Junior doctors today have worked in the NHS
through some of its most tumultuous times. Those who commenced their working life in 2016 will have had the start of their careers coincide with the junior doctor strikes
, and will now have seen many of their colleagues leave the NHS to work abroad, on a temporary, or indeed, on a permanent basis; however, junior doctors are key to the future running of NHS services. One way to inspire these doctors, and thus to safeguard the future of the NHS, is via leadership development
. An article published in Clinical Radiology
, reviews several first-hand experiences of leadership development programmes available across a range of sectors, highlighting the breadth of opportunity currently available, and finally, to cover what today's consultants can to do to support the future generation of NHS doctors.
This is not only essential for the future of the NHS, but may also be key to patient safety. Veronesi et al. examined strategic governance in NHS hospital trusts, finding higher representation of clinicians on governing boards appeared to be associated with better hospital performance, higher patient satisfaction, and lower morbidity rates. They also found that the percentage of clinicians on governing boards was low in the UK compared to international rates.
A number of programmes have emerged to fill the need for leadership development in junior doctors. The evidence basis for these programmes tends to be qualitative. Stoll et al. found that those who had completed the “Darzi” Fellowship in clinical leadership reported a “mind-shift in their self-understanding, confidence, and knowledge of leadership”.
The Health Foundation's leadership fellowship, which ran from 2004–2010, found participants self-reported benefits, with a review noting the importance of supportive environments for transferring and applying skills both while on and after, the programme. A later review of The Health Foundation's portfolio of leader development courses suggested that leadership development is helpful in enabling organisational improvement in healthcare. In order to see these skills translate into improvements in the day-to-day running of the NHS, consultants and other senior staff members must be supportive of the further development of skills learnt on these programmes in the clinical workplace. As many staff across the NHS identify senior doctors as “leaders”, whether they are in a formal leadership position or not, developing personal skills in leadership is vital for all doctors.
What leadership skills are important for junior doctors?
The increasing move among doctors of all career stages towards a “portfolio” career is suggestive that something is now missing from the traditional medical pathway. More and more doctors are taking time out of medicine to expand their skill set, but what skills are they learning? Many of the leadership schemes and programmes seek to expand skills in the areas of project management; strategy and policy development; financial awareness; understanding of healthcare organisations; services and systems; research and analysis; writing and publishing; stakeholder engagement; and business and operations.
Skills in many of these areas are considered essential for consultants, but they are often not covered at medical schools or in any routine postgraduate training. Clinical work is, for many, far too busy to develop these skills within any “normal” working day. This means that one must either develop these skills in their own time, or not develop them at all. The concept of “burnout” has been increasingly recognised amongst the medical profession, with many suggesting a major contributing factor is the amount of extra work required to progress, on top of day-to-day clinical commitments; however, the development of these skills is considered essential at any consultant interview, meaning training doctors need to acquire them.
In addition to the more transactional skills above, leadership programmes also develop the personal qualities of individuals, recognising individual behaviours are influential in establishing the culture within any organisation. The NHS Leadership Academy proposes a “Healthcare Leadership Model”: a framework encompassing nine leadership dimensions, for how an individual might consider and develop these skills. It also includes a self-assessment tool, assessing personal leadership behaviours and giving insight into other people's perceptions of one's leadership abilities and behaviour.
Due to the need for development in these areas, there is increasing support for leadership schemes, which aim to not only build the future leaders of the NHS, but to train every doctor in the skills they are presumed to have, but that they are rarely taught.
Learning from other sectors
The Faculty of Medical Leadership and Management (FMLM
) has described a “a clear, compelling, and urgent need for leadership cooperation across boundaries within and across organisations”.
Healthcare is increasingly delivered by an interdependent network of organisations. This requires that leaders work together across organisational boundaries, prioritising overall patient care.
Leadership development programmes within a variety of sectors offer the opportunity for individuals to develop an increased understanding of the wider healthcare environment, and to develop individuals who understand system-level leadership. Taking these skills back to the hospitals and primary care should foster an environment where cross-sector plans flow more smoothly. For the purpose of this article, we will group these sectors into charities, governmental bodies, and commercial industry.
Charity: Royal College of Radiologists and Macmillan Cancer Support — Dr A.R. Sharkey
Spending a year split between two registered charities has been a great opportunity to compare and contrast various ways of working, and to determine the most effective way to change health practices.
Macmillan Cancer Support is an organisation that creates a recognisable voice in cancer care through developing relationships, networks, and effective conversation, rather than formal political authority. Macmillan's leadership model is based around creating these “communities of influence” to enable and encourage change from the ground-up. Macmillan is one of the Richmond Group of charities, which has explored leadership opportunities for medical professionals across the third sector, with the hope that bringing together aspiring medical leaders with those in formal leadership roles would identify areas for increased collaboration. This leadership model, which encourages sharing solutions and good practice, has been able to shape and improve local care, and influence national policy.
The Royal College of Radiologists (RCR
) is a registered charity that leads, educates, and supports doctors who are training and working in the specialties of clinical oncology and clinical radiology. It works as a network with the other Royal Colleges and the Academy of Medical Royal Colleges not only to effect change, but also to manage the interests of its members, and the patient body. It runs a number of leadership events and programmes, including the Leadership and Quality Improvement Programme for senior trainees and consultants
and a leadership webinar series
The presence of a joint fellow between RCR and Macmillan gives benefits to both organisations to support the work of the leadership programme across radiology and clinical oncology. A major project this year has linked the two disciplines: looking at unexpected findings of metastatic disease at the point of imaging, and the pathway of these patients through the system. The skills I have learnt from working on projects such as this have allowed me to gain an understanding of the system as a whole, to develop skills in research analysis, and to understand how to change policy and patient pathways. I will return to clinical work with an increased understanding of how to work collaboratively to drive beneficial change in the NHS.
Governmental bodies: NHS improvement — Dr L. Magee
NHS Improvement (NHSI) was formed in 2016, bringing together several National Organisations including Monitor, NHS Trust Development Authority, Patient Safety, Advancing Change Team and Intensive Support Teams. It operates as a national regulator, working closely with acute hospital trusts to ensure care given to patients is safe, effective, and meets national standards. I have been working within the medical directorate, which comprises of multiple teams covering a range of areas including patient safety policy, national reporting systems, professional leadership, and quality insight and intelligence.
Working within my role as Clinical Fellow on the National Medical Director's Scheme, I have had the opportunity to work on a range of different work streams. This has included development of a national leadership programme and working with the team that supports challenged providers.
I have had the opportunity to attend regular stakeholder meetings with arms-length bodies, partake in consensus workshops on medical training and patient safety, and attend development days in strategy, project management and leadership development. My Clinical Fellow colleagues, also working at NHSI with me this year, have been working on topics that include workforce strategy, hospital mergers, and developing the national cancer strategy.
We have been fortunate to work with senior clinical leaders within the organisation, developing an understanding of the importance of clinical insight in healthcare decision-making at a national scale. Attending NHSI led Trust visits to special-measure hospitals has provided the opportunity to understand the challenges that these organisations face. Appreciating the importance of tackling improvement through the pillars of leadership, engagement, culture, governance, and quality improvement6 has been helpful insight into system-level improvement.
As NHS England and NHSI develop stronger links and more aligned working, I look forward to the opportunity to work within teams that will be shaping delivery of the long-term plan. Overall, this experience has provided a valuable opportunity to understand the process of national health policymaking and contribute to delivering improvement at scale.
Commercial industry: the McKinsey Elective Programme — Dr A Trent
The McKinsey Elective Programme was developed with “the aim of encouraging young doctors to become effective clinical leaders”.7 The competitive programme targets medical students with an interest in healthcare management, providing valuable exposure to leadership in a commercial environment.
Elective students are engaged in projects often involving NHS-specific work, from large-scale transformation to specific service improvement. This not only provides experience in high-level strategy, but also a working knowledge of NHS management and leadership structures.
McKinsey & Company, one of the most successful global management consultancy firms, invests heavily in understanding effective leadership and management. Research completed by the firm across a diverse set of organisations and industries identified four key behaviours accounting for 89% of leadership effectiveness: supporting others, operating with strong results orientation, seeking different perspectives, and solving problems effectively.8 Working as part of a healthcare consulting team, students engage directly with the formalised processes introduced to support key leadership behaviours. Whether that be weekly one-to-one discussions with senior colleagues to analyse progress and identify targets for improvement, or team “barometers” designed to assess morale and effectiveness.
In my experience, the culture of “strong results orientation” was most notable and most interesting to consider when returning to an NHS environment. Results were considered broadly, in terms of personal development and team dynamics, but also in terms of deliverables on a particular project. Importantly, this approach was employed each time a team or project changed, and was actively led by senior colleagues. The practice ensured that all team members, at all times, understood what they were aiming to achieve and how their success would be assessed.
This approach to formal leadership is highly transferrable, and generates engagement and learning in addition to hard “results”. Although such processes may appear unfeasibly time-consuming in hard-pressed medical environments, I hope to bring some of my experiences to bear when working in and leading teams.
What opportunities are available?
The case studies above give an insight into the experience of doctors working in non-clinical environments within a range of sectors. These are not the only leadership opportunities existing; Box 1 provides a non-comprehensive list of opportunities available to medical students and clinicians. Many of these can be carried out alongside clinical work, therefore, not requiring time out of practice, and in some these cases may include a leadership or education qualification. In addition, several trusts run their own leadership and management programmes, such as the GSTT Junior Doctor Leadership Group (https://www.guysandstthomaseducation.com/project/junior-doctor-leadership-group/), which is available to training and staff-grade clinicians.
Some of the leadership opportunities available to medical students and clinicians
• Darzi Fellowship: run by NHS London Leadership Academy (as above)
What can consultants do to support this?
Working patterns of doctors are changing, with many junior doctors not wanting to have the same work patterns as their predecessors. Increasing flexibility in terms of working hours and working location has become the norm in the majority of careers. Medical careers have not kept pace with this change, and the rigidity of the medical career structure in the UK is a major drawback for many. Medicine must change in line with other industries to support this changing workforce, or risk falling behind.
The importance of work–life balance is also increasingly considered, and the development of personal skills, such as leadership and management, are seen as essential in keeping people “in role”. Increased flexibility for trainees to pursue other opportunities, including time to improve their non-clinical skillset, is key to retaining trainees in the NHS. Collaboration between senior medical leaders and junior doctors trained in leadership may support this transition, but clinical consultants must also be supportive of this.
The consultant body also needs to make the workplace supportive for those returning from leadership development programmes, in order to allow them to implement the skillset they have learnt, which often proves beneficial to the department. Some research suggests this is not always the case; one study following junior doctors pursuing leadership roles in healthcare found that these doctors reported multiple barriers in their hospital settings upon completion of their leadership programme, including a lack of appreciation for their new skill set.9 For these programmes to be effective, the workplace must alter to accommodate new ways and methods of working.
A key challenge facing all healthcare organisations is to nurture cultures that ensure the delivery of continuously improving safe delivery of care. Leadership is one of the most influential factors in shaping organisational culture, and so ensuring the necessary leadership skills are developed is fundamental. This has been previously evidenced; where health service staff report they are well-led and have high levels of satisfaction with their immediate supervisors, patients report that they, in turn, are treated with respect, care, and compassion.10 Data suggest that when healthcare staff feel their work climate is positive and supportive, as evidenced by coherent, integrated, and supportive people management practices, there are low and declining levels of patient mortality.10 These associations are consistent across all the domains of healthcare.
The benefits of being part of a well-led organisation are clear; however, skills in leadership and management should not be for the lucky few who are granted an opportunity early in their career. Leaders in an organisation are not always those with formal management roles, but rather the people with the largest network of influence. To build a sustainable future for the NHS, every doctor must recognise him or herself as a change and thought leader.
Conflict of interest
The authors declare no conflict of interest.
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