How to design and deliver a clinically led organisation

In parts of the hospital sector greater involvement of doctors is being seen as talismanic for safe delivery of the £20bn quality, innovation, productivity and prevention challenge. It is the best way to ensure quality remains our focus in difficult times.

We see growing numbers of trusts grappling with the issue of clinical engagement, leadership and clinical managerial accountability.

A number of trusts have made gains and are successfully putting senior doctors into positions of accountable authority over business units responsible for hundreds of millions of taxpayer pounds a year. But while some are successful, there persists a widespread deficit of clinical involvement in hospital management.

‘A number of trusts have made gains and are successfully putting senior doctors into positions of accountable authority over business units responsible for hundreds of millions of taxpayer pounds a year’

Many trusts have found it difficult to either generate the support of medical staff for the necessary culture change or do not appreciate the need to restructure their businesses to see the benefits promised by this new model.

Other trusts are struggling with the basic concept. Their executive teams are questioning the governance, practical delivery and even the legitimacy of such a sea change with a workforce that often seems disengaged to say the least.

The Auld Enemy

Some chief executives are sceptical about talking to their doctors, seeing the task as too big when cost savings, FT applications, and competitive tenders present a greater urgency than dealing with “the Auld Enemy”.

A good example of the conundrum is a successful FT seeking to develop “best-in-class” clinical leadership in preparation for the challenges of the future. When asked to describe the problem the executive team was a little disappointed: “We can’t persuade the docs to take on the responsibility of true accountable leadership.” Asked the same question, the senior medical leads in the organisation replied, frustrated: “The trust won’t trust us with the authority we want nor provide us with the skills.”

‘Do you want doctors and nurses to be responsible and engaged with the issues of the trust or really accountable for the delivery of its objectives?’

In common with many things in life, the first and often most difficult thing to figure out is where you want to go. Do you want doctors and nurses to be available for advice, to chair various divisional teams, or to actually run the business?

Do you want them to be responsible and engaged with the issues of the trust or really accountable for the delivery of its objectives? How big is your ambition and how strongly is it shared? Where is the collaboration between clinicians going to be fostered?

The buy-in

The answer here needs more than your assessment of likely medical enagement. The more you wish to transform the accountability structure, the more the rest of the management team, trust executive and even the board will need to adjust to support a dramatically new system of governance.

The first pitfall is failing to understand the full significance of your intended change. The second is not realising the extent of accord within your trust that you require for success. From the start you will need to engage current and potential future leaders together to get buy-in for the direction and distance of travel.

The ambition of your goal needs to be agreed between your clinical leadership and executive team but also endorsed and owned at board level. The board needs to feel that its direction, strategy and vision is embodied in the new model of leadership. It may even need to change its own formulation to truly reflect the change. Proper time and effort spent at this point will reap huge rewards once the detail starts.

The go-get

Once you have consulted, agreed the vision, painted large your goal, and aligned the board, the devil will be in the detail.

There are some important concepts and principles that must guide your design process or all will go to waste. Two main pillars support the successful design of an operationally effective clinically led service - proper training and a structure that helps them do their job. If you live in a part of the country significantly populated by the military, you will be familiar with the five Ps: “Proper preparation prevents poor performance”.

Doctors spend about 15 years getting to a position of being able to practise their craft as an expert without supervision. Their postgraduate structure is now focused on avoiding a “see one, do one, teach one” learning culture. The same is true in preparing to run hugely complicated organisations. A consultant anaesthetist, recently interviewed not long after appointment to a position of significant leadership, described herself as “wholly unskilled for the job”. 

‘A consultant anaesthetist, recently interviewed not long after appointment to a position of significant leadership, described herself as “wholly unskilled for the job”’

Despite this, many doctors are now coming forward, in unprecedented numbers, keen to engage in management, and excited by a new vision of clinical leadership. They deserve and should rightly expect to be provided with the basic management and leadership skills that are still not widely taught as part of the medical curriculum.

Some trusts are embracing this but others, possibly short-sightedly, struggle to justify investing this time and expense in times of hardship.

Be prepared

There are many ways to prepare your clinicians for senior leadership roles but a priority is to address knowledge gaps in personal leadership development, and standard management techniques not usually covered in medical training. Subjects like budgets and performance management may cause anxiety in the uninitiated. Wider aspects of leadership development are often best approached with practical rather than theoretical examples.

Focusing your programme around a task such as developing, refreshing or implementing a clinical strategy gives training a valuable and useful edge. It is not about turning doctors into general managers, but giving them the skills to be more effective strategic and operational leaders.

Once you have invested your time in training the individuals, a major pitfall awaits, neglecting to change the working environment. The system must change to support the new leaders. 

Structure that works

Fortunately we now have more doctors across the wider NHS who have been exposed to leadership training. Some enlightened health authorities, for example erstwhile South Central, under the leadership of Peter Lees, trained many doctors and other professionals. We have IHI, Harkness and other scholars,“Darzi” and Leadership Academy Fellows and numerous other channels for clinical staff to get practical exposure. This has led to examples of great leadership at system, clinical network and Trust level. 

The Royal Colleges, traditionally slow to the table in such areas, are now supporting the Faculty of Medical Leadership and Management. Despite these innovations there is still too slow a flow of medical leaders taking up positions of senior accountability.

Maybe one of the reasons for slow translation of training into structural leadership is the structure itself. Doctors return from training to find their organisations unchanged and unsympathetic with no place for them to practise their new art. Roles and career progression for medical management still has little visibility outside the traditional “up to medical director” route. 

Examining arrangements at a local level, individual solutions might be easier to see. These structural blockages to career development and progression can be removed when trusts create a clinically led system.

‘There is still too slow a flow of medical leaders taking up positions of senior accountability’

Many trusts are moving to a flatter management structure, with a larger number of clinical business units reporting directly to executive level each headed by a clinical director. While this model has issues around heavy reporting lines leading to the chief operating officer and the need to have a large number of capable business leads, it cuts out management tiers, brings the executive closer to the clinical workforce and signals the desire to have a structure that supports rather than inhibits clinical leadership. Clinical staff and board members interacting can forge a very powerful mutual commitment to the maintenance of quality standards and improvement of patient experience.

The most difficult issue for clinicians is time. To be able to resolve this concern the trust needs to be able to support the decision makers in their new roles and allow sufficient resource in job plans. To do this correctly requires a clear and precise understanding of what you agree your medical leader will actually do. This avoids the serious pitfall of ambiguity.

Often forgotten but very important to deliver is the need to individually support each new business unit with the financial, HR, service line reporting and data analysis function needed to form legitimate strategic decisions. This requires a balancing disinvestment from the centre. Doing this as an explicit act of decentralisation is a powerful message.

The let-go

The trust board and executive needs to be able to delegate its authority and decision-making powers. This is crucial for true clinical accountability. Anyone who has stood near the QIPP/CIP trust solvency fault line in recent years knows how difficult that can be. The first time you decide to bring small budget expenditure back to the executive team as a cost control exercise, your cause will be weakened severely.

You may need to consider a process of earned autonomy to help the system to adjust, but the direction of travel needs to be clear. It takes courage to move on from traditional accountabilities but there are examples around the country of effective and solvent clinically led organisations whose transformational programmes deliver patient-focused benefits

Dr Chris Gordon is programme director for QIPP at the NHS Leadership Academy