Taking time out of training to shed light on “the dark side”BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5231 (Published 23 November 2015) Cite this as: BMJ 2015;351:h5231
- Rory Conn, year 5 specialist trainee in child and adolescent psychiatry, Tavistock and Portman NHS Foundation Trust,
- Amit Bali, year 6 specialist trainee in neonatology, Imperial College Healthcare NHS Trust,
- Elizabeth Akers, paediatric nurse educator, Great Ormond Street Hospital
Rory Conn, Amit Bali, and Elizabeth Akers describe their Darzi fellowship, a year long secondment opportunity in leadership and management for healthcare professionals
The importance of effective management and leadership is increasingly accepted in medicine, moving from “the dark side to centre stage.”1 However, few trainees are exposed to formal leadership opportunities. On many courses theory predominates over hands-on experience and reflective practice, and trainees are often observers rather than active participants in management decisions.
Some appropriate leadership programmes do exist, however, and increasing numbers of trainees are pursuing these formal learning avenues. One such scheme is the Darzi fellowship, which we completed between 2014 and 2015.
The Darzi fellowship acts across multiple health trusts and clinical commissioning groups, which apply to “host” a fellow, and is overseen by the London Leadership Academy. Although based in the capital, applications are accepted from any healthcare professional within the NHS. Jobs are advertised nationally via NHS Jobs and are competitively allocated after interviews at the host organisations.
The programme supports clinicians through project based leadership attachments. It focuses on the acquisition of adaptable skills, enabling the trainee to think critically about leading change. Fellows have the opportunity to continue some clinical work, negotiated locally as specialist interest time, to a maximum of two sessions a week. Each Darzi fellow is allocated a supervisor (or sponsor) at their host organisation, with whom they meet regularly. These sponsors tend to be medical, nursing, or other executive directors; participants are being prepared to become the senior clinical leaders of the future.
To date, six cohorts have completed the programme, with more than 200 fellowships awarded. Initially, a small group of trainee doctors took part, but the number and diversity of participants has increased. In 2014-15, 58 fellows participated, including hospital physicians, general practitioners, psychiatrists, surgeons, nurses, paramedics, pharmacists, and allied health professionals. This deliberate emphasis on multiprofessional inclusiveness challenges traditional hierarchies and power dynamics, allowing collective learning across boundaries. Host organisations report service improvement benefits, alongside the longer term rewards of building networks and capability.
Collectively, we hoped to learn more about the complexities of our healthcare system and evaluate our own suitability to take on leadership roles in the future.
Projects and experiential learning
Reflecting the increasing prominence given to quality improvement in clinical training, fellows are employed to carry out one year transformation projects. Though host organisations ultimately determine how fellows’ time is invested, the process of shaping, defining, and often negotiating the nature and scope of project work is in itself a learning experience.
RC’s introduction of Schwartz Rounds2 has promoted a culture of reflective, compassionate care. He taught and mentored participants of EQuIP,3 a quality improvement and patient safety course (shortlisted for a national award) and contributed to Situation Awareness for Everyone,4 a national collaborative project to introduce “huddles”—multidisciplinary briefings designed to predict clinical deterioration.
EA’s scoping research study showed the impact interprofessional undergraduate education can have on the quality of clinical decision making by those caring for children and young people and their families.
AB’s involvement of patients and families, alongside stakeholders across health, education, and social care, helped develop a framework for integrated, person centred care in epilepsy.5 His work has influenced policy at local, regional, and national levels. He is continuing work to implement a national registry, young people’s networks, and is commissioning a health economic analysis.
Other Darzi fellows’ projects in 2014-15 included reducing frequent attenders to accident and emergency departments, creating a general practitioner federation, piloting the use of physicians’ assistants, initiating a regional healthcare scientists’ network, and co-designing satellite clinics and ambulatory care services.
Importantly, the Darzi programme introduces participants to skills and techniques required to undertake such large scale projects. The teaching faculty, from the Centre for Innovation in Health Management,6 provides one to one meetings (project surgeries) where challenges are discussed and novel approaches developed. This is integral to the Darzi fellowship ethos, promoting opportunities for experiential learning,7 a formative process which accurately reflects real life leadership challenges.
Nature of learning
The deliberately abstract approach adopted by the faculty differs from traditionally didactic medical training. The aim is for fellows to support one another in thinking flexibly, sharing narratives about leading systems change.
In contrast to other leadership programmes89—some of which use distance learning—face to face, active teaching predominates, enabling a focus on applied knowledge. Understanding is gained through experiential learning around decision making processes, systems, power, and influence. Debate is encouraged, with case studies and interactive workshops engendering a dynamic learning environment.
The taught programme develops understanding of the structure and function of healthcare organisations. Careful attention is paid to the history of the NHS and the social and political climates that have shaped it, including recent sweeping reforms. The interface of hospital and community is debated to understand and develop concepts around integrated care. Innovative concepts, such as co-production, are discussed in detail.
Fellows have regular opportunities to meet senior leaders from a range of clinical backgrounds and service users; these exchanges are both challenging and rewarding.
Reflective practice is considered crucial to facilitate continuous meaningful learning through the year. Even those with initial cynicism about reflective practice view this constructively.
One to one coaching sessions with experienced personal coaches provide robust external challenge to thought processes. The coaches also enable fellows to discover authority and agency in their work, as well as providing a method to deal with the uncertainty associated with “leaving” training. All three of us discovered tools to approach and manage difficult conversations through a better understanding of our personal and political contexts.
Independent time management gives fellows the freedom to attend conferences and meetings of interest, broadening their training portfolio and providing fertile ground for the testing of ideas. Our own opportunities included attending Institute of Healthcare Improvement conferences (nationally and internationally), presenting at an all party parliamentary group, and contributing to the Commission on Patient Safety. We have raised our career profiles and become part of wider healthcare networks.
For many, the Darzi fellowship has been an invaluable learning experience. It is a way of coming off the treadmill, enabling trainees to reflect on professional goals and think about their careers. Above all, past fellows speak of their enhanced self awareness, moving from a position of “unconscious incompetence” to “conscious incompetence.”
Previous fellows consistently note the resilience they have built during a challenging and novel year’s work. Learning how to handle negative experiences and navigate conflict predominates in feedback. For example, each of us suffered setbacks in our project development at various stages; however, we were able to overcome this using newly acquired knowledge of organisational behaviour and strategic tools and by adapting conversations to realise new possibilities.
Complex project work has demanded tactical consideration of our interpersonal strengths and weaknesses, surfacing beliefs and behaviours which can facilitate or impede effective change.
The multiprofessional nature of the fellowship, with a wide range of perspectives, gives participants a greater understanding of other professions, their common goals, and their challenges. Fellows also join a community of former fellows who continue to lead change in healthcare.
A Darzi fellowship gives doctors a taste of clinical leadership for a considerable period of time, within a highly supportive environment. Some fellows may go on to senior leadership roles, while others may decide that it is not for them.
The fellowship was a transformational process, leading to much greater confidence and self belief. Our development has extended to a deeper understanding of complex systems and organisations, culture, and the political and historical contexts affecting the NHS. This puts us in a stronger position to question, understand, and advocate, all of which are essential skills for clinical leaders.
● To find out more, visit www.londonleadingforhealth.nhs.uk/programmes/fellowships-clinical-leadership-darzi-fellowships.
Competing interests: We have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.