Should hospitals have doctors as Chief Executives?

There has been quite a debate recently about Medical Chief Executives, started by David Oliver’s column in the BMJ,(Why aren’t more doctors NHS Chief Executives)  and a second column (Radical pragmatism and medical leadership), and a feature article by Jacqui Thornton (“Doctors need to step up” – why are there still so few medical chief executives in the NHS?), drawing from interviews with 5 medical chief executives. All of these pieces are admirably balanced, but there are some points which deserve scrutiny.

 The first is the evidence that ‘clinically led teams and organisations are better able to meet challenges around quality, improvement, and safety.’(David Oliver’s words). In this regard, Amanda Goodall’s work on expert leadership is often cited. She showed that in America, hospitals led by doctors tended to perform better than others. This study was included in a 2017 review by Robyn Clay-Williams et al: Do hospitals and healthcare organisations perform better when led by doctors? which concluded that there was (only) a modest body of evidence. The review also included studies that looked at the number of doctors on Boards, rather than only the Chief Executive, which might be considered a separate issue.

Amanda Goodall’s work in highlighting the results of expert leadership is very useful, and she has also considered the mechanisms through which those results might be obtained. With Agnes Baker she has outlined a theory about how expert leaders influence performance. They identify two mechanisms. First through better decisions and actions, including developing knowledge based strategy and evaluating key workers. Second, through expertise as a signal for senior leader credibly and strategic priority. This is a general text about expert leaders, rather than specifically about doctors as experts in hospitals, but they do include hospitals. They say that “professional managers do not have expert knowledge in the core-business of hospitals which is the practice of medicine; only clinically-trained medics have this.”

There are though two major reasons why this theory of expert leadership is a problem for hospitals. The first is the exclusive claim for expert knowledge on behalf of doctors. As noted above, teams and teamwork are acknowledged as important in the delivery of high quality services.  The term ‘Clinical leadership’ includes all clinical professions, as does the NHSI framework for action on clinical leadership. which encourages Trusts to ask some challenging questions about clinical leadership. Professional knowledge of organisations and systems is also a key area of expertise, and this may be held more clearly by professional managers, a point that David Oliver makes.

Second, the model proposed takes a heroic perspective on leadership, with attention exclusively on the Chief Executive. This model of leadership is not promoted by the NHS. The idea of  no more heroes was developed by the King’s Fund and others after the Mid-Staffordshire scandal, and the NHS Leadership Academy’s Healthcare Leadership Model explicitly promotes a distributed form of leadership.

Goodall and Baker have subsequently suggested that it is not enough that the leaders are doctors, but that they are the most distinguished ones. The mechanism for this is in direct supervision of medical staff, and it may therefore be applied to the middle of the organisation, within Directorates and clinical teams where this research was undertaken, in university hospitals in Zurich. The application of this at the top of the organisation is not clear, as the near leadership process relevant for line managers is not applicable to all doctors in the organisation.  This is an important issue for future research and practice.

The relationship between the specific skills required of Chief Executives and those required by doctors in practice is not explored sufficiently in the theory of expert leadership, which is based on who the leader is and what they do, but not how they do it.  Jacqui Bene (Chief Executive of Bolton Hospitals, and a Consultant in Geriatric and Acute Medicine) says (in Jacqui Thornton’s article) that being a chief executive “is a colossal job, but it’s very doable. You’ve got all the skills you need as a doctor, as a Consultant. You’ve got a lot of leadership skills that already that are just intrinsic, and it’s easy to translate them into a wider leadership role.” Sally Fuller, senior responsible officer at Surrey Heartlands integrated care system says that she is “just a jobbing GP. There’s nothing exceptional in the skills I have got along the way”. These views are very post-heroic, and modest, but they also seem a little dismissive of the leadership skills that are required to succeed as a Chief Executive. Clearly doctors need leadership skills (it is a regulatory requirement), but to suggest that the skills needed to be a Consultant or a GP equip all who have them to be a Chief Executive seems doubtful. The experience gained through a medical background can enhance leadership skills in a unique way, but they are not a guarantee of success. 

The debate on whether more hospitals should have doctors as chief executives is interesting, but it may be a distraction from more pressing issues about leadership in hospitals. We should be addressing the well known barriers that prevent doctors and other clinicians achieve senior leadership roles, and NHSI has made a start on that. We should also be ensuring that Boards in NHS organisations have an appropriative balance of skills and diversity in membership. The “Snowy White peaks” show little evidence of change. We should also be working to improve the partnership between clinicians and mangers whatever their background, especially in the middle of organisations.

Further research considering the mechanisms through which clinical leadership seems to provide an advantage would be welcome, not only to encourage clinicians to take up leadership roles, but also to consider how their leadership can be developed.  

Charlotte Grainger - Qualified doctor from the University of Birmingham, graduate of the Health Management and Leadership intercalated programme. Charlotte's dissertation research investigated the dynamics between medical chief executives and their medical directors. @c_grainger1

Iain Snelling -  Lead for Clinical Leadership, Centre for Health and Social Care Leadership, University of Birmingham. @iainHSMC