Teaching doctors in training about management and leadershipBMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d5672 (Published 13 September 2011) Cite this as: BMJ 2011;343:d5672
- Stephen Gillam, director, public health teaching
Various trends demand ever greater involvement of doctors in management roles. Several factors have changed the ways in which health professionals are monitored, paid, and regulated. These include the expansion and systemisation of medical knowledge, constrained health service budgets, informed users, and changing attitudes towards the professions. Doctors everywhere must be prepared to engage in the continual transformation of the services they provide throughout their career. However, medical training has traditionally emphasised clinical autonomy in decision making and allegiance to professional rather than organisational values. The need to strengthen the training of students and young doctors in management and leadership is therefore widely accepted. The General Medical Council and the royal colleges now emphasise the importance of management related training goals.1 What should be taught and learnt, and how?
“Clinical leadership” takes many forms. Some lead through local innovation; others lead through their professional bodies or through managerial involvement at various levels in the NHS. Successful medical managers are usually experienced clinicians with good “people skills.” They are also strategic thinkers and visionaries who look beyond the boundaries of their own specialty; they exhibit passion and are prepared to take reasonable risks to achieve their goals. Most importantly, they know how to engage colleagues and effect change.2
Formal training is not always a prerequisite, but the idea that all doctors can just “manage” is hopelessly naive. It is one reason why, for example, previous iterations of primary care based commissioning have delivered less than their proponents anticipated.3 The notion of clinical leadership can seem presumptuous, even patronising, to the health service managers who spend many years in training programmes learning the technical tools of their profession. They know what we seldom acknowledge—that many doctors, without preparation, do not make natural managers.
The absence of an agreed curriculum presents a major challenge. Most doctors in management learn by experience. Their training in this field is usually piecemeal, delivered on the job, by a plethora of different organisations in short courses. The Medical Leadership Competency Framework, developed jointly by the Academy of Medical Royal Colleges and the NHS Institute for Innovation and Improvement, is therefore a worthy attempt to describe the territory. The framework describes the competencies doctors need to become more actively involved in the planning and delivery of health services. It comprises five domains (figure⇓), each of which is subdivided into four competencies.4
The framework is built on the concept of “shared leadership.” In most NHS organisations responsibility for the success of services is shared by many members of staff. Leadership is not restricted to those in designated roles. Sharing power requires trust and collaboration between doctors and managers. Collective leadership has been shown to assist successful implementation of, for example, new care pathways,5 but it may not easily align with the individualistic culture of medicine.
The framework appears atheoretical, which points to a more fundamental problem. Much management lore is construed by medical scientists as inadequately evidence based. Doctors are concrete thinkers trained to think linearly, for whom traditional models of leadership and management, using military and industrial metaphors, make sense. Unfortunately, although the specification of work routines (for example, through evidence based guidelines and standard operating procedures) may be appropriate for dealing with regular processes with clear products, many healthcare outcomes are uncertain.6 They depend to a large extent on the commitment of health professionals and service users with their individual perspectives, experiences, and motivations. More diffuse (distributed) models of leadership and management in healthcare may be appropriate. Unfortunately, much post-modern management theory is opaque, if not incomprehensible.
Various medical management courses and curriculums have been developed for postgraduates in several countries.7 The Medical Leadership Competency Framework is unusual in trying to integrate development over the course of a professional career. It helpfully suggests what individuals will require at different stages of training. All doctors need to understand early on in their career the sciences of quality improvement. A finer appreciation of policy, change management, or business and financial planning may be useful in the different roles that doctors play later on in their careers. However, further research is needed to examine the behaviour of clinical leaders in practice and their training requirements.8
The current NHS reforms promise to return power to the front line (wherever that is),9 but they are bound to strain working relationships between doctors and managers. The lives of NHS managers are hard and getting harder, as the decision to cut their numbers by 45% underlined. Current confusion over basic NHS structures, future roles and job prospects, and the impact of consultants from the private sector are just some of the uncertainties undermining their position as dependable role models. More opportunities for closer interdisciplinary training and working (such as “buddying” arrangements) are needed but may be harder to realise. This is potentially damaging in a period of such organisational turbulence.
Giving new managerial responsibilities to doctors therefore places new responsibilities on all undergraduate and postgraduate medical training institutions. We need greater clarity about curricular content and evaluative educational research on how and when to provide it.10 Evidence shows that employing clinically qualified staff in hospital management yields better outcomes,11 yet little is known about how and why this is the case.
We need more opportunities to share experience and learning with other disciplines, other sectors, and other countries. The proposed national Leadership Academy to accredit development programmes, support their delivery and evaluation, and investigate the effects of investment in this area makes sense.12 The grooming of clinical leaders needs to be more clearly structured, grounded in evidence, and properly managed.
Cite this as: BMJ 2011;343:d5672
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer reviewed.