Tomorrow's leaders – the role of leadership in medical ­education and training

The importance of leadership capabilities

Delivering safe and effective patient care requires clinicians to have high-level clinical knowledge and technical skills; it also requires a range of non-technical skills and behaviours to ensure that the clinical team work effectively together and with patients and their carers. Delivering effective healthcare has become increasingly complex; our ageing patient population are more likely to have multiple comorbidities and want to be actively involved in decisions about their healthcare. In addition, our knowledge of the impact of human factors on medical error and the steps that can be taken to understand, anticipate and minimise them has grown significantly over the last decade. There is clear evidence that patient care is improved where there is strong leadership and effective team working¹ and that the NHS needs leaders who are able to work collaboratively, supporting those with whom they work to deliver high-quality patient care.² Medical leadership is essential for system analysis and transformational change within healthcare and medical leaders have the necessary credibility to steer experts to work to a common goal. Medical leadership is also essential in the clinical arena. Bohmer describes three modes of care – repetitive, constrained and unconstrained – each of which requires different leadership approaches. These approaches extend from ensuring that best practice is reliably implemented to focusing a diverse team on selecting the best treatment option for the individual patient and creating an environment that fosters exploration and rapid discovery of solutions – where the leader enables the team to cope with and manage high levels of uncertainty, leading the collective learning.³ Medical leaders are familiar with the clinical setting and work comfortably across all three modes. Our trainees need opportunities to learn these skills.

The General Medical Council (GMC) has set out a framework of generic professional capabilities⁴ that will be incorporated into all medical curricula. One domain focuses specifically on leadership and team working, and all the domains include elements of the NHS leadership framework.⁵ The Faculty of Medical Leadership and Management (FMLM) has developed a set of core values and behaviours for medical professionals⁶ that are intended to cover all career stages. They focus on self, team leader and corporate responsibility and the standards, at least for the first two elements, could and should apply to all trainees on completion of their training and many aspects will apply throughout undergraduate education and postgraduate training.

Leadership and management have traditionally been seen as qualities that are best learned towards the end of medical training; but if the NHS is to achieve its vision, as described in the Five Year Forward View,⁷ of a more collaborative and patient-focused approach to care, more emphasis must be placed on developing and assessing leadership skills, qualities and capabilities throughout undergraduate and postgraduate years. The skills of listening, reflecting and summarising are needed both in the boardroom and when working with individual patients and carers. The ability to manage one's own emotions, remaining calm and objective when in pressurised situations, and taking full accountability for actions applies equally in clinical and managerial activity. Perhaps most importantly, medical trainees need the attributes of humility and respect, together with the time and space to fully understand the reasons for the patient seeking medical attention.⁸

Developing a culture to learn clinical leadership

There is a wealth of opportunities for trainees to get involved in activities to develop their leadership skills, from quality improvement⁹ to structured programmes; these could be achieved either within a training programme or through specific time out of training.¹⁰ However, just as we expect all members of our profession to have critical reading skills and to understand research, with some taking additional opportunities to gain a much greater understanding of research, so with leadership we need to create the opportunities for all students and trainees to learn how to manage themselves and lead a team with some trainees acquiring the additional skills of corporate leadership.

Sadly, leadership and management are viewed with cynicism by some clinicians; inappropriate and careless remarks, such as moving to the dark side, are sometimes made about trainees aspiring to develop leadership skills. Comments such as these are comparable to the hierarchy of specialties within the profession and are frequently fuelled by lack of understanding. The ability to assimilate the information to reach a working diagnosis and agree a treatment plan and measures of improvement is similar to the ability to identify and assess issues creating a management problem and agree an action plan and measures of change. Furthermore, the skill set needed to persuade others to change behaviour – whether they are patients or team members – are the same: active listening, negotiation and influencing. Negativism towards leadership and management are at best unhelpful and may, if left unchecked, create a rift between the medical profession and health service managers.

The role of trainers

Having accepted that leadership of self and team should now be part of the requirements for the award of Certificate of Completion of Training, and possibly full registration, we need as a profession to review how we embed the leadership curriculum in workplace learning. Each and every day senior clinicians will work with trainees and students to discuss the activity that has taken place prior to the handover. Some, but not many, may use the opportunity to reflect on the leadership and management skills used during the period of clinical activity: asking the higher trainee how they supported their colleague during their first period of on call or how each of them supported the team following an unexpected death or how they worked with the managers to cope with an unexpected surge in admissions could all be part of the post-take discussion. As a profession, we traditionally focused our assessment of leadership capability on positional leadership as a measure of competence, looking for the trainee's appointment to the training committee or rota manager rather than using a situation, background, assessment, recommendation (SBAR) approach to every day leadership challenges or using some of the assessment tools under development such as the assessment of non-technical skills for surgeons (NOTSS).

The GMC standards for trainers are now a pre-requisite for all doctors to take responsibility as a clinical or educational supervisor. In preparation for those roles, all doctors may wish to reflect on how they will supervise and create opportunities for their trainees and students to learn and reflect on leadership. Those who are responsible for formal training programmes may wish to consider how they could incorporate activities into their teaching programmes to help students and trainees understand the different team roles and which role they prefer and excel in; and how they could facilitate an action learning approach to their programmes so that trainees can learn together from leadership activity. However, leadership requires the ability to identify and maximise opportunities and as trainees move through their programme they will now be expected to reflect on and learn from leadership situations.

Wider leadership opportunities

Learning the third element of leadership – corporate or systems leadership – may be possible during a training programme. Across the UK, most local Health Education England offices and deaneries have created local opportunities to engage in leadership activity. In addition, there are national programmes such as the FMLM Clinical Fellows Programme and the chief registrar project at the Royal College of Physicians.¹¹ These offer trainees the opportunities to work in national organisations, contributing to and leading projects. There are other opportunities: many trusts offer leadership development to all new consultants, the FMLM offers development for GPs taking up leadership roles and many parts of the UK offer learning sets and specific leadership programmes. There are also national programmes such as those offered by the Leadership Academy and the King's Fund.

Leadership, like clinical medicine, is best learned through practical experience. Lectures and lecture-based programmes will only provide theoretical knowledge. For most trainees and students, the important aspect of leadership development will continue to be the skills and behaviours necessary to work effectively with others. These include the ability to delegate, negotiate, support and motivate, in addition to the skills necessary to recognise error and act to correct it.

Conflicts of interest

JH is a member of the Faculty of Medical Leadership and Management Council.