Good clinical leadership can fix urgent care

Urgent and emergency care is neither satisfactory nor sustainable. Chronically overcrowded emergency departments staffed by too many locum doctors and agency nurses; persistently over-capacity acute hospital provider sites that struggle to contain admissions and discharge at a pace which at least matches incoming activity; out of hours general practice provision which varies hour-to-hour in some regions let alone day-to-day.

The system that has developed around often conflicting priorities now fails to deliver many vital aspects of a fit-for-purpose unscheduled healthcare system.

Contextualised by this and other weaknesses in the healthcare system is the growing awareness and promotion of clinical leadership. How can we translate what leadership is - and isn’t - into something useful for setting urgent and emergency care on the right path? What does effective medical leadership look like in unscheduled care? How do we know when it is working, and what do we do if it is not?

‘We have all been working hard. But we’ve been working hard at the wrong things’

Admit there is a problem

To begin the healing process in urgent care, leadership needs to begin with an admission. It’s not right. It’s not working. We’ve made some mistakes. We’re all pretty much to blame. This is different from introspective navel-gazing and it is different from a position where this or that professional group blames another.

“It’s all the fault of those lazy GPs who just say call 999!” moan the overworked emergency department doctors as they admit yet another frail elderly patient who has arrived by ambulance – unaccompanied – from a nursing home having apparently been “not quite right” since this morning.

“We’re at capacity in the surgery!” moan the hard-working GPs who have laid on extra evening surgeries to cope with commuter demand, let alone those they now see at 7am on three mornings a week. “We don’t know who to ring or what to do,” complain the hapless patients lost in the middle of it all.

Everyone has a point of view, and everyone has an opinion. The first real step in leadership in unscheduled care is accepting that, like it or not, all these opinions have a basis in fact. We have all been working hard. But we’ve been working hard at the wrong things. And now we all need to hold hands and lead each other out of the mud and on to firmer ground.

Awareness of shared resources

You may be familiar with the concept of the tragedy of the commons. It was conceived by the ecologist Garrett Hardin in the 1960s as a methodology to explain the dynamics of a finite shared resource.

There is a striking parallel between our current experiences in urgent and emergency care and the classical scenario of crowded cattle-grazing which the tragedy often uses as its exemplification. Put simply, imagine the provision of urgent care as a meadow.

Back in the day, all of us, as patients, quite fancied spending time in the meadow as the grass was sweet and plentiful. But over time more and more people have joined the herd. The grass is getting stubbly. Some patches are even bare. The farmers – that’s all our doctors, nurses, care workers, community matrons, physiotherapists, and others – try to nurture the grass as best they can, but this meadow was never designed to hold so many animals. The farmers start to leave: they’ve had enough. The common resource has now been worn down.

It is a great model with which to visualise urgent care. All who seek to lead within that domain should take time to revise Hardin’s work around it. Effective medical leadership is about more than theory: it demands a wider awareness of the sociological pressures on the healthcare landscape. The problems and solutions around effective urgent care are not peculiar to medicine. There is a wider world with lessons to teach us, and we must be aware of that world and be receptive to those lessons.

Leadership is a conversation

Somewhere along the way in the growth of our current model (if you could call it one) of urgent care, we stopped talking to each other. We still have meetings, develop strategy, enumerate risk and account for target attainment – indeed, some might say we have done little else recently. But we have lost an altogether more basic element of clinical life: the peer-to-peer chat, the informal discussion, the airing of views and suggestions in a way which more closely reflects real life. This is an issue well described in a paper by Groysberg and Slind in the June 2012 edition of Harvard Business Review which again illustrates the benefits of a wider awareness of context.

They make a compelling case for the renegotiation of what leadership is in terms of basic professional intimacy. Let’s call this “leadership with a little l”. You don’t have to go far into a hospital emergency department or a GP’s surgery to pick up on a general sadness about the demise of the lunchtime sessions in the postgraduate centre where doctors from both the community and the hospital met up to chat, to learn and, yes, enjoy a hot lunch as well.

The recent history of urgent care has seen such activity squeezed out, and in many cases eliminated, from a local health economy in the rush to re-deploy clinical time towards ever-expanding patient demands. This was a short-sighted turn of events that has come back to haunt us.

‘Effective medical leadership demands a wider awareness of the sociological pressures on the healthcare landscape’

Now, we need to demonstrate good leadership by recognising that the best ideas, the most sensible plans, the most useful ways forward, will be seeded and nurtured in just those hot-lunch conversations we are now having to re-energise after their untimely demise.

There can be a tendency for any clinical conversation not officially mediated or at which minutes are not taken to be viewed with apprehension: what if someone says the wrong thing or gives something away? Take courage – effective grass-roots leadership isn’t about saying something wrong or right, it is about saying what you believe the best ideas to be and describing what you think the problems are. We must help each other translate those conversations into something we can build on. Organising meetings, writing out timelines and developing action plans is only as useful as the sheer clinical content of what underpins those meetings and plans. Otherwise, you’ll be meeting forever and developing nothing more than a sense of frustration.

Bold commissioning and new identities

So we acknowledge the mistakes and parts we have all played. We take a look at the wider world and try to understand how there’s nothing new under the sun. We look to evidence from elsewhere and try to deconstruct high-level leadership into something meaningful and workaday. How do we take all that forwards and actually make a difference?

We do it by capitalising on the challenge and excitement before us as we seek to commission the future of urgent and emergency care. By paying heed to the simple principles of acknowledgement, sociological context and the need for conversations, we can agree the following:

• The tragedy of the commons has proved its point in urgent care. The status-quo is not a future option. There is a pressing and fundamental need to close the gates on the meadow of unscheduled care, find new ways in which to sustain the population who want to use it, and put into place alternatives which are more manageable and satisfactory. And that demands effective leadership which starts with agreeing we all have an equal part to play. We all got us here.
• Our professional identities across the landscape of urgent care are outdated and have not kept pace with the wider needs of society. Continuing to compartmentalise how care is delivered by articulating it in terms of simplistic primary, secondary, community or other care provider are obscuring the reality of healthcare need.

We need to talk more, not through meetings or seminars, essential though some of these are to give structure to complexity, but simply to pick up the phone, to chat around an issue. Leadership is, at its most fundamental, about having the courage to spark those informal conversations, to speak one’s mind among colleagues, and talk through a point or an opinion.

The bold and successful commissioners will embrace the simple principles of “leadership with a little l” and weather the storm. Yes, we are all still wading in the mud. Some of us can wade more strongly while some need more help, but we don’t lose grasp on the stragglers – we all need to get clear. And we’ll be glad that we saw it through together.

Darren Kilroy is director of network leadership and development for unscheduled care at Stockport Foundation Trust