Medical Leadership: at a tipping point?

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By Iain Snelling

Recently Mark Exworthy and I have completed an evaluation of the Royal College of Physician’s (RCP’s) Chief Registrar scheme. The programme gives Medical Registrars appointed as Chief registrars the opportunity of spending 40% of their time working as a Medical Leader, focusing on engaging the junior doctor workforce, quality improvement initiatives, and education and training. In 2016/7 21 Chief registrars were appointed as part of the pilot project. In 2017/8 this number has increased to 36. The RCP’s vision is that every hospital should have a Chief Registrar.

Our report is available here. Chief Registrars made significant contributions to service improvement, but perhaps more importantly they laid the foundations for future years’ schemes. The role provides a ‘bridge’ between senior clinicians, managers and junior doctors to ensure that junior doctors are fully ‘enaged’ – that they feel valued, motivated, and supported, and that their ideas and concerns are listened to. Gilbert et al (2012) found that 91.2% of junior doctors had had ideas for service improvement, but only 10.7% had had an idea implemented. 43.8% were unsure about how to get an idea implemented. The benefits of an engaged junior doctor workforce are significant.

The role also provides an excellent leadership development opportunity, with a bespoke programme provided for the pilot by the RCP and the Faculty of Medical Leadership and Management. One major aim has been to grow future senior medical leaders. This aspect of the posts was emphasised by the medical leaders in Trusts who we spoke to.

This is a significant development, and as far as we know the first by a Medical Royal College. In 2013 I was involved as part of a team with Chris Ham, Helen Dickinson, and Peter Spurgeon that asked ‘Are We There Yet?’ in terms of medical leadership. We traced back the development of medical leadership within organisations to the Griffiths report, perhaps a little controversially as that has become know as the impetus for General Management. The Griffiths report did say that hospital doctors ‘must accept the management responsibility which goes with clinical freedom’. Our view then was that progress had been made but it was ‘by no means complete’.

Since our report was published there seems to have been a shift in the organisational logic of engaging doctors in organisational leadership. From Griffiths’ idea of management responsibility (mainly financial of course in the pre-Clinicial Governance era: the quote above was preceded by ‘Their decisions largely dictate the use of all resources…”). After the Francis reports, the emphasis was on leadership for quality (and by implication, safety). Perhaps the pendulum is now swinging back towards a more traditional managerial agenda. A recent Nuffield Trust report found little change in attitudes between 2002 and 2015. They found that the Francis reports (2010 and 2013), the Berwick review into patient safety (2013) and the Keogh mortality review (2013) were the factors that had the biggest positive impact on medical leadership. Negative impacts were “financial pressures, changes in the role of external monitoring bodies and the Health and Social Care Act (2012).”

There is also now more academic interest in medical leadership, and recently a number of reviews and significant studies have been published.

Sarto and Veronesi (2016) and Clay-Williams et al (2017) have both reviewed the evidence about hospital performance and clinical leadership. From slightly different perspectives they both found evidence that increasing the number of doctors in leadership positions is associated with improved hospital performance, although the evidence was described as ‘modest’ and is not unequivocal. Most of the evidence comes from the USA which is a significantly different context, with only one series of studies in the UK.

Two other recent reviews give useful summaries of medical leadership issues. Berghout et al (2017) highlight differences between formal (with a specific appointment) and informal (as part of a professional role) leadership by doctors. This is a useful distinction: it sometimes seems as though ‘medical leadership’ was captured by organisations in the post-Griffiths world for purposes of control, and that despite the Francis reports it hasn’t been given up. The importance of ‘boundary work’ is also identified in this review.

Savage et al (2017) in a review for the Swedish Medical Association identified the possibility of virtuous cycles of physician leadership, with willing leaders developing wide medical engagement. There is though, also a vicious cycle, with incidental leaders being forced or persuaded to take on roles, and finding it difficult to manage the conflicts between management, colleagues and medicine. Developing leadership interest, particularly in service improvement, in the junior doctor body will be part of the virtuous cycle, and will be support service improvement processes.

Which takes us back to the RCP’s Chief Registrar scheme, as both an individual development role, but also a role model for other junior doctors. It is early days yet for the programme, but it is a significant step in the right direction, and one which will develop over the years. The Faculty of Medical Leadership and Management was established in 2011 and is going from strength to strength, with the recent establishment of a new BMJ title: BMJ Leader. Perhaps we are at a ‘tipping point’