ABSTRACT
Medical training in the UK provides limited exposure to formal training in leadership and management, and yet the role of a consultant or general practitioner requires such skills which deal with commissioning arrangements, service transformation, quality improvement, Care Quality Commission visits, complaints and supervision of junior colleagues. A number of clinical fellowships in leadership now exist to bridge this gap, and provide training in leadership and management, together with experiential learning in a complex organisation. Well-established leadership schemes suited to junior doctors include the National Medical Director’s Clinical Fellow Scheme, the Royal College of Physicians’ chief registrar scheme, the Darzi Fellowship scheme and local schemes run by Health Education England. Here we describe and compare our experience of these schemes, and outline what junior doctors should consider when applying for a clinical fellowship.
Introduction
Medical training in the UK, from foundation year 1 through to certificate of completion of training, provides the means to acquire the knowledge and skills in a chosen specialty through experiential learning, practical procedures and plenty of exams along the way. The role of a consultant or general practitioner (GP) goes beyond clinical acumen requiring teamwork, together with leadership and management skills to deal with commissioning arrangements, service transformation, quality improvement, Care Quality Commission (CQC) visits, complaints and supervision of junior colleagues.
While the requirements of the portfolio box marked ‘leadership and management’ can (for most specialty postgraduate curricula), be completed through a 2-day course, it has been the experience of the authors that these are rather theory-based, with too much focus on topics such as ‘The structure of the NHS’ and not enough emphasis on the practical application of skills or reflective learning required to be an effective leader.
Leadership and management skills are best developed through experiential learning, supported by a programme of formal teaching, reflective practice, and access to senior leaders and role models. A variety of fellowship schemes now exist which are particularly suitable for trainees to develop their leadership skills, through a full- or part-time programme, based in a clinical setting or an external organisation.
We are specialty registrars currently undertaking different fellowship schemes. Here, we compare what our respective schemes offer, describe our experiences and outline what to consider if you’re a trainee looking to apply for a clinical fellowship with a view to improving your leadership skills.
The National Medical Director’s Clinical Fellow Scheme
Dr Helen Grote, ST7 neurology registrar
The unique opportunity to develop leadership skills while working in national organisation made the National Medical Director’s Clinical Fellow Scheme hugely appealing. The CQC was my first choice post; I felt that the opportunity to visit hospitals, learn from examples of good practice and understand how regulation is used to promote both quality assurance and improvement would be extremely valuable for my future career as a consultant physician.
My key projects have included a national programme to examine how mental health care is provided in acute hospitals and establishing a programme of junior doctor focus groups to inform the well-led domain of CQC’s inspections.
I’ve been surprised by how much responsibility I have been given, and the need to engage with other stakeholders around my work has challenged me to work on silencing my ‘imposter syndrome’, develop my networking skills and ask senior people for help. I still take on more than I should, though; the work laptop has come home with me most evenings and weekends, and I need to get better at saying ‘no’. The absence of patient contact was difficult at first; I’ve always derived huge satisfaction from helping individuals understand and manage their symptoms, and the year has confirmed my desire to pursue clinical practice alongside opportunities to lead.
The Darzi Fellowship scheme
Dr Joanna Smith, ST4 geriatrics registrar
The Darzi Fellowship is a postgraduate certificate programme combining leadership development and organisational change open to clinicians from all backgrounds.
I was enthused by a Darzi project in community geriatrics, leading the development of an integrated team to work towards novel approaches in caring for the most ‘complex’ of Croydon’s elderly population. As the year progressed, many further avenues of interest evolved such as co-designing and delivering a ‘Thinking systems’ workshop series spanning organisational and professional boundaries. The experience of systems leadership has given me a found awareness of the central role of relationships, context and purpose in delivering complex change,1 with learning focused on the value of, and need for, more collective models of leadership.2
My personal reflections on the fellowship so far are that it has been able to constructively challenge my previously held assumptions and beliefs, and has transformed my perceptions of learning and leading. I have acquired tools to understand and develop the systems I am living and working in for the better, while giving me both the confidence to challenge the status quo and the hope that change is possible. It has been a demanding and humbling experience, but one which has given me countless opportunities, a fundamental awareness of perspective and has inspired me to strive towards ‘doing better things’.2
The RCP’s chief registrar scheme
The RCP’s chief registrar scheme is a 12-month workplace-based leadership programme, supported by a tailored education and training package, open to all senior trainees of any specialty. It equips senior trainees with the requisite technical and leadership skills to directly improve quality and safety systematically, sustainably and effectively.
Dr Jayne Little, ST6 rheumatology
For me the great attraction of this scheme was the promise of protected time. As a clinician, I frequently encountered structural problems that I would recognise, endure and then leave unaltered for my successors. The most pleasant surprise of my year as chief registrar was how many of these problems proved soluble given the time to think, engage the right people and apply a rigorous quality improvement (QI) methodology.
The formal QI training was highly engaging because I was able to apply the content directly to day-to-day problem solving. Over the past year, I have led on trust-wide projects including the development of fellowship posts to reduce rota gaps, and a network of QI champions. The opportunity to experience varied leadership personalities and practices through direct participation in the hospital management structure has certainly helped me to develop my own leadership style.
There have been challenges, however. Leading change in specialties other than my own and earning the respect of senior colleagues has required persistence and tact. I’ve also been surprised by the cultural differences between different generations of doctors. Changes in the shape of training and structure of rotations have led to a rapid change in attitudes. As a result, I found representing the concerns of the junior workforce more challenging than I had expected.
I have thoroughly enjoyed my time on the scheme. The guidance provided by my mentor, the RCP and the other chief registrars has been invaluable.
The Health Education England Future Leaders Programme
Dr Michelle Horridge, staff grade registrar, paediatric surgery
Health Education England (HEE) offers a variety of local leadership schemes; including the Future Leaders Programme offered by HEE Yorkshire and Humber. This offers doctors and allied healthcare professionals the opportunity to undertake a 1-year programme incorporating a postgraduate certificate in clinical leadership, alongside leading projects in a local organisation.
I am currently working on three projects and am particularly excited by the work I am doing to improve the emotional support provided to staff following traumatic events at work. This speaks to my core values, which I have been able to identify through the courses available to the ‘future leaders’. I have had the autonomy to create and develop this project, with senior leadership support, giving me further insight into organisational culture, project management and development of skills and networks.
It has been liberating and, at the same time, daunting to be working on large-scale projects. I have felt trusted and given responsibility with regards to people, budgets and involvement with the executive board. The fellowship has highlighted personal strengths which I have had the opportunity to develop further. The experience of being embedded within a team for a whole year and not rotating has also provided a real opportunity to forge good working relationships with a diverse and knowledgeable group of colleagues. This year has led to me feeling inspired, motivated and excited about my work.
The value of clinical fellowships
While the National Medical Director’s Clinical Fellow Scheme provides the opportunity to work on national projects, local schemes such as the Darzi, RCP and HEE schemes are equally valuable in providing opportunities in experiential leadership, and access to senior NHS leaders. Furthermore, learning to make a difference locally is a useful skill which provides the satisfaction of facilitating tangible benefits in patient care, which are often easier to appreciate in a short timeframe and can, in some cases, be scaled up and replicated elsewhere.
No new venture is without challenges, but we have all found these integral to the process of ‘learning to lead’ – and, on occasion, these challenges (and sometimes failures) produced the most valuable learning lessons. We all became quite absorbed in our respective projects, and learning to say ‘no’ was difficult at times. Approaching the end of our fellowships, our next challenge is to navigate how best to continue developing our new approaches to leadership and systems as we re-enter the clinical workforce, as well as adjusting to the reduced autonomy that comes with being a junior doctor once again.
We have all enjoyed the opportunity to test out leadership skills in new roles, as well as the opportunities to network, socialise and share ideas with other fellows. The opportunity for ‘headspace’ to reflect individually, as well as through action learning sets, has facilitated important personal development, giving us all a greater understanding of our own traits and strengths as leaders, and an understanding of the diversity in others. Alongside formal training, we have all appreciated the flexibility inherent in the schemes, enabling valuable opportunities to attend events, conferences and pursue other professional interests. The added autonomy also provided space for learning journeys and productive conversations with leaders in other organisations.
The value of clinical fellowships goes beyond personal and professional growth for the individual, however. Leadership at every level is influential in determining organisational performance,3 and the need for doctors to step up is clear;4 increased medical engagement and good leadership correlate with improved patient care and outcomes.5,6 However, healthcare is a complex environment, characterised by ‘wicked problems’7 for which there is no clear solution, and where a collective, collaborative model of leadership brings the greatest benefit to organisations, rather than ‘heroic’ leadership by individuals.3,8,9
There is increasing evidence that that the acquisition of leadership qualifications and portfolio competencies alone are no substitute for programmes which foster real-world experience of knowledge, enquiry, adaptability and collaboration to develop effective leadership.8 All of the leadership schemes described here fulfil the characteristics of effective leadership development programmes which combine personal development, and opportunities to link theory to practice in a complex organisation.10 Independent evaluations of the RCP’s chief registrar scheme,11 the National Medical Director’s Clinical Fellow Scheme12 and the Darzi scheme13 have also confirmed that fellows provide a valuable benefit to host organisations though improvements in quality and safety, cost savings and deliverables including publications, reports and research studies.
Applying for fellowships
A summary of these clinical fellow schemes is provided in Table 1, with details of how to apply in Table 2. In addition, the NHS Leadership Academy provides a variety of leadership schemes which incorporate online and face-to-face training, supplemented by work-based application, leading to an NHS Leadership Academy award.14
An overview of available fellowship schemes for junior doctors interested in clinical leadership
Links to apply for fellowship schemes
When considering schemes, review the eligibility criteria carefully, and decide whether an in- or out-of-programme experience is right for you. Most of the RCP’s chief registrars remain in programme – which enables the time to count towards training.11 Conversely, having a year out of programme can provide the valuable opportunity to test out leadership skills in a new environment, forge new connections with employees working across the public sector – and, in some cases, can open the door to a different career path in policy or the civil service.12 If you are currently on a training scheme, remember to apply for prospective approval to go out of programme. Discuss this with your educational supervisor and training programme director well in advance, and ensure you complete the necessary forms for Annual Review of Competency Progression purposes. Consider too what you hope to get out of a scheme, and whether this is the right stage in your career to take time away from clinical practice.
All of us have thoroughly enjoyed our year as a clinical fellow and regard the opportunity as a huge privilege. We hope that the experiential learning and new friendships formed will last a lifetime of clinical practice and would encourage any interested junior doctors to consider applying for a fellowship scheme.
Acknowledgements
The authors would like to acknowledge the support of the Faculty of Medical Leadership and Management, the RCP, HEE and the Darzi scheme, as well as their respective host organisations for their support and encouragement.
- © Royal College of Physicians 2019. All rights reserved.
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