We need a stronger prescription for medical leadership

There is a good rule of health policy: will it allow the proponent to claim the change gives “more power to doctors”? Policy makers have good reason to believe the public are reassured when they think doctors are in charge. There is also the useful fact that it tends to improve the quality of outcomes too.

So given we have had more than two decades of reform in the health service – why are we still asking, despite some advances, “What will produce a fundamental shift in the numbers of hospital doctors prepared to take on leadership roles?”

‘Medical leadership at organisational level or system leadership within the NHS is deviant behaviour’

This is the question the King’s Fund explored for the National Institute for Health Research. You can read about the headline findings here, while chief executive Chris Ham sets out its main conclusions in our comment section.

One of the key points the research makes is that doctors are more in charge than they think − especially when deciding what resources get used in what way. This “frontline autonomy” has “continued to be a major factor in how the NHS was run… even if it did not always appear to be so to the teams concerned.”

Another telling comment comes directly from one of the medical leaders surveyed: “Management is seen as more stressful and constraining than clinical work [and the] rewards are not sufficient.”

In other words, “What can I gain from leadership responsibility other than trouble?”

What good leadership looks like

This conclusion gets to the heart of the medical leadership conundrum. Doctors can have very fulfilling, well-paid and high-status careers without ever having to dirty their hands with the messy world of NHS leadership. You can imagine the response of many medics to the recent Daily Telegraph story on the “8,000 NHS staff on six-figure salaries” − the majority of them doctors. Leadership roles are only likely to attract more of that sort of attention.

Most doctors who become medical leaders do so because their inherent curiosity and belief they can do better overcomes personal reservations and peer pressure about “going over to the dark side”. In short, medical leadership at organisational level or system leadership within the NHS is deviant behaviour.

The King’s Fund proposes some practical solutions to normalising medical leadership,  but there is one theme which perhaps offers the best chance to produce a step-change. Policy makers have been cautious in determining what good medical leadership should look like in hospitals.

‘Encouraging medical leadership is more of an art than a science’

They have tended to be more bullish around nursing leadership, knowing that “bringing back matron” always plays well. As a result there are myriad different systems of medical leadership producing a variety of outcomes.

The new system leaders should be more prescriptive − on the basis of what gets measured, gets attention and in the knowledge that a more permissive approach has not led to substantive change. 

Encouraging medical leadership is more of an art than a science: for example, doctors are more likely to be engaged by structures aligned to clinical logic than organisational convenience. And while the King’s Fund was not able to identify the perfect approach to encouraging hospital doctors to take on leadership roles, trusts such as University College London Hospitals and Newcastle Hospitals have a highly effective system and others − such as Imperial − have seen an increased emphasis on medical leadership produce a much more mixed result.

The regulators could employ these examples and others, along with the medical engagement score highlighted in the King’s Fund’s research, to ask providers to comply with best practice or demonstrate that an alternative approach will deliver similar results. This should not unreasonably constrain provider autonomy, but would produce a much greater focus on consistency in, and awareness of, medical leadership throughout the NHS.