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This month’s edition of Healthcare Review – OnlineTM is the final in the series on "Leadership in Health". In this edition, we consider the leadership model in the UK and specifically consider its impact on service quality.
Dr Rowland Hopkinson, Medical Director, Birmingham Heartlands and Solihull NHS Trust (Teaching) and a consultant in anaesthesia and intensive care considers clinical leadership in the UK setting. He focuses on the practical issues for senior clinicians involved in management in an acute trust, ie the hospital(s) providing the acute medical care for a catchment population.
The dual responsibility of clinical leaders as clinical service managers, as well as providers of a service themselves, is highlighted. Hopkinson regards continued activity in delivering a clinical service as essential for "street credibility" for any doctor involved in management.
Hopkinson reviews the history of clinician involvement in management in the UK, considering the management organisation based on clinical directorates used in the acute hospital setting and the impact of the "purchaser-provider" relationship in the National Health Service (NHS) on management structures. He considers the Medical Director role that emerged in the newly formed Trust boards and outlines an alternative to that arrangement which has been used in the Birmingham Heartlands and Solihull NHS Trust.
Hopkinson explains how the emergence of the concept of clinical governance has resulted in some modifications of the Board structure in the NHS trusts. He uses an example to show how the components of clinical governance are represented through subcommittees to the Clinical Governance Committee itself, and then the Trust Board.
Hopkinson reviews the various competencies required of a medical leader, including financial and personnel skills, familiarity with operational management, knowledge of the external environment and personal attributes such as good time management and communication skills. He also outlines reasons why there is sometimes limited interest from clinicians in medical management roles, including impact on personal time and limited financial rewards.
In his closing comments, Hopkinson emphasises the need for the clinical leader in the NHS to be able to wear many different hats to respond to the many different situations demanding leadership attention.
In a two-part paper, Anthea Penny, Director of RH Penny Ltd, Auckland, New Zealand, considers clinical governance in the UK with a focus on its impact on the delivery of high quality services.
In Part I "Clinical Governance in Britain Defined", Penny defines the concept of clinical governance in the UK, outlines the conditions that precipitated the emergence of clinical governance in the UK and considers the question of whether this approach to quality was different to what had previously been in place.
Penny outlines, how, following the 1983 Griffiths Report, a "Total Quality Management" (TQM) approach was adopted within the NHS which led to health sector management implementing TQM in the pursuit of better quality health care. Despite the implementation of TQM involving high levels of activity it failed to involve all parts of the NHS organisations and effectively excluded clinical activities of medical practitioners.
The 1999 report from the Bristol Inquiry, which investigated the circumstances surrounding unacceptable mortality rates in paediatric cardiac surgical patients at the Bristol Royal Infirmary, highlighted a 1989 NHS report about 23 TQM schemes that "made it quite clear that these projects were not intended to address quality within professional boundaries nor to impinge on the exercise of judgement".
The Bristol Inquiry provided "the emotional fuel for change" from this situation where clinical activities of doctors were effectively excluded from the NHS quality initiatives. The new Labour Government introduced policy to drive the NHS to provide a "first class service" which placed quality and accessibility of health care at the centre of health services. A 10-year modernisation strategy designed to overcome unacceptable variations in performance and practice included clear central elements related to service quality.
Clinical governance within the NHS was intended to create a systematic set of mechanisms to support all staff and to develop all NHS Trusts and organisations to adopt a new approach to delivery of high quality care using national principles and national standard setting, delivery and monitoring mechanisms.
Although some of the building blocks of TQM were already in place throughout the NHS, many were incomplete and ineffective. There was little evidence of a systematic approach to quality of care issues throughout the NHS, while doctors excluded themselves from the accountability process through their collective autonomy and the clinical freedom of self-regulation.
The introduction of a "first class service" and clinical governance were indeed different to earlier quality of care initiatives. This plan for change placed quality of care and the management of clinical risk within new structures and processes and introduced an ethos of accountability and lifelong learning for all staff and clinicians involved in health care delivery.
In Part II "Implementation of Clinical Governance in the NHS", Penny reviews the process of implementation of clinical governance in the UK.
Not surprisingly, there have been issues associated with the implementation of a change process as significant as the shift to clinical governance throughout the entire NHS.
Change, at the outset, was not consistent at all levels of the organisation. Barriers to change included the need for marked cultural and attitudinal changes, lack of necessary knowledge and skills, and short timeframes for the introduction of change.
The NHS has invested heavily in the process of change including the establishment of a Clinical Governance Support Team to support the shift.
Penny concludes that for the change to clinical governance to occur successfully, it requires an interactive environment for those in clinical positions, and participation, involvement and ongoing coaching and mentoring from senior clinical levels, management within health organisations, and health professional associations to ensure open communication. Realigning the way that services are delivered is also crucial to the success of such change, creating an environment where service and patient issues can be reviewed and new more efficient and effective methods of delivery can be formed.
The edition follows the first in the series in March 1999 "Leadership in Health – The Role of Clinical Leadership in New Zealand", which focussed on clinical leadership in New Zealand, both on the need for clinical leadership and issues surrounding clinical leadership. Papers considered the importance of clinical leadership in the health reform process in New Zealand and pointed to the need to recognise the valid role of management and Government, with all parties ideally working together to optimise service leadership.
The second edition in the series in February 2000 "Leadership in Health – A UK Perspective on Clinical Leadership", considered clinical leadership from a UK perspective with papers contributed from members of the British Association of Medical Managers. Papers examined the meaning of clinical leadership in the context of the NHS and the role of clinicians in the management of health care services.
NB: Readers may also wish to note that an edition in April 2000 presented the proceedings from the Clinical Governance in Healthcare forum held in Auckland, New Zealand, on 4 April 2000 "Clinical Governance in Healthcare". This edition examined the concept and experience of clinical governance with the objective of more fully defining the concept and its relevance to New Zealand in terms of quality care and professional practice.
