Supporting and driving trainee-led leadership
ABSTRACT
Medical leadership saves lives. Hospitals with high levels of medical engagement, where all doctors are actively involved in management, leadership and service improvement, have better outcomes. Leadership competencies are not only required by senior clinicians and trainees who aspire to positional leadership roles. From the moment they step onto the wards, all trainee doctors require a range of leadership and management competencies; however, trainee leadership capability remains an undervalued resource in the NHS. The rotation of trainees provides them with unique insights into healthcare systems, and with many challenges facing the NHS and trainees responsible for so much front-line clinical activity, all trainees must be engaged in leadership. The health system must engage and support trainees in leadership development, so trainees take responsibility for driving the quality and safety agenda and demonstrate leadership in transforming services. There is a need to professionalise medical leadership and attract trainees to leadership as an investment in the future of the NHS.
Why engage trainee doctors in leadership?
Medical leadership saves lives; therefore it is imperative that all doctors develop leadership skills. This includes doctors in training. There is now an established evidence base linking medical leadership to improved health outcomes, including lower patient mortality, higher patient satisfaction and quality of care, and higher levels of staff wellbeing and engagement.1 Hospitals with high levels of medical engagement, where staff are invested in the performance of the organisation and actively involved in management, leadership and service improvement, have better outcomes.2–5 Leadership and management competencies are not only required by senior clinicians or trainees who aspire to positional leadership roles; leadership is an integral component of everyday clinical practice and is essential to the delivery of high-quality, continually improving, compassionate, patient-centred care. From the moment they step onto the wards, trainee doctors require a range of leadership and management competencies, which become a more significant element of their role as they progress throughout their careers.4 Every doctor has a professional obligation to develop leadership and management competencies and take responsibility for patient safety, quality and service improvement.6,7 Increasingly, NHS doctors are leading the design, delivery and commissioning of healthcare services through clinical commissioning groups or positional roles ie specialty leads, medical directors, clinical directors or CEOs. There is evidence that organisations led by doctors in formal leadership roles perform better.8 The NHS therefore needs to attract trainee doctors into leadership roles as an investment in the future.
Shining the spotlight on trainee leaders
Trainees are uniquely placed to lead the change needed in healthcare. Sir Robert Francis QC highlighted lack of medical leadership as a fundamental contributor to the failures in care at the Mid Staffordshire NHS Foundation Trust.9 In the report, Francis highlighted the importance of leadership at all levels and called trainees the ‘eyes and ears’ of the hospital. Trainees work on the frontline and experience the challenges first hand, they also rotate, which provides unique and fresh perspectives on healthcare systems and how they might be improved, so they are aptly placed to influence the design of the services they deliver and spread innovation across trusts. In the Berwick Review, trainee doctors were identified as powerful agents for change. Trainees’ leadership capability is currently an undervalued resource in the NHS. No other industry takes their freshest, most enthusiastic and driven employees and uses them solely to deliver a service. While good clinical training is invaluable, delaying engagement with medical leadership is arguably a waste of the most productive and innovative years of a trainee's career.10 There are many challenges facing the NHS that today's trainees will work within throughout their careers ahead, with increasing pressure on the healthcare systems from a growing, ageing population with more long-term conditions and comorbidities, increasingly expensive treatments and advancing technologies, and escalating demands and expectations.11 Now, more than ever, there is a need to unleash the intellectual capabilities and harness the creative energy of the over 58000 trainee doctors12 working on the frontline in the NHS to act as agents for change.13 Professor Sir Bruce Keogh, the current NHS medical director, has called on trainees to lead the drive to improve quality, productivity and innovations in the NHS, highlighting trainees not only as the clinical leaders of tomorrow, but clinical leaders of today.14
Trainees’ preparedness to lead
Despite their leadership capabilities, the majority of trainees receive little formal training in leadership, often leaving them poorly prepared for clinical leadership responsibilities or more senior managerial roles.15
A General Medical Council (GMC) report found 1 in 10 graduates feel inadequately prepared for practice, with key areas of concern, including core leadership and management competencies such as self-management, resilience, patient safety, effective communication and interprofessional team working.16
The Royal College of Physicians (RCP) found that 80% of core medical trainees feel unprepared to become medical registrars, with concerns around running the acute take and leading the on-call team at night.17 With increasing pressures on service provision and an appropriate focus on patient safety, there has been a move towards greater senior presence and rapid review of patients.
Increased supervision can undermine registrars experience of independently managing patients and leading the junior team, which some consider ‘infantilisation’ of senior trainees’ leadership capability and capacity.20 However, by contrast, many feel that the out-of-hours supervision and support that they often receive is inadequate when operating as the most senior doctor on call dealing with complex issues.18
New consultants also report a lack of awareness and preparation for the leadership and managerial aspects of the job, with many going on ‘crash courses’ in leadership.19,20
Lack of preparedness for leadership responsibilities can lead to stress, frustration and disengagement because trainee doctors do not have the skills to effectively lead change. From the moment they step onto the wards, trainees need to be able to recognise quality gaps, feel empowered to champion change and have the skills to lead improvements.21,22
Developing the next generation of medical leaders
There has been an explosion of leadership development initiatives to support the existing and future healthcare workforce to develop leadership and management competencies, understand quality improvement (QI) methodologies and become patient safety champions.
A number of leadership competency frameworks23–27 have been developed to support doctors to develop leadership skills, behaviours and competencies. The Medical Leadership Competency Framework23 has been integrated into undergraduate and postgraduate curriculums; however, there is little evidence that competency frameworks improve leaders effectiveness1 and curriculum integration has been slow and variable.28 The Faculty of Medical Leadership and Management (FMLM) recently published the first ever UK Leadership and management standards for medical professionals,27 which go beyond a developmental competency framework. The standards provide a benchmark against which trainees can assess their skills, experience and impact as a medical leader; measure their leadership development; and gain certification for their leadership competencies.
The FMLM has over 1000 student and trainee members and dedicated trainee and medical student groups, which provide trainees with leadership development support through events, skills courses, resources, mentoring and leadership opportunities. The NHS Leadership Academy also delivers professional leadership programmes, with online learning resources and fellowships. A number of leadership fellowships have been established to fast track and support emergent senior NHS leaders. For example, the National Medical Director's Clinical Fellows Scheme, 29 run by FMLM and sponsored by Professor Sir Bruce Keogh, enables trainees to take one year out of clinical practice to work alongside the senior leadership of NHS and healthcare affiliated organisations, with protected time to develop competencies in leadership, management and health policy. In comparison, the Darzi Clinical Fellowship programme,30 a regional programme, run by the London Local Education and Training Boards, and sponsored by The King's Fund, enables trainees from multiprofessional backgrounds to take one year out to lead a service improvement project in an NHS trust, mentored by a medical director and supported by a leadership development programme. Similar leadership fellowships are available in all four nations31–33 and there are several regional leadership fellowships for example, the North West34 and Yorkshire and the Humber.35
International fellowship opportunities include the Health Foundation/Institute of Healthcare Improvement (IHI) Quality Improvement Fellowships,36 the Commonwealth Fund Harkness Fellowships37 and the Thames Valley and Wessex Leadership Academy Improving Global Health through Leadership Development Programme.38
There are established leadership development courses, such as the Wessex lead and be led,39 leadership skills courses such as those delivered by the British Medical Association and the FMLM, and online leadership courses, including the Leadership Academy Edward Jenner Programme40 and the IHI Open School.41
There are also opportunities for trainees to complete degrees, for example, in healthcare leadership and management, health services improvement, health policy, business and public health.
Many trainee leadership initiatives focus on QI and patient safety. Several local education training boards have integrated QI into training programmes,42,43 while many trusts have established QI groups to provide structured support to trainee engagement in QI.44 The RCP deliver the Learning to make a difference45 programme for core medical trainees, and Health Education England delivered Better training better care,46 a national trainee-led QI programme. The IHI supports trainees to engage in interprofessional QI through Chapters across the UK.41 BMJ Quality (http://quality.bmj.com/) provides learning resources to support trainees to conduct QI projects from inception, through to publication. There has been an organic growth of trainee-driven peer-support initiatives, including Doctors Advancing Patient Safety (http://dapsglobal.com/) and the Quality Improvement Database (www.quid.org.uk/). Another trainee established initiative Doctorpreneurs (www.doctorpreneurs.com/)provides support to trainees interested in improving healthcare through innovation and entrepreneurship.
There are also dedicated student and trainee leadership conferences, for example, Agents for change,47 organised by FMLM and the British Medical Journal, and the Royal Society of Medicine's, Future clinical leaders,48 which provides an opportunity for trainees to find out more about leadership, meet like-minded peers and senior leaders, showcase their achievements and get involved.
There is a range of other trainee leadership development opportunities, from representing peers on their junior doctor forum, to shadowing their CEO, to joining the Care Quality Commission inspection team49 or chairing the board of a national charity.50 For students, there are internships, intercalation or electives in medical leadership and management.51
Social media outlets such as Twitter are a fantastic networking resource for emergent leaders to share ideas and experiences, and have driven the momentum for the trainee doctor and medical student leadership movement with campaigns such as #studentledchange52 growing out of NHS Change Day.
Trainees are now rightly gaining increasing recognition for their leadership capabilities. For example, via the Health Service Journal Rising Stars Awards.53
Leadership development initiatives have clear value in enabling trainees to develop leadership skills. However, evaluating their effectiveness in terms of impact on patient outcomes and long-term trainee engagement in leadership is challenging. There is a breadth of different leadership programmes available, delivered on different scales, by providers with different levels of experience, involving a spectrum of trainee grades, often with small numbers of trainees who are mobile and inherently difficult to follow up. It is important to evaluate and publish the effectiveness of different leadership development initiatives to inform and spread evidence-based approaches to guide the leadership development of emergent NHS leaders.4
Supporting and enabling trainees to lead
Trainees are keen to engage with medical leadership; they have many ideas about how to improve services and many have the skills needed to lead change. However, in practice, many trainees face barriers to leading in the NHS. It is the collective responsibility of everyone involved in the delivery of the health service and the professional development of doctors, including medical educators, undergraduate and postgraduate deans, training programme directors, the Royal Colleges, professional bodies, healthcare-affiliated organisations, senior NHS leaders, hospitals, managers, senior clinicians, allied healthcare professionals and trainees themselves, to create training environments and organisational cultures which engage trainees in leadership and management and support their leadership development, for the benefit of patient care.
Invest in the leadership development of trainee doctors
Start early
Most trainees have frustrations about the systems they work in that prevent them from delivering the care they want to patients, and many have ideas for improvements. However, despite recent focus on the role of trainee doctors as leaders, many trainees do not identify as leaders and do not feel empowered to lead change. Leadership development needs to begin at an undergraduate level so trainee doctors understand the value of medical leadership and can hit the ground running at point of qualification. One example is Imperial College London who offer medical students an intercalated BSc in management. Students have commented that it prepared them for teamwork and enabled them to think more innovatively about delivering services.54 Leadership development needs to start early and continue throughout clinical training, with additional support at key transition points.22
Make leadership development the norm, not the exception
The benefits of taking time to develop leadership capacity and capability should not only be available to a privileged few. Demand for leadership fellowships outweighs capacity55 and the majority of leadership development initiatives exist outside training curricula and are undertaken by a self-select highly engaged group. Leadership development needs to be embedded throughout clinical training, so it becomes business as usual for every doctor. It is not sufficient to only send trainees on leadership courses. The evidence supports sustained, experiential ‘learning by doing’;1 this relies on senior clinicians taking responsibility for the leadership development of their trainees.10 There are examples of NHS organisations that have successfully created cultures that engage trainees in leadership. In Salford Hospital, which has high levels of engagement, all trainees attend a five-day leadership course on induction and are then encouraged to conduct QI projects and contribute to quality assurance and governance meetings.56
Promote what works
More coordinated evaluations of leadership interventions are needed to inform evidence-based approaches to leadership development in healthcare.
Value trainee leaders
Stop the denigration of trainee leaders
Trainee doctors’ leadership capabilities remain underutilised and undervalued in the NHS.55 Many trainees object to the terms ‘trainee’ or ‘junior doctor’ because they fail to capture that doctors in training are not a homogenous group, but range from newly qualified doctors to senior registrars, with a breadth of skills and experiences and high levels of clinical responsibility.57 Trainees who demonstrate leadership in the NHS are often referred to pejoratively as ‘troublemakers’ or warned ‘don't rock the boat’ by senior clinicians; the trainee doctor's ability to lead is often challenged.55 There is a need to create an environment in the NHS where the individual skills and contributions of trainees are valued and their opinions are sought out and valued by senior clinicians and managers. In West Hertfordshire Hospitals NHS Trust58 trainees are encouraged to play a key role in reporting incidents and leading change in the trust. Every morning the executive team gather in the emergency department, all staff are encouraged to attend, and they ask the question, ‘what can we do today to make a difference to our patients tomorrow?’ It has been coined the ‘Onion’ because it peels back the layers and gives staff at all levels direct access to the trust executive directors who will listen to their concerns and work with them to make immediate changes to ensure high-quality patient care. The ‘Onion’ has led to improved performance outcomes for the trust and high levels of staff engagement. The chief executive writes a letter of welcome to each trainee inviting them to attend the ‘Onion’ and the junior doctors’ forum, and once a month there is a trainee-focused ‘Onion’.
Create cultures that support trainees to lead
Create cultures that support trainees to flourish as leaders
Trainee doctors want to contribute to improving services, but their working environment is often not receptive to their skills.59 The King's Fund56 evaluated six trainee leadership fellowships and found them to be transformative, both for the trainee and the organisation they worked in. However, when trainees returned to practice the majority received no ongoing leadership support and some were discouraged or faced active resistance to demonstrating leadership. This demotivated many trainees and discouraged them from ongoing engagement in leadership activities. The leadership skills of trainee doctors in the NHS need to be valued and trainees need to be supported to adopt leadership roles and lead innovations and improvements. An example of where this has been achieved is Health Education England Kent, Surrey and Sussex,43 who empower trainee doctors to undertake service improvement projects that improve patient care by pairing them with graduate trainee managers and supporting them through teaching, action-learning sets and a postgraduate module in leadership.
Create open cultures of safety and improvement
The Freedom to speak up enquiry60 found that many trainees find it challenging to speak up about training and patient safety concerns, due to unsupportive environments, fear of negative impact on their training and lack of faith that their concerns will be addressed.
The GMC survey demonstrates that bullying and undermining remain a problem within training programmes.61 There is a need to create an environment where the most junior member of a team can challenge the most senior. Trainees need to feel safe to raise concerns and report mistakes, so they can learn without blame. In Yeovil District Hospital62 a trainee established a junior doctors’ monthly ‘near misses’ session, facilitated by a senior doctor and patient safety lead, where trainees can discuss mistakes openly and share learning. The sessions have shifted the discussion about mistakes from a culture of fear to one of openness and ‘no blame’.
Make it easy for trainees to lead
Give trainees time to lead
Many trainees are unable to engage in leadership due to heavy clinical responsibilities or face resistance to taking time out of programme to complete leadership fellowships. Trainees need to have protected time away from clinical responsibilities to engage in leadership and management activities. Southern Health NHS Foundation Trust,55 which has high levels of engagement, encourages trainees to participate in leadership development programmes and allocates time for trainees to pursue special interests.
Promote coordination and sustainability of trainee-led improvements
Due to their mobility many trainees don't see the results of their QI interventions or rush through small-scale projects to complete them in time before moving on. Many trusts have established QI groups, which engage trainees with QI projects by offering structured support. For example, the Exeter Quality Improvement Academy (QIA)44 teams trainees who want to complete QI projects with senior clinicians and managers to provide resource and support. The QIA, coordinates QI activity across the hospital to ensure efforts aren't duplicated, involves trainees with larger system improvements aligned with hospitals aims, teaches trainees QI methodology, ensures sustainability by handing projects over to new trainees as they rotate and continually re-measures the impact of trainee-led interventions. Other trusts have embedded QI into postgraduate training;42,43 however it is important to ensure that QI doesn't become a ‘tick-box’ exercise like some audits.63
Engage trainees with wider healthcare systems
Promote organisational engagement
Trainees frequently move jobs and are often away from their core team contributing to the acute take, which makes it challenging for them to integrate and form relationships with their team.64 Trainees also frequently move hospitals, which means they can feel disconnected to the hospital they work in, seeing themselves as an individual working in an organisation, instead of a core part of the organisation. One benefit of doing QI projects is that it engages staff in their working environment.42 However, if trainees don't feel valued and have no loyalty to the hospital they work in they are less driven to work to improve the systems they work in.65,18 There is a need to develop organisational cultures in the NHS that encourage and support trainees to engage in leadership and empower trainees to identify and lead change.
Promote trainees’ understanding of healthcare systems
To address the challenges the NHS requires leaders who can operate across interprofessional and health system boundaries.11 Medical leaders require an understanding of the healthcare systems within which they work and an awareness of the wider social, economic and political influences which impact on their ability to lead change. Trainees often have a poor understanding of the complexity of the healthcare system in which they work, which can undermine their ability to lead change. Often trainees lack insight into the role they can play in influencing the planning and organisation of services and improving quality.66,67 Trainees on the Darzi Fellowship found that the fellowships helped them to appreciate the bigger picture of healthcare and enabled them to more effectively lead change because they saw improvement as part of a system, not individual projects.68 Medical schools need to provide early exposure to management and leadership to establish trainees understanding of their professional responsibilities not only to themselves and their patients, but to the team, the organisation and the wider healthcare community.65
Make a career in leadership attractive
Value senior leaders
The NHS does not value senior leaders and their importance in delivering high-quality healthcare. In what can be lonely roles, senior leaders receive no additional remuneration, little job security and minimal training or support.69–72 The NHS needs to retain good senior leaders by valuing their leadership experience and capabilities, rewarding them with financial and job security, and supporting them through mentoring and coaching. This will in turn attract trainees into careers in medical leadership.
Tackle tribalism
There remains a ‘divide’ between doctors and managers. Doctors who become managers are commonly accused of ‘going over to the dark side’.69 To deliver better outcomes, the NHS needs to create a culture where doctors value and work closely with non-medical managers. University College London Hospital Trust runs an executive shadowing programme55 where trainees and managers complete QI projects together and learn from each other. This programme has promoted understanding of clinical and managerial perspectives and their interdependence.
Professionalise medical leadership
There is currently no assessment of the leadership capability of NHS senior leaders, which has contributed to notable failures in leadership, such as at Mid Staffordshire. To bring credibility to leadership roles and ensure high standards of leadership in the NHS, medical leadership needs to be professionalised, as underpinned by the FMLM's medical leadership standards.27
Create career pathways
If the NHS is to attract more doctors into formal leadership roles, it needs to make it easy for doctors to assume leadership and management positions by creating clear career pathways. Demand for leadership fellowships currently outweighs capacity.55 After completing a fellowship trainees often receive no on-going support and many face opposition to leading in practice. This has led some trainees to no longer engage in leadership activities and some to work outside the NHS where their skills are valued and utilised.55 With the current challenges facing the NHS, the system cannot afford to lose these highly skilled trainees. More leadership tracks need to be developed to support the emergent senior leaders in the NHS.11 The RCP is piloting the role of the chief registrar,73 a healthcare leadership and management development role aimed at senior trainees nearing completion of training. Trainees are responsible for planning service delivery, coordinating medical care and quality and service improvement 2–3 days a week alongside clinical practice. The programme will be evaluated and if effective, it will be promoted.
Conclusion
Trainees want to improve the systems they work in and are uniquely placed to lead transformation and drive innovation across the NHS. Medical leadership has significant impact on health outcomes and with the health service facing increasing pressures and trainees responsible for so much frontline clinical activity, the NHS can't afford not to engage all trainees in leadership.
Leadership and management are core competencies for all doctors, not only those who aspire to positional leadership roles. The leadership development of medical students and doctors in training needs to be given the same commitment as research and medical education. There has been rapid growth of leadership development initiatives which need coordination and evaluation to inform evidence-based approaches to leadership development. To make leadership development part of everyday business for trainees, senior clinicians and NHS organisations need to be supported to nurture the leadership development of trainees in everyday clinical practice. Organisations led by doctors have better outcomes; therefore the NHS needs to invest in its future leadership by developing medical leadership tracks that make leadership careers an attractive and professionally viable option for trainee doctors. It is the collective responsibility of everyone involved in the delivery of the health service and the professional development of doctors to create training environments and organisational cultures which address barriers, engage trainees in leadership and management, and support their leadership development, this will enable trainees to take responsibility for patient safety, quality and service improvement. Trainees shouldn't wait for this to happen; individually trainees can have an impact, but collectively they will have far greater output and effect and can be a significant force for leading this change. It is appropriate to shine the spotlight on trainee doctors, who to date have been undervalued as medical leaders, but it is not sufficient to focus on trainees alone. There is a need in the NHS to engage team members at all levels with leadership; to ensure the continued delivery of high-quality, continually improving, patient-centred and compassionate care.
- © Royal College of Physicians 2015. All rights reserved.
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- Article
- ABSTRACT
- Why engage trainee doctors in leadership?
- Shining the spotlight on trainee leaders
- Trainees’ preparedness to lead
- Developing the next generation of medical leaders
- Supporting and enabling trainees to lead
- Invest in the leadership development of trainee doctors
- Value trainee leaders
- Create cultures that support trainees to lead
- Make it easy for trainees to lead
- Engage trainees with wider healthcare systems
- Make a career in leadership attractive
- Conclusion
- References
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