Career Focus

Learning to lead

BMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7087.2 (Published 12 April 1997) Cite this as: BMJ 1997;314:S2-7087
  1. Jenny Simpson, chief executive
  1. British Association of Medical Managers, Barnes Hospital, Kingsway,Cheadle SK8 2NY

    Medical director Dr Jenny Simpson, chief executive of the British Association of Medical Managers, outlines a schema of personal development for aspirants to trusts' top jobs


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    Doctors aspiring to positions as medical directors should think carefully about the skills they will need to do the job. Most newly appointed medical directors soon find themselves in foreign territory and, as the job develops, find that the need to learn a great deal in a short time becomes even more pressing. Whenever possible, learning for the post should begin sometime before full responsibility begins, perhaps by shadowing one's predecessor or by taking on discrete aspects of the job.

    Reviewing personal attributes

    Some form of personal analysis of the individual's various strengths and weaknesses should also be undertaken before the post begins. There are several approaches to this - for example, seeking advice and counselling from a trusted senior colleague or taking part in a career assessment exercise designed specifically for providing career advice to doctors.

    The British Association of Medical Managers (BAMM) is currently undertaking work on behalf of the NHS Executive to pilot a development centre at which aspiring medical managers' strengths, weaknesses, interpersonal skills, and aptitudes are reviewed, and the results discussed in small groups. A range of doctor role models who have taken specific career routes is used to allow participants to explore opportunities and possibilities. The pilot event, due to take place in May 1997, will provide valuable information on which approaches work well for doctors.

    Core curriculum

    Armed with some self knowledge and objective assessment, the aspiring medical director then needs education and development in the skills of medical management. The “core curriculum” of medical management reflects the state of evolution of the emergent specialty. Wide ranging skills are required, which cannot simply be learnt from a textbook. The required knowledge falls roughly into three areas.

    Three key areas

    Firstly, medical directors need a sophisticated understanding of management in its broadest sense - a superficial overview of NHS administration will not do. They require an understanding of the wider environment in which the health service exists: the political and financial pressures, the fundamentals of marketing, and the principles of strategic planning and decision making. Skill in the management of change, human resources, and information are all essential to the medical director's ability to perform effectively at board level.

    Secondly, a medical director must understand the specifics of management within the NHS. Many a newly appointed medical director finds himself or herself on an uncomfortably steep learning curve. For example, medical directors may face the complexities of disciplinary procedures, a trust merger, a strategic service review, or the challenge of leading a radical change programme. These areas of learning can most effectively be covered by case study analysis with a skilled facilitator, by small group work, and by project work approaches such as those used in the British Association of Medical Managers' leadership programme and other courses.

    The third area of management crucial to the success of the medical director involves a detailed understanding of how the trust itself functions as an organisation. The medical director must understand precisely the anatomy and physiology of the trust — how the decisions get made, who holds the power, whose voices really count on committees, and why things are the way they are.

    Alongside this knowledge — which is vital, but can be difficult to acquire — individuals must develop and refine their personal skills of politics and influence which span both the clinical and the managerial worlds. The medical director must be able to speak, listen, persuade, and lead because he or she has skill, knowledge, and insight, not simply because he or she is a doctor.

    The insight needed by doctors taking on these roles demands rather more investment of time and energy than a three day course or a good book. However, the amount of education required by any individual is variable, and depends on the degree of exposure to management the doctor has already experienced. A clinician aspiring to be a medical director with relatively little management knowledge and experience, must address in detail all these areas described.

    Developing managerial skills

    Those with significant management experience who have already undergone basic management and medical management education programmes may be better advised to focus on the third area — development of personal skills and strategic thinking.

    Turning to the provision of education appropriate to the needs of medical directors, the picture is far from complete. Agencies offering programmes on the basics of management are many, but the quality and value can be variable. The principal problem for clinicians is to fathom which courses provide high quality programmes, are relevant to their needs, are pitched at the right academic level, and are on the right timescale. Doctors are strongly advised to research the options thoroughly and seek advice from others who have undertaken specific courses before investing considerable amounts of time and money in an educational programme.

    Besides developing skills and taking part in appropriate educational activities, aspiring managers should get increasingly involved in managerial work at the trust. Clinical audit often provides a useful starting point, as might taking on a role in a management initiative at the trust. Suitable examples would include projects on quality management, taking an interest in medical staffing or other strategic issues, carrying out projects within a directorate or, in discussion with the current medical director, seeking ways in which to get a good feel for the role. The best way of doing this is to shadow the medical director for a period of time if this is possible. The sensible medical director and chief executive will have a major interest in developing those doctors with an enthusiasm and commitment to medical management.

    Courses on the specifics of medical management and personal skill development are less easy to come by and to fill this gap the British Association of Medical Managers has developed its leadership programme, pitched at master's degree level and based on specially commissioned, robust NHS case studies. Alongside programmes which address the wider medical management issues, topics such as disciplinary procedures, risk management, and the dynamics of managing the workforce must also be addressed. The association, along with the Association of Trust Medical Directors, is currently developing two and three day modules to address each of these areas, to enable medical directors to design their own education programmes from a range of offerings.

    Coaching and mentoring schemes which allow clinicians to develop the skills needed, at a pace compatible with performing the job, are also under development. To complete the package of training BAMM is keen to see medical managers playing major roles in national projects and in action learning sets, developing a network of peers which will broaden the educative process, support medical directors in their challenging jobs, and create a culture of continuous management learning.

    Robust training is needed

    To run trusts effectively, medical directors and their teams — medical and managerial — must take management seriously. Investment must be made in robust training and education. The job carries major responsibilities and failure in the role rapidly becomes public knowledge. This is not a cosy preretirement slot for the tired, jaded clinician.

    In the early days of medical management a medical director could be forgiven for taking some time to find his or her managerial feet. Today's and tomorrow's medical directors need to hit the ground running — mistakes tend to be high profile and difficult to rectify. As standards for entrants to the role are set, there will be expectations of a prior level of training and experience in medical management. Medical directors will want to maintain and develop these skills and BAMM is developing a framework for continuing professional development for medical managers, with the intention of integration with clinical continuing medical education requirements for the medical manager.

    Job satisfaction

    Hard work, lots of hassle, and a major need for education and development: is it all worth it? On the whole the answer from those in post is “yes.” With the challenges go both satisfaction and frustration. The satisfaction of making things work, of steering the service much more closely to the needs of patients, and of making big things happen is exciting. The frustration is part and parcel of management; the very time scale of managerial decisions is innately frustrating to clinicians — it can seem to take forever to bring relatively straightforward ideas to fruition.

    Phenomenal results are possible

    The bright, committed, enthusiastic, and determined doctor who makes the investment in learning and developing management skills is a major asset to any trust. With a top class team of chief executive and chairman, phenomenal results can be achieved. Furthermore, those medical directors who are now demanding high calibre management education, development, and support in their roles are in turn demanding the highest calibre management, from colleagues, clinical and managerial alike. A truly excellent clinical service is always underpinned by truly excellent management and is characterised by clinicians and managers united in their determination to work together to deliver the highest quality clinical care. The medical profession must take the opportunity to learn to lead this quest for excellence — and settle for nothing less.

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