Intended for healthcare professionals

Careers

Medical leadership must move from “amateur sport” to professional discipline

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6577 (Published 06 November 2013) Cite this as: BMJ 2013;347:f6577
  1. Marc Wittenberg, BMJ clinical fellow
  1. 1BMJ
  1. mwittenberg{at}bmj.com

Abstract

The economic and demographic challenges facing the health service will require stronger and more engaged medical leadership, according to speakers at the Faculty of Medical Leadership and Management’s annual conference. Marc Wittenberg reports and reflects on discussions at the conference

Medical leadership will have to become a true professional discipline if it is to deal with the challenges facing the health service, the Faculty of Medical Leadership and Management (FMLM) believes.

Speaking at the faculty’s second annual conference in Edinburgh in October, the faculty’s medical director, Peter Lees, said that medical leadership must move beyond its status as an “amateur sport.” He said that, if the profession were to manage the complex economic and demographic challenges that the health service faced, its leadership would need to be robust, with strong teams and the right culture.

Lees said that medical leadership had been “damned with faint praise” in the joint King’s Fund and National Institute for Health Research report published earlier this year.1 The report provided an up to date picture of the state of medical leadership in NHS trusts, and found that, in many cases, only a small minority of doctors were in leadership positions, and most of these committed only one day a week to the role.

Chris Ham, chief executive of the King’s Fund and an author of the report, said at the conference that medical leadership could not remain a minority interest on the margins of the NHS. The risks of this had been made stark in the recent Francis and Keogh reports, which both identified a lack of strong clinical leadership as a fundamental contributor to the failures of some hospital trusts.23 But he said that there was a perception that doctors who became managers went to the “dark side” within an NHS culture that failed to value and reward those taking on leadership roles.

Nikita Kanani, a London general practitioner, said there was an “epidemic” of loneliness among medical managers, who were often seen as rebels or misfits. This could result in aspiring and gifted people abandoning a career in medical management for fear of isolation from their colleagues.

Leadership skills increasingly recognised

The important role of medical leadership in the delivery of high quality health services has been increasingly recognised over the past 30 years. In 1983, the Griffiths Report introduced the notion of clinical directorates within hospitals, giving doctors a major role in general management and encouraging their involvement in resource allocation and budgeting.4 Before this, the profile of the medical profession in hospital management was low.

In 2008, Ara Darzi’s report High Quality Care for All brought sharply into focus the need for strong and engaged medical leadership.5 In February 2013, Robert Francis concluded in his report into the failings at Mid Staffordshire NHS Trust that leadership and management needed to be seen as respectable professions within the healthcare system.2

Historically, the NHS has had a strong culture of general management. In addition, the phenomenon of a clinician climbing the ladder and ending up as a manager is one that is often seen in the NHS, driven by the assumption that great clinical skills translate to equally good managerial ones.

The assumption that a good clinician will by default have good managerial skills is erroneous, however, especially as these skills are rarely taught or nurtured. This results in medical managers with a poor understanding of their role, which until recently has led to further conflict between doctors and managers, through an emphasis on targets designed to improve access rather than quality. This is now beginning to change through paired learning initiatives, but these are still the exception.

There is emerging evidence linking medical engagement and robust medical leadership with high quality outcomes. At the FMLM conference, Michael West, professor of organisational psychology at Lancaster University, showcased the initial findings of joint research work between the FMLM, the King’s Fund, and the Centre for Creative Leadership. This work has begun to provide a firm evidence base that links collective leadership to high quality, safe, and compassionate clinical outcomes for patients.

Peter Spurgeon, director of the Institute of Clinical Leadership at Warwick University, also discussed evidence that linked strong leadership to improved patient outcomes. He has collected data showing a strong correlation between medical engagement in leadership and management and lower standardised mortality rates, better patient experience, and lower emergency readmission rates.

Importance of training

Securing greater engagement will require a cultural change that is backed up by structural and organisational change. Giving clinicians the right training and experience is key, starting from medical school. At postgraduate level, it is essential that medical leadership and management have parity of esteem with more traditional training routes. Lees describes this in his concept of fast track medical management training. In many postgraduate curriculums, however, this remains neglected.

The structures to support fast track medical management training are nascent, such as the embedding of the medical leadership competency framework in the General Medical Council’s Tomorrow’s Doctors in 2009.6 In addition, initiatives have been developed at various levels, including the national medical director’s clinical fellow scheme and the Darzi fellowships.

However, several medical directors in workshop discussions at the conference remarked that there was still no clear career path for doctors who wished to pursue a portfolio career in clinical practice and management, and little support for those making the transition.

Lack of respect for leadership

The poor perception of leadership and management in comparison with academia by some parts of the hierarchy was a theme frequently repeated at the conference, particularly by trainee doctors. After being accepted on to a national leadership development scheme, one registrar was told, “You are becoming one of them” by his consultant.

Recognition of leadership and management experience within a trainee’s portfolio and at the appraisal process is often not viewed by senior colleagues with the same regard as are other important aspects of training.

Ham said that great medical leaders were bilingual in clinical and management language. Bruce Keogh, medical director of NHS England, said that he had never been able to do anything significant in his career without the support of a good manager. Nurturing the relationship between clinicians and general managers was fundamental to this, reinforced by mutual understanding, he said.

Clare Marx, an orthopaedic surgeon from Ipswich and lead for patient safety at the Royal College of Surgeons, said that the development of standards would be the key to this.

Engaging the medical profession in leadership and management and supporting aspiring leaders is essential for delivering a high quality health service, especially in austere times. As Andrew Vincent, a partner at healthcare analysis and training company Academyst, put it, “We need more people that are willing to disrupt the system and create an environment where it is acceptable to innovate and take risk.”

Footnotes

  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.

References