Doctors as leaders
Authors: Aniket Tavare, Peter Lees
Publication date: 16 Oct 2012
Aniket Tavare and Peter Lees pin
down the “nebulous and intangible”
concept of medical leadership
Bruce Keogh, NHS medical director,
said in his evidence to the inquiry
investigating abnormally high
mortality rates at Mid-Staffordshire
NHS Foundation Trust that the poor
care was caused partly by a “failure of
clinical leadership.” [1] Such
comments highlight the fact that
leadership is increasingly being seen
as an essential feature of high
performing healthcare teams,
organisations, and systems. [2] When
leadership is poor or absent, the
consequences can be devastating.[2]
[3] Despite this, the concept of
medical leadership remains
somewhat nebulous and intangible to
many people, [4] though recognition
of its importance is growing.
A unified definition of medical
leadership remains elusive, [5] but the
many attempts centre on key
elements, such as managing change,
setting agendas, and influencing
others. [4] We suggest that leadership
entails “getting results with and
through people.”
Need for leaders
Some clinicians regard leadership
skills as necessary only for those
doctors in a formal management role,
such as the trust medical director or
the president of a royal college.
Although such individuals clearly need
strong leadership skills, most doctors
lead multidisciplinary healthcare
teams, often commanding
considerable clinical resources.
Moreover, the UK parliament’s recent
Health and Social Care Act put primary
care clinicians in control of £60bn
(€76bn; $94bn) of the NHS budget for
commissioning services, marking an
enormous transfer of responsibility
for leadership. Many have argued that
all doctors should regard the
acquisition of leadership and
management skills as essential, [6]
irrespective of specialty and setting. [7]
A growing body of evidence links so
called “soft skills” with hard clinical
outcomes, including mortality. [8]
Cultural barriers remain: leadership is
often construed as woolly, full of
buzzwords, and a distraction from
clinical endeavours. Consequently,
leadership training has been regarded
as something that can be delivered in
a short course to senior doctors
immediately before they become
consultants.
Training leaders
More recent thinking, however, argues
that learning leadership, like much of
medicine, entails the development of
often complex skills [7] and requires
practical experience. [9] There has
been a rapid expansion in the
number of programmes giving
medical trainees the chance to flex
their leadership muscles by taking
time out of clinical practice to
participate in management and
leadership fellowships. In the United
Kingdom, ventures have sprung up at
trust, regional (Darzi fellowship,
Prepare to Lead, NHS North West, and
NHS South Central schemes), and
national (NHS medical director’s
clinical fellows scheme) levels. [10]
Funded mainly by postgraduate
deaneries and hospital trusts, NHS
organisations seem increasingly keen
on nurturing medical leadership.
Although these immersive
programmes are clearly desirable for
those intending to become future
healthcare leaders, there is also an
increasing attempt to embed
leadership training for all doctors into
the NHS. The General Medical
Council’s Leadership and
Management for All Doctors states:
“[Doctors are] expected to offer
leadership and to work with others to
change systems when it is necessary
for the benefit of patients.” [11] Many
doctors complete their training with
strong technical and academic skills
but underdeveloped leadership
capabilities. [9]
Establishing a framework
Attempting to deal with this is the
nascent Faculty of Medical Leadership
and Management, which is supported
by all the UK royal colleges and
faculties and the Academy of Medical
Royal Colleges. It aims to promote
medical leadership and to establish
the necessary standards for achieving
it. The academy has been involved in
producing the Medical Leadership
Competency Framework,[7] which
defines the leadership and
management competencies that
doctors need to achieve at various
career stages. An aim of the
framework is to influence
undergraduate and postgraduate
curriculums, thereby embedding
leadership in the medical profession
at an early stage. All UK medical
schools now support the framework.
The United Kingdom is not alone in
such endeavours: Denmark, Australia,
the United States, and Canada have
developed their own frameworks. [12]
Although such models are to be
applauded, competency based
approaches have drawn criticism for
their relatively rigid focus and
potential to overlook complex
organisational factors that are often
barriers to healthcare quality
improvement. [12]
In testing economic times, clinicians
trained in leadership are unlikely to
receive increased remuneration.
Instead, having demonstrable
leadership skills will make candidates
stand out in job applications, where
trainees often have indistinguishable
clinical and academic CVs. Alongside
this individual advantage, advocates of
medical leadership believe that its
promotion will lead to the emergence
of a more cost effective and clinically
effective NHS. Current economic
forecasts suggest that the financial
challenge to the NHS will not abate
this decade, if ever, and that the
impact of clinical innovation and
inexorable demographic shifts will
change things further. Doctors are
uniquely positioned—indeed, in our
opinion, have a unique responsibility
—to bring their experience and ability
to bear in tackling these issues.
It is clear that being a good doctor
now requires more than just first rate
clinical skills. Leadership has been a
neglected area in the past but is set to
rise in prominence; hopefully this will
bring tangible benefits to patients,
doctors, and health systems.
Competing interests: AT is a member
of the NHS medical director’s clinical
fellows scheme.


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