become involved in management. This stemmed from the NHS Resource Management Initiative (RMI), an attempt to involve clinicians in the husbanding of financial resources. The result of this was that many acute hospitals developed a management organisation based upon Clinical Directorates. Each clinical area or department had a lead clinician appointed as clinical director (CD) with the intention that they would take responsibility for the resources in the department and deliver the activity within that resource. The CD was usually supported by a business manager and (often in clinical areas) a nurse. This multi-disciplinary team was then to manage the Directorate with support from the financial management and human resources departments. Over the years many variations on this theme have evolved. Other clinicians (usually nurses) have taken on the CD role and a variety of different titles have been used. The numbers of directorates created in each hospital also varied (and varies) considerably, as did the directorate size ranging from big with large numbers of consultants to small (2-4 consultants). Often these arrangements are the result of attempts to satisfy departmental aspirations when and where suitable "leaders" existed. It was at this time that the first substantial efforts were made to organise doctors involved in management and to provide them with the skills that they would need in their new job.

The usual arrangement now is for CDs to give up one or two clinical sessions and/or to be paid for one or two sessions as an acknowledgement of the additional responsibility. The intention was that individuals with the necessary abilities should be selected for these posts, rather than for a post to be "rotational" amongst the senior members of the Department. There was little training available for aspiring CDs and experience was gained "on the job".

The next stage in the evolution of the doctor in management was galvanised by the introduction of the "purchaser-provider" relationship in the NHS. In 1989 the Conservative government, in an attempt to gain more control over resource use, introduced the concept of Health Authorities "purchasing" care for their local populations from "providing" trusts. Each trust is made up of a hospital or hospitals and has a Board (Trust Board) comprising executive and non-executive directors, which is responsible for managing the organisation. The first of these trusts were established in 1991 and very nearly all hospitals were within such organisations by 1995. This was in a political environment where the trust competed for business against its neighbours.

At the same time general practitioners were encouraged to become "fund holders" and to take over a proportion of their elective health care budget. The aim of this latter move was to introduce more competition with trusts bidding to provide the best quality service and cost.

  The Medical Director

Each Trust Board had five or six non-executive directors with skills that would contribute to the "business" of the organisation and to include a Chairman appointed by the government. The executive directors had to include a Chief Executive, Director of Finance, a Director of Nursing and a Medical Director (MD).

It was the introduction of the MD concept that promoted the further development of the medical manager, and it is this evolution that is considered further in this paper. The need to appoint MDs posed a number of problems for trusts. Most concluded that an internal appointment of a consultant would be most appropriate to maintain the confidence of the medical staff within the trust. As with the CD it was also clear that the time committed to participating at the Trust Board and in supporting meetings must be finite. The candidate had to enjoy the support of the Chief Executive and his/her consultant colleagues while being willing to relinquish some clinical commitments (which might include private practice). Posts were therefore attractive to consultants soon to retire. Responsibilities were also very varied, however, the MD figured in most trust’s medical disciplinary process and took some role in providing advice for the "contracting" process with purchasers.

A later survey of MDs showed that there was substantial variety in the way that these posts were established. Sessional commitment varied from none to five, pay from nothing to five to six sessions and that there was little "line management" commitment. The MD appointed to the Trust Board is still the most common arrangement in acute trusts.

  An Alternative Arrangement

In the author’s own Trust, the first MD retired 18 months after appointment. There was then considerable discussion about the nature of the post as he had felt "disenfranchised" from the management process because, though he was there for advice in many forums, he had no direct influence in line management. He also considered that the portfolio of activity for the MD was too large for one individual in a trust with a turnover (in 1993) of around £90 million.

As a consequence, the Trust adopted a fairly unique arrangement with three MDs, each responsible for their functional area (medicine, surgery, other clinical services) and with a divided corporate portfolio (see Table 1). It was agreed that all three would attend the Trust Board but would share a single vote between them. This provided the additional benefit of continuity of clinical advice as there is always at least one MD at each meeting, and a greater depth of expertise than one individual could provide. While initially there was concern about the potential for the Board to receive conflicting advice, this has not been found to be a problem in practice.

Table 1 is a list of some of the corporate responsibilities of MDs. The introduction of "clinical governance" has imposed other demands, such as the development of systems of appraisal for consultants, a topic that will be expanded further below.

In this Trust, the three MDs are each responsible to the Chief Executive for a budget of about £40 million (the size of a small-medium trust). Each MD is supported in this function by an "Operations Director" (a senior non-medical manager) and a Clinical Financial Advisor who provides financial advice to the directorates in the MD’s area. There is also a human resources advisor and advice from the Business Development Unit (that looks after the contracting).

  The Acute Trust Organisation

The diagram below shows the sort of structure that MDs work within in the NHS. Most acute Trusts will have a structure that will address similar functions Trust Committee Structure

The Board Structure used within the author’s Trust is illustrated below.

Each MD is responsible for a Board, which represents a number of clinical directorates.The emergence of the concept of "clinical governance" (See Box) in the NHS has resulted in some modifications of this structure. The purpose of clinical governance is to ensure that there is an integrated approach, to enable high quality patient care. While ultimate responsibility lies with the Chief Executive, a clinician is required to lead its implementation. This is generally a doctor, a nurse or both. The doctor involved in acute trusts is generally a MD.

The example below shows how the components of clinical governance are represented through subcommittees to the Clinical Governance Committee itself, and then the Trust Board.

All MDs are members of the Clinical Governance Committee and the Clinical Standards and Risk Management Committees are chaired by two of them. Patient Quality is chaired by the Director of Nursing.

The Clinical Standards Committee leads the development and integration of evidence-based practice, clinical audit and knowledge management around the Trust.

The Risk Management Committee brings together all elements of risk other than financial risk. It is responsible for monitoring such issues as incident reporting, medico-legal claims, resuscitation outcomes and cross infection.

Monitoring of complaints and the responses to them, waiting times in outpatients and other "Patients Charter" outcomes is the responsibility of the Patient Quality Committee.

All this work requires considerable clinical leadership to produce an integrated system with robust outcome indicators that will assure the quality of care that is being provided in the Trust.

  Competencies

Financial

What sorts of abilities are expected of these medical leaders? The first concern of most when taking up their posts is to better understand the financial management of their services. It is here that they feel most vulnerable and it here that their colleagues have an expectation of them being able to exert significant influence in obtaining resources. In most acute trusts there will be considerable expertise in financial management, which it is up to the medical manager to harness. The key issue for the medical manager is to ensure that the financial and business planning parts of the organisation understand the clinical issues and priorities that must influence the commissioning (or contracting) of health care, ie, the agreements with health authorities and general practice that fund activity.

This requires of medical managers, particularly the MD, a willingness to understand clinical services other than their own. A corollary to this is the need to understand the business planning process, an essential prerequisite for participation in the strategic development of the trust or business unit.

Personnel/Human Resources

One of the most important consequences of becoming a medical manager is that, for the first time, a doctor will become responsible for managing other professionals and health care workers. An understanding of relevant policies and procedures is essential to ensure that when problems occur they are correctly managed from the beginning. In the UK workers who have been disciplined now have ready access to Industrial Tribunals where they can air their grievances and (potentially) obtain considerable financial recompense from trusts that have not managed their cases correctly. Time taken in these, and in local appeals, can represent a substantial penalty for the clinically active medical manager. A working knowledge of current legislation - equal opportunities, hours of work and that affecting the disciplinary process - is required.

Increasing their understanding of personnel issues is often neglected by medical managers, and it is particularly in this field that their leadership abilities are likely to be most tested.

Undoubtedly the issues that most tax (and endanger) the medical leader are those that occur when dealing with poor professional performance. The monitoring of the performance of doctors in the UK is the subject of much public and political debate. As a result of considerable criticism of the self-regulation provided by the General Medical Council (GMC), it has proposed that a system of Revalidation be introduced in 2001. This is likely to be based on a system of appraisal for all medical staff. Medical managers will be key to the successful implementation of such a system. While used to being appraised within the performance management system of a trust, medical managers will also be the subject of clinical appraisal themselves. It follows that successful clinical leaders must themselves be willing to be performance managed.

In addition, for MDs, the duties imposed by the GMC have become more explicit and the publication Maintaining Good Medical Practice gives advice as to how the relevant standards should be applied to individual doctors. This document reinforces the concept of doctors working within clinical teams (including non-doctors) and requires that there are regular reviews of individual member’s performance. MDs have a very specific responsibility in drawing the GMC’s attention to poorly performing doctors, whether because of failing health, unprofessional conduct or professional incompetence. New procedures have recently been proposed by the Chief Medical Officer in England for the performance management of doctors - again medical managers, particularly MDs, will have a key role to play in these arrangements.

Operational Management

Those appointed as medical managers are likely to have considerable experience at running a clinical service, and therefore the concepts of operational management will not be new. The scale is, however, greater and the number of disciplines that must be co-ordinated increases. To succeed, medical managers will have to learn to work with their non-medical colleagues, professional managers, nurses and paramedical staff to develop a managerial team that works effectively and efficiently. For MDs particularly, an ability to work within a trust’s "top team" is essential. This is particularly the case in a rapidly changing environment, such as that typified by the NHS at present.

The good leader will necessarily have to have some knowledge of the concepts of project management. In the modern health service the value of accurate and timely information in the form of relevant performance indicators must be appreciated.

The External Environment and Strategic Development

For the MD, it is particularly important to develop a good knowledge of the external environment. Here, as in many other aspects of the job, a good relationship with the Chief Executive is essential. Chief executives will generally have a good appreciation of the issues in the local health care community. Mergers of trusts pose an immense challenge and threat to the medical leader. Not only must they bring together disparate services that have probably been competing in the past, but the merger may mean the loss of their own managerial post.

Personal Attributes

One of the biggest problems for medical managers is finding the time to combine management and clinical duties. Good time management is essential. Communication is the essence of good management and time has to be found to do this, both inside and outside the trust. A MD being unknown outside a trust is a marker of failure, as they cannot do their job without being aware of what is happening in the wider health community. Managerial and professional networks are essential. These can be found in most NHS regions and through the British Association of Medical Managers (BAMM), which runs courses and conferences for all clinical managers, and the Association of Trust Medical Directors, which is aimed specifically at this group.

While medical managers will generally want to enjoy cordial relationships with their colleagues, medical and non-medical, they cannot be afraid to disagree with others. In such management positions it is impossible to please all of the people all of the time. An ability to negotiate "win-win" outcomes whenever possible is therefore a great attribute.

A good medical manager will appreciate that not only will others within their organisation need replacing, for good reasons and bad, but that they themselves might require replacement. An appreciation of the need for succession planning is important.

  Conclusion

Clinical leaders in the NHS have to have many attributes. However, the most important has to be an ability to wear many different hats. At one moment one may be required to represent a clinical discipline and then ten minutes later to disadvantage that discipline to the greater corporate need of another area or of the trust or NHS at large.

There is generally no great clamour of people wishing to become medical managers. There may be many reasons for this. Management for doctors is only now beginning to figure in the undergraduate medical curriculum. There is token management training for trainee doctors and little incentive to understand the discipline of management. There are few training programmes in medical management within trusts and external courses are not well co-ordinated and tend to be fragmented. It is only recently that the NHS and the BAMM have introduced a training programme that brings together Chief Executives and MDs, though the latter have run leadership courses for consultants for some years now.

Many consultants are unwilling to become medical managers because of the penalties that are incurred. Medical management is very time consuming and family life suffers. It is easy to incur the wrath of colleagues. Financial rewards are poor, particularly when compared (in some specialties) to private practice and participation in medical management may be detrimental to progress in the merit award process, which provides substantial additions to salaries for consultants in the UK.