The General Medical Council recently published a report by Dr Suzanne Shale, entitled ‘How doctors in senior leadership roles establish and maintain a positive patient-centred culture.’ This is important research – medical leadership has been described as an evidence-free zone by Peter Lees and Kirsten Armit of the Faculty of Medical Leadershipand Management.
The General Medical Council research addresses four broad, related, questions about:
- how senior medical leaders conceptualise a positive culture
- how they identify the presence or absence of a positive culture
- how they have tried to build a positive culture
- how far their approaches align with behaviours being promoted by ‘commentators and system leaders’
The full report and the executive summary include a useful table showing the ‘soft signals’ of positive and negative cultures, and a description of several ‘notable subcultures’, including ‘diva subcultures’ where ‘powerful and successful professionals are not called to account for inappropriate behaviour,’ such as ill-tempered outbursts, disrespecting colleagues, or ignoring protocols. Diva sub-cultures were understood to be remarkably resistant to change, although other types of negative cultures have been changed. This element of the research caught the eye of the Guardian ‘Diva doctors are the symptoms of a rotten culture, and put patients at risk’ and the Health Services Journal Medical leaders must tackle untouchable doctors. The BMJ had a slightly different take: ‘Clinical Directors need more support, quoting Dame Clare Marx, the General Medical Council Chair: “We cannot just assume that doctors in senior leadership roles will automatically be good leaders,” she said. “Leading in healthcare isn’t easy. Leaders are developed, not born, and doctors who choose to take on these roles deserve to have all the necessary support and resources to help them succeed.”
Highlighting one particular issue misses the breadth of the report. Discussions about how medical leaders conceptualise a positive culture, and how different clinical and organisational contexts influence leadership, present a nuanced picture. With this caveat, four issues stand out as priorities for further attention.
First, a key issue in thinking about medical leadership, is whether it is assumed that medical leaders are leading other doctors, or all groups of staff, which isn’t always clear in research. The analysis and the illustrative quotes in this report suggest that senior medical leaders are primarily concerned with the medical workforce. That would be reasonable from the view of the General Medical Council which commissioned the research, presumably in order to understand how doctors can be supported in senior leadership roles. Leadership is a regulated duty of all doctors and failures of leadership can lead to regulatory action. How medical cultures and leaders interact with other cultures and leaders in health care organisations are important questions. Multidisciplinary team meetings were identified as useful resources in developing a positive culture, but the interface between doctors and other professionals and the wider organisation is not fully developed.
Second, one prominent leadership action identified to develop a culture of high standards is good performance management of doctors. “For many, addressing causes for concern was a pivotal responsibility and the most direct way in which they impacted on culture day to day.” It was identified that it is important that senior medical leaders are seen to be tackling poor behaviour, and that action was understood to be fair and reasonable. Although the importance of relationships was emphasised more generally, within the profession at least (‘with the people they lead’), and role modelling was understood as particularly valuable, it is difficult to avoid the impression that the main way that doctors in senior medical roles establish and maintain a positive patient-centred culture is to take action to prevent poor performance, particularly that of individual doctors. With the emphasis on tackling poor behaviour, there is less attention given to improving quality where there are no major concerns or risks. Appreciative inquiry offers a process of learning from the best of what individuals and organisations can do. Learning from Excellence is an initiative, or a social movement, to improve cultures with appreciation, which offers an alternative view to the traditional ‘’deficit’ model of improvement and it is interesting that this process didn’t feature in the interviews.
Third, there is very little emphasis on the context of poor performance, with only around a quarter of the sample, for example exploring human factors. The role of context was highlighted in the Bawa-Garba case, and is an important area for research and practice, and the roles of senior doctors in influencing context might have been developed.
Finally, the report addresses senior medical leaders. The interviewees were mainly Medical Directors and Associate Medical Directors, which of course reflected the commissioning brief. The ‘pivotal’ role of Clinical Directors, and the issue of where the key leadership influence is within the medical profession, were acknowledged, which explains the title of the BMJ report of the research. Clinical Directors within specialties or departments are often the first level of medical leadership. In the professional context, the idea of ‘line management’ is complex. The emphasis in the report on day to day leadership suggests that ‘near’ leadership undertaken by Clinical Directors and other medical leaders in part time posts, or indeed informal leaders, is very important in establishing a positive culture, and this level of leadership may be an area to focus on in future research.
It seems likely that the fact that this research was commissioned by the General Medical Council affected the results towards perceptions of regulatory issues such as poor performance, as the participants would have known that (although the report also drew on other interviews that were reported in a book, Moral Leadership in Medicine, which I am very happy to recommend).
I hope that this report will encourage further research, particularly in these 4 areas. It makes a significant contribution to addressing the evidence-free zone of medical leadership.