Who are the great medical leaders of our era?
The Faculty of Medical Leadership and Management 2015 Annual Conference heard an uplifting run through of the great British inventions and innovations of the past fifty years from the NHS England medical director. The list is impressive and by head of population, globally unbeatable; in short, UK medicine punches way above its weight on the international stage.
There is no one on that list whose lauded contribution was to make the NHS as a system work better. Aneurin Bevan is rightly praised but is one Bevan in 60 odd years enough? So, the doctors in the hall of fame invented clever technical advances, but none how to afford them? If the NHS is to enjoy another 60 years as the envy of the world and remain the US Commonwealth Fund number one, we need to focus significant brainpower on how to deliver better care, not just what we deliver. Technological advance alone will not be enough unless, of course, we conquer Alzheimer's disease, vascular disease, cancer, obesity and diabetes more quickly than appears likely.
Politicians appear to interfere relatively little in the world of innovation and research perhaps because the sector is highly assertive and, to the outsider, feels remarkably unified, presumably washing any dirty linen in private. The NHS could not be more different. Politicians interfere all of the time and the profession responds disparately with what can sound like self-interest. Worse still, dirty linen is regularly washed in public and denigration of individuals, professional disciplines, national medical bodies etc goes way deeper than the apparent superficial jocularity. This is a gift to divide and rule, a technique which politicians will freely admit is very handy when dealing with doctors.
We need a new approach which does not continually pitch the professional against the politician. Patients deserve more constructive medical input into policy and its direction. We need the medical profession to punch above its weight in guiding the NHS through the current and future turbulent waters. To descend into an array of metaphors, we need to be inside the proverbial tent; we need to get on the pitch, and we need to pull as one more often than not and cheer when someone else scores a great goal, not keep the ball to ourselves and miss! Doctors do not hold the monopoly on ideas, innovation and brainpower, but they are vital major shareholders in the collective wisdom and intellect of the NHS.
In short, we need medical leaders as competent and capable as they are clinicians. The profession must end its deprecation of the colleagues who invest their time and effort into managing systems or organisations, to allow others to focus on delivering the quality of care patients deserve. In coming of age, medical leadership and management needs to rise above being an amateur sport and it now has the wherewithal to do so. In 2011, the UK medical colleges and faculties en masse and the Academy of Medical Royal Colleges (AoMRC) had the wisdom to establish the Faculty of Medical Leadership and Management (FMLM). In so doing, medicine became the only profession to have addressed the recommendation in the Francis report1 that healthcare leadership should become a profession. The standards of medical leadership and management are already published and, come the end of 2015, these will underpin the opportunity for medical leaders to be certified at three levels.2 With accidental timing, the standards were published the same day as Bill Kirkup's Morecambe Bay report3 which stated: Clear national standards should be drawn up setting out the professional duties and expectations of clinical leads at all levels, including, but not limited to, clinical directors, clinical leads, heads of service, medical directors, nurse directors. Astoundingly, with no reference to Francis, Kirkup or FMLM, the Rose review4 recommended the requirement for senior managers to attend accredited courses for a qualification to show that consistent levels of experience and training have been reached across the NHS.
Seemingly also ignorant of the well-established General Medical Council process of medical revalidation, Rose also recommended:
Establish and embed an NHS system of simple, rational appraisal…supported by a regular course in giving and receiving appraisals as part of the core provision of the single training body. At a senior level, these appraisals should be standardised across the NHS.4
Reference to the AoMRC/FMLM appraisal guidance for medical leaders and managers was there none!
As a supplementary question to my opening, I would ask: who leads the medical profession? Try it on your colleagues and you will get my point. When most of us think of medical leadership, we tend to think of teams, organisations and increasingly of systems and networks, but there is widespread ignorance of the nature of politics which so profoundly impacts on our daily lives, our jobs and our patients. A small few are adept at navigating this Machiavellian world, but they are still largely playing for ‘clubs’ – few play for the national team! A respected peer pointed out to me some years ago how many lawyers there are in the House of Commons and how few doctors there are. The implication is clear – if we wish for more clinically coherent policy, there is no substitute for being well represented in the highest decision-making body. This has driven the design of an FMLM taster course to encourage doctors into parliament.
Despite this barren UK landscape, in this issue of the Journal, many of the pieces in our special section focused upon leadership, show us the way. First, there is much reference to the significant evidence base linking aspects of leadership to hard patient outcomes, with Kirsten Armit drawing heavily on the recently published collaborative literature review she co-authored. Peter Spurgeon demonstrates that a truly engaged medical workforce is associated with a better quality of patient care, and Ron Kerr shows what can be achieved in a very large trust by focusing on values and behaviour, not just the urgent and the ‘transactional’. Olivia Jagger makes a strong case for development starting early and positively offers solutions to some of the disincentives to junior doctors. In one of the best reviews of leadership in recent times, Karen Lynas highlights both the consequences of getting it wrong with clear pointers on how to get it right. Sir Neil Douglas and Jonathan Fielden give balanced accounts of the contribution doctors should and could make and are refreshingly forthright in expounding what the profession, as well as the system, must do. Finally, two reassuring observations from Federico Lega (Bocconi University): we share many issues with countries across Europe; and his assertion that clinical leadership is no longer optional!
The conclusion is that healthcare needs professional medical leaders at every level. From more academic rigor in policy making, to better teamworking at the front line; medicine has much to offer. Compromise will be needed; the profession must move away from the comfort of the commentator and either join, follow or support those who venture into leadership positions. The evidence in this journal suggests that we need more doctors on boards and more than the pitifully small number in chief executive posts. More doctors in parliament would be good too. To underpin all of this we need to adopt the newly available standards of medical leadership and focus on talent management and succession planning; in short we need to professionalise medical leadership and reach a state where we are every bit as proud of it as we are of the practice of clinical medicine. The evidence would suggest that patients will be the major beneficiaries.
- © Royal College of Physicians 2015. All rights reserved.
References
- 1.↵Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Chaired by Francis QC Robert. London: Stationery Office, 2013. Available online at www.midstaffspublicinquiry.com/report [Accessed 10 July 2015].
- 2.↵
- Faculty of Medical Leadership and Management
- 3.↵
- Kirkup B.
- 4.↵
- Rose Lord
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