Grassroots trainees have the desire to lead

The controversy over the junior doctors’ contract galvanised many trainees into action. Trainees who had not held organisational leadership positions became active; many gained prominence in both traditional and social media, discussing how they were fighting for patient safety as well as against contractual inequities.1

The relative public absence of current doctors or alumni from traditional medical leadership schemes was striking and suggests that organisations such as the Faculty of Medical Leadership and Management (FMLM)—created in 2011 as a response to growing demands for better teaching and training in this area2—are struggling to reach their potential. Are existing models to develop medical leadership fit for purpose?

The flagship NHS leadership scheme in England is the national medical director’s clinical fellow scheme, which began in 2007 as the chief medical officer’s clinical advisors scheme. Around 30 trainees are seconded for a year to advise senior officials within medical organisations. Similar schemes exist in Wales and Scotland.

Darzi fellowships were launched in 2009, allowing registrars to work on quality improvement in primary or secondary care alongside an academic programme that led to a postgraduate qualification. Similar regional programmes also exist.34

Under the guidance of established formal leaders, these schemes have provided valuable experiential learning. However, a strained relationship between “grassroots” doctors and senior medical officials has become evident.56 During the recent dispute, trainees, including some who were previously involved in these fellowships, were openly critical of senior officials.78

As a result, key officials with trainees under their wing may no longer have the same influence with junior doctors as before.9 This is problematic for a leadership system where association with high profile officials and executive organisations is key to learning.

Trainees in official leadership schemes have a unique position, bridging the worlds of clinical medicine, policy, and service transformation. The contractual dispute provided an opportunity to draw these worlds together. This opportunity was not fully realised, however, partly because of new conflicts of interest highlighted by the dispute. Fellows in national leadership schemes may be fairly or unfairly seen to have vested interests in nominal patrons not losing face.

Many graduates from schemes such as the national medical director’s clinical fellow scheme leave clinical practice shortly afterwards, usually for industry or academia. Such attrition may explain why the first version of the new contract incentivised leadership scheme graduates. Registrars remaining within the NHS were to receive a yearly flexible pay premium of £4000 post-fellowship.10

Such incentives do not recognise that different qualifications can build similar skills. Many doctors develop robust leadership skills through portfolio careers rather than in a formally delineated year out. Some pursue a part time MBA alongside clinical work. Doctors doing medicine as a second career may have relevant qualifications and experience from prior employment.

A strategy to develop the leadership skills of the majority of trainees is lacking although some progress is being made, for example, through the Health Foundation’s Q initiative.11

Reform of the existing opportunities for leadership is clearly needed. Is patronage or strong association with executive agencies an appropriate or a restrictive model for developing leadership?

The dispute has shown that junior doctors want to be engaged in broader issues. Grassroots teams of trainees emerged to organise protests, coordinate media appearances, take the lead in lobbying, and much more. These groups sprang up outside pre-existing organisational structures. Social media was instrumental in connecting doctors with relevant skills across specialty or location boundaries. Peer learning has been used, with doctors informally teaching skills ranging from lobbying to media management.

After the Keogh Review and Francis Inquiry, there were repeated calls for medical leadership to be more than a minority interest.12 How can we improve the opportunities, networks, and funding available to trainees more broadly, to develop their potential without restricting opportunities to an elite cadre? The conflict over the contract has shown that the wider trainee population is prepared to lead—we must now build on that.