Training and education in healthcare leadership: Is it time for a NHS healthcare academy?

The training requirement

Most respondents felt that there is a pressing requirement to identify and develop capable individuals, from across the whole NHS, who not only have the attributes required, but are also ‘comfortable in both the clinical and managerial leadership roles’.^{Respondent 2} There was a consistent opinion stating the absolute need for significant investment in this area. This sentiment was captured by the statement: ‘If the NHS really means business it will have to invest significantly in this agenda; it depends what it really wants’.^{Respondent 3}

It was felt that the current approach to identifying and nurturing talent for the future in the NHS was ‘confused and not joined up, with everyone doing their own thing’.^{Respondent 4} Interviewees described doctors’ corporate knowledge, in particular, as ‘appalling’,^{Respondent 5} ‘very, very disappointing’^{Respondent 1} and ‘poor’, while one specifically stated that, for doctors, the ‘training need is just not met’.^{Respondent 6}

There was a lack of agreement between respondents as to how training organisations might deliver the requirement for training; however, it was specifically stated that ‘teaching of [these leadership and management] skills must not be left to partially the organisation that employs you, partially to the Colleges and partially left to the deaneries, an incoherent triumvirate’.^{Respondent 4} It was also stated that ‘developing the [wider corporate and leadership] attitudes is difficult when clinicians are so focussed on achieving their clinical training’,^{Respondent 3} while many felt that a simple NHS induction developing a more corporate mentality from the outset of an individual's career was missing.

There was a broad agreement that the ‘value of leadership and management is not well understood in the NHS’^{Respondent 7} and that generic funding opportunities for this learning have been sparse: ‘historically individuals funded [their own] managerial professional development’. ^{Respondent 8} It was argued that while motivated individuals invested in themselves, their employing, educational and professional organisations did not, often taking the view that ‘the problem in investing in this area is financial and this training requirement has not been written into the budget nor the opportunity costs considered’.^{Respondent 4}

This opinion was tempered by several respondents who felt the cost of this investment would be easily countered as ‘the benefits of [a] corporate approach are huge; return on investment is massive’,^{Respondent 2} while in the longer term this would also potentially reduce the need for the ‘massive investment in external management consultancy in the NHS, which is a scandalous waste of public money when we have such a capable workforce.’^{Respondent 6} In conclusion nearly all respondents felt that ‘these [management and leadership] skills should be as core to the clinician's portfolio on graduation as their clinical skills’.^{Respondent 9}

The timing of training and education

The timing of management and leadership training and education was contentious. Some respondents felt it should commence at the outset of professional training, with a broader emphasis on healthcare education for clinicians in particular. This is exemplified by the quote: ‘medical schools focus on the pure science of it [medicine] and if we don't change the context of medical training to include the wider system we will continue to struggle’.^{Respondent 6} Those pushing for an immediate corporate strand in undergraduate medical education argued that ‘the evidence would suggest the earlier you do it the more enthusiastic individuals are as they are [more] open to suggestion [and] they are not yet indoctrinated and cynical,’^{Respondent 3} and ‘it is bizarre that medical schools do not induct people into the NHS’.^{Respondent 7} However, it was agreed that this should not be overemphasised at undergraduate level and the question of ‘what would you take out of the clinical curriculum?’ was raised by several respondents and not resolved by the end of the research.

For those already working within the NHS there was a split in opinion as to when the optimal time for corporate training should be. Some felt that the need to deliver a minimum corporate requirement could be underpinned by an NHS induction, stating both that ‘It is ridiculous that healthcare workers are not inducted into the NHS’^{Respondent 7} and that the failure to do so has missed an opportunity ‘to engender a loyalty to the NHS from the outset that has led to a complex set of loyalties’.^{Respondent 14}

Others felt that clinical training must take priority in the early years, with a graduated increase in focus on the broader corporate issues as one neared independent practitioner status. It was argued that all clinicians ‘required experience to be credible’^{Respondent 10} but ‘senior trainee doctors are a good target, [as they are] starting to learn that there are many other attributes that make them a good doctor’.^{Respondent 11} The current focus on senior trainees was also felt to be appropriate as these individuals would ‘rapidly become junior consultants with a real opportunity to deliver change’.^{Respondent 9}

Content of leadership training

As might be expected, the Medical Leadership Competency Framework (MLCF) was cited as a good example for both broad content and a step-wise approach to titrating the knowledge required with an individual's career development and progression. It was argued that independent practitioners should, as a minimum, ‘have basic understandings of finance, the structure of the organisation in which they operate and the strengths and weakness of their directorate in the organisation’.^{Respondent 9}

From the responses gathered it appeared that collectively respondents thought that the aims for the generic corporate training should be twofold. The firstly aim should be to improve organisational and corporate knowledge, to ‘translate narrow clinical work into [the] broader picture’^{Respondent 12} and to get NHS staff to ‘understand [healthcare] processes, flows of work, systems and how they work and fit together’.^{Respondent 9} This ‘must include exposure to other areas of healthcare i.e. ‘management’ and breakdown the ‘negative stereotyping that starts very early in people's careers’.^{Respondent 3}

Secondly, and almost universally, respondents highlighted the need for individuals to develop emotional intelligence and a much broader set of relationship skills from very early stages in their careers. This would allow individuals to ‘understand themselves, their personal skills and attributes and how they play out in interaction with others’^{Respondent 6} but also to ‘understanding the system and [how to] lead service improvement’.^{Respondent 4}

Many respondents believed that multi-disciplinary learning was the most appropriate forum for this type of training, from the outset, with much stronger early interaction between all forms of clinicians and their managerial colleagues.

Selection

There was a division as to whether all NHS staff should be trained in corporate partnership skills and leadership or whether all should have the former while only those with particular potential in that direction should be selected for the latter. There was also significant disagreement as to whether training should be mandatory of voluntary.

While many shared the view that ‘corporate skills need to be routine for all’,^{Respondent 7} as ‘clinicians are the people who use resources and define how the money is spent’,^{Respondent 9} most did not believe that everyone should be given higher leadership training. ‘[Higher] leadership for all misses the point’ ^{Respondent 12} and ‘financial constraints deter the extent everyone can be exposed to high end leadership training’^{Respondent 5}. One respondent stated ‘it would be an ill-advised approach even if financially viable’. ^{Respondent 13} It was felt that higher leadership training should be voluntary and predicated on enthusiasm, talent spotting, assessment and selection. It was also suggested that ‘poor team working kills patients whilst good leadership defines high quality care’,^{Respondent 9} mandating full investment in both.

For those selected for higher leadership training two additional requirements were deemed important. Firstly, it was felt by many that there was a requirement for a much greater depth of understanding of the health system but also a fundamental requirement to ‘understand the bigger picture and the interplay between stakeholders’.^{Respondent 14} Focus on strategic thinking was felt to be important and a skill set ‘most clinicians do not inherently have’.^{Respondent 5} It was felt that higher level training should include ‘horizon scanning [and an understanding of the] interplay between the hard stuff (contracts and KPIs) and soft [relationship] skills’.^{Respondent 2} These skills were felt to be required to lead effectively at higher levels. It was suggested that this level of training might incorporate ‘interplay with finance and management training programmes, that were multi-professional [in their approach and delivery] and not just health related but should also include [traditional] finance and management.’^{Respondent 4}

Assessment and feedback

It was felt that to support talent identification, both robust assessment of individuals taking part in initial training, and honest and robust feedback was required. Most respondents felt ‘not everyone wants to be a leader and some don't have the required skills’;^{Respondent 5} therefore ‘for higher leadership there will be a need for further assessment of broad managerial and leadership competence’.^{Respondent 1} Most respondents felt individuals should be formally assessed in any education and training programme, such as with clinical competence, and this would identify and allow those with an interest and aptitude ‘to be picked up early in their careers, [and demonstrate] the thirst and commitment to seek out the opportunities [to develop further]’.^{Respondent 16} To be useful to the NHS as a whole the results of assessment must be available to both clinical educational supervisors (to form part of the individual's annual appraisal) and more broadly to those looking to develop future leaders, locally, regionally and nationally. One respondent stated that ‘a common reporting and appraisal system for this type of training would certainly help; with e-portfolios and twenty-first century IT this would not be impossible to do’.^{Respondent 3}

There was a feeling among many respondents that the unintended consequence of the current ‘clinical leadership’ agenda was that many junior doctors now had ‘unrealistic expectations as to their broad leadership competence’ and a ‘mismatch between their own self- belief versus those around them’ was common. It was felt that this was largely due to a failure of constructive feedback.

Views of the Armed Forces Leadership Model

Having discussed the management and leadership training need in detail, the Armed Forces Leadership model was introduced (Table 1) and respondents were asked to comment on whether the model could be used to deliver an NHS corporate training requirement. The model was broadly well received by non-military interviewees, with comments such as ‘it is brilliant in its concept’, ^{Respondent 2} ‘thought through rationally’,^{Respondent 4} ‘having complete validity’, ^{Respondent 1} and ‘I would love to see this implemented as it would almost quality assure leadership’^{Respondent 6} highlighting interviewees’ enthusiasm for the overall concept. In particular the ‘modular approach’^{Respondent 3} and ‘comprehensive content’^{Respondent 5} were seen as positive features, with the ‘idea of defining entry points to schemes being good, the multi-disciplinary approach key, and breaking down silos between different groups very helpful’.^{Respondent 7} Others commented positively on the ‘consistency of approach’^{Respondent 11} and the fact that this model ‘illuminates the path for potential clinical leaders’,^{Respondent 8} while it could be used support the existing ‘MLCF continuum of development between undergraduate and postgraduate training’.^{Respondent 4} There was broad agreement that ‘clear, explicit structure allows people know what they have to do’^{Respondent 9} and the model ‘gives you a curriculum you could link to the MLCF’.^{Respondent 2} Furthermore, for higher levels of training ‘serially gated competition’^{Respondent 7} was deemed appropriate and the model could ultimately ‘provide an accredited pool of individuals, allowing a chief executive who wanted someone with these skills from this talent pool to be recognised as ready’.^{Respondent 10}

Senior military healthcare leaders added that ‘it is a different way of nurturing people from the beginning; trained from the outset in corporate and plc. business’,^{Respondent 12} that ‘there was no “dark side” in the military and we select the best and the brightest to do it regardless of specialty background’^{Respondent 15} and ‘this training is also an integral part of the system, it influences the managerial context of job and further selects individuals whom we encourage to take the specialist managerial route’.^{Respondent 16} Moreover, anecdotal evidence from deanery level suggests that military trainees are often held in high regard: ‘At a recent ARCP [Annual Review of Competence Progression] panel it was said that “These [Defence Medical Services] trainees are a cut above their NHS colleagues”‘ ^{Respondent 17} and this is a common theme and is the most obvious manifestation of their ‘ability to demonstrate their leadership and management competencies’.^{Respondent 12}

By contrast, others expressed reservations about both the model itself and its applicability to the NHS. Caution was advocated as ‘This is not the core business of the NHS in the same way it is in the military’^{Respondent 17} and the ‘sheer size of the NHS and its semi-feudal structure may make delivery nigh-on impossible’.^{Respondent 1} Others felt that no single organisation ‘should be a monopoly provider at higher levels’^{Respondent 10} and there must be room for organisations to ‘use external organisations’^{Respondent 7} if that was more appropriate for their needs.

Given the size difference between the military and the NHS and the structural challenges presented by the NHS, further discussion of the need to adapt the model then focussed debate on how one could deliver a health leadership model in the NHS.

Challenges to implementing a health academy model in the NHS

The biggest challenge to implementing a health academy model akin to that seen in the Armed Forces was seen to be that ‘the NHS does not operate as one employer’.^{Respondent 10} Key stakeholders required to buy into any attempt to deliver a national model included DH, NHS England, clinical commissioning groups (CCGs), acute provider trusts, royal colleges (medical, mursing and allied health professionals) and local education and training boards (LETBs). Although there was much debate about potential delivery mechanisms, a general trend of opinion suggested that training could be ‘centrally owned if it was the norm, with central funding, and a centrally devised curriculum and standards but with local implementation and interpretation encouraged’. ^{Respondent 4} ‘The role of the National Leadership Council (NLC) (now Academy [NLA]) and NHS Institute (NHSI) (as was) could be to define the high level framework and curriculum’^{Respondent 6} in ‘close conjunction with the Academy of Royal Colleges’.^{Respondent 9}

The actual delivery of training was felt to be dependent on whether it was generic or higher-level leadership training; it was thought that the former could become the responsibility of the regional NHS England offices, with national strategic oversight at NHS England medical director level as ‘East of England, Northwest, South Central and London [strategic health authorities] have previously developed very good programmes and should come together in this kind of endeavour’.^{Respondent 1} Delivery could be done either in-house, ‘such as at University College London Hospitals‘,^{Respondent 7} through ‘regional health academies (as in the North West)’,^{Respondent 8} ‘sub-regionally through Health, Innovation and Education Clusters (HIECs)’^{Respondent 10} or via ‘lead NHS organisations within the region’.^{Respondent 11} It could also be ‘put out to the marketplace, either shared with commercial partners or tendered in its entirety, while delivered against the NHS framework from the NLC/NHSI’. ^{Respondent 10} Organisations such as the Kings Fund, Ashridge, Unipart, Birbeck, the Royal Colleges and academic partners were all cited as potential interested commercial partners. Several respondents argued that the principle of ‘subsidiarity’ was important; delivering centrally only what could not be delivered regionally, or locally.

Higher leadership training was seen as more contentious. Several of those interviewed argued that ‘management in medicine needs to be recognised with a more academic, respected and acknowledged focus’^{Respondent 9} but while innovative initiatives such as ‘formal “Walport”-style academic training in management and leadership for doctors’^{Respondent 1} was favoured by some it garnered a lukewarm response from others, partly being seen as lacking a multi-professional focus. Likewise the concept of a ‘College of Health Management’^{Respondent 16} was positively favoured by many for higher level health leadership training but others dismissed this as elitist and expensive. This model however could become the professional home for health leadership and it was argued succinctly that ‘given the size, complexity and cost of the NHS then it [a College of Health Management and Leadership College] could be money well spent. It should not just deliver training and teaching but also is a place to be used to re-invigorate, share ideas and learn from colleagues at the same level, from chief executive downwards. It could if necessary offer two-day courses to several months, again with commercial partnership to keep it fresh and innovative’. ^{Respondent 17}

Conflict of Interest

EDN is a Royal Air Force Medical Officer and a member of the Defence Medical Services who has undertaken training at both RAF College Cranwell and JSCSC.