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Trusts fail to engage consultants in leadership

Senior doctors are reluctant to take control of budgets and services at a time when the NHS desperately needs effective leadership, says a new report.

Only a small minority of doctors are involved in leadership roles in NHS trusts reveals the study by the Health Services Management Centre at the University of Birmingham and The King’s Fund.

A survey of 72 NHS trusts found that most had only one medic on their board and the maximum number on any trust’s board was four. Only 17% of trusts had medics on their finance committee.

Most trusts reported that only between 10 and 20% of medical consultants were involved in formal leadership roles. In many sites competition for leadership roles was often limited and in some cases non-existent.

Medical directors usually committed at least half of their time to leadership roles and clinical directors committed around 20% of their time. In some cases both medical directors and clinical directors reported giving more time to their leadership roles than allowed for in their contracts.

Barriers preventing doctors taking up leadership roles included the preference of most doctors for clinical work, lack of financial incentives, training and support and the absence of career structures. There was also an ‘engagement gap’ between medical leaders and their colleagues and a perception that doctors who go into leadership roles have gone over to the ‘dark side’.

Other challenges included lack of support from general managers and variations in the willingness of medical leaders to deal with difficult issues. For medical leaders the main challenges were balancing clinical and leadership commitments and engaging followers.

However the survey found examples of medical leaders making a real difference to their organisations. Respondents were mostly positive about the effectiveness of medical leadership arrangements in their trusts.

The report warns that the active and enthusiastic engagement of doctors in medical management is currently needed more than ever to address both the Nicholson challenge to reduce waste and inefficiency and the issues facing the NHS in responding to the Francis report.

Professor Chris Ham, chief executive of the King’s fund and one of the report’s authors, says: “There are clear echoes of Robert Francis’ warnings of doctors and other clinicians being disengaged from management and of the risks this poses to the quality and safety of patient care. Failure to involve more doctors in leadership also represents a major missed opportunity in the light of evidence linking medical engagement with positive organisational performance. For all of these reasons, our report provides a wake-up call at a time when the NHS is facing unprecedented financial and service pressures.

He calls for every NHS trust to attach high priority to medical leadership and engagement and to commit time and resources to making it happen. This includes investing in the development of medical leaders and pairing them with experienced managers to create partnerships that are found in high-performing healthcare organisations like Mayo Clinic and Kaiser Permanente.

“Becoming a medical leader must become seen as a prize to be won rather than a burden to be borne in organisations where there is an expectation that those in leadership roles are among the brightest and the best.”

Since the study was completed, the Faculty of Medical Leadership and Management has been established by the medical royal colleges and the King’s Fund says it is currently reviewing our leadership programmes in the light of current reforms to the NHS.

Consultants responding to the study’s survey of 72 NHS said the main barriers to engaging in leadership roles were:

– “It feels as though there is an expectation that involvement in new leadership activities is taken on within existing job plans which is often difficult to achieve. I have been asked to take on leadership activities which I am keen to do but this is not possible within my current 10PA job plan consisting of 9.5 DCC.”

“Management is seen as more stressful and constraining than clinical work. Having to manage colleagues is always stressful – rewards are not sufficient and then difficult reintegrating once time is up.”

“The pressure to increase Consultant Lead clinical service at the detriment of service development. In short there is not enough time in the working day to see & clinically manage all the patients as well as be involved in leadership roles”

“Lack of communication between managerial and medical staff, lack of engagement with junior medical staff.”

“Lack of real managerial engagement – the medical staff are either ignored or side-lined if we have an opinion which does not fit the party line.”

When asked what would encourage more effective engagement in leadership roles they said:

“Some feeling of ownership – I think doctors feel increasingly powerless to influence change. All consultants need some leadership and team playing training – of course those most in need often don’t realise it.”

“I’m not sure I have the answer, but sending out emails with long attachments which never get read or using acronyms without explaining what they stand for certainly does not help.”

“The belief that their opinions are listened to, taken seriously and acted upon.”

“The ability to action a decision quickly and decisively, without being de-railed by intransigence at middle levels (both medical and non-medical management). The encouragement of good staff and supporting them with a reasonable work load, not punishing them by getting them to cover for the less able staff.”

“If the trust management ever listened to what the consultant body as a group felt strongly about then they would gain our respect. We occasionally are informed about planned changes. Clearly the decision has already been made and no amount of collective reasoning by the consultant body ever changes any of these management decisions. It is therefore much simpler to ignore the management and get on providing the best clinical service we can without management interference.”

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4 Responses to “Trusts fail to engage consultants in leadership”

  1. HeartDr says:

    Trusts failing to engage doctors (PERIOD)! Let alone leadership roles. This is excluding medical and clinical directors who have sold out.

  2. Dr Grumpy says:

    I have spent my time as clinical service lead, got the obligatory MBA, got loads of ideas. My local chief exec/med director office walls are full of fancy Gantt charts none of which will make things any better or will lead to any real service improvement in my speciality. I think of the Groucho Marx comment about not wanting to be a member of a club that would have me as a member. I agree with HeartDr – totally disengaged.

  3. Neelam Dugar says:

    Leaders need followers.
    Democracy is about true leadership as followers have elected their leaders.
    Arab spring is a reflection of why democracy is considered better than appointed kings etc
    Appointed positions are commonly “yes ministers”
    Hence the disengagement with the followers.
    Doctors are extremely intelligent & hardworking. One would not become a doctor otherwise. Leading doctors can be challenging as they are more likely to debate. But due to their intellect it is always possible to convince them with good debate.
    Leaders who complain about their followers themselves show their inabilities to convince a very intelligent group.

  4. james jollingworth says:

    I am a medical consultant who has been involved in leadership roles for 13 years in a small/medium sized NHS foundation Trust which is now under intense pressure as a consequence of the politically driven NHS reforms. In the future we will recognise that the implementation of NHS reforms was chaotic and resulted in major social and healthcare problems for our citizens (the crisis in ED is a current example). If the intelligent followers are engaging in alternative pursuits to management and leadership roles in the NHS (eg. by supporting private healthcare initiatives, promoted by the current government) then perhaps it is because the NHS strategy they are being asked to support is opaque and does not make sense. As medical leaders we must be honest about what our priorities for the health of our population are and I would expect that honesty to be reciprocated by our political leaders. The problem here is a lack of a sensible transparent strategy and the courage required to support the NHS. This is why senior doctors are reluctant to engage. The Francis report let politicians off the hook and ultimately many of the frontline NHS employees have been hung out to dry.

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