Clinical leaders badly needed but not appreciated
By Richard Smith
All health systems need clinical leaders to flourish, but being a clinical leader is hard, particularly in the NHS. Those were the main messages from last night’s meeting of the Cambridge Health Network.
The reason we need clinical leaders, said Jonathan Fielden, currently medical director of University College London but about to become director specialist commissioning for NHS England, is to improve care for patients. And that’s patients in their millions, which clinicians who do not become leaders cannot achieve. The evidence is clear, he said, that clinical leaders lead to better care. University College London has developed clinician leaders and has eight clinicians on its board. But the NHS has only around 20 chief executives who are clinicians—despite longstanding calls for more clinician leaders.
It’s important to be clear what is meant by clinical leaders. Although the two speakers at the meeting were doctors, clinical leaders can come from any of the clinical professions, including nursing and professions allied to medicine. There may be more nurses than doctors who are leaders, and the ideal combination, said Fielden, is to have a clinical leadership triad of doctor, nurse, and professional allied to medicine. And leaders are needed at all levels, not just as chief executive or medical directors. Clinical leadership at lower levels is crucially important and probably less stressful than leadership at higher managers, although I can’t help reflecting that in companies the greatest pressure is often on middle managers.
Travelling around the country it’s clear, said one person at the meeting, that the best hospitals, those that deliver the highest quality care within budget, have strong clinical leaders. Importantly those leaders think about all patients and recognise, for example, the huge variations in care and cost. If all routine surgery—on hips, eyes, and hearts–were done to the highest standard then there would be no NHS deficit.
Jonathan Perlin, chief medical officer of HCA (a US for-profit provider of health services also operating in Britain), who also spoke at the meeting, showed the power of clinician leaders when he turned the Veterans Health Administration, the US’s largest integrated health system, from one of the poorest performing health systems to one of the best. He did it at least in part by implementing an electronic record system and using the data it generated to improve patient care. He emphasised too connecting staff to the mission of the organisation, something that should be much easier to achieve in one that is about lessening suffering and promoting health rather than making rubber ducks or cigarettes. Leaders should, he said, think about the triple aim of health, recognising the importance of socioeconomic determinants, care, and cost.
Clinician leaders, like all leaders, said Fielden, should have a clear personal philosophy. His has three parts: putting patients first; driving value, which means getting the best outcomes that matter to patients for the lowest cost; and making your organisation a great place to work, train, and learn. Somebody in the audience said that all doctors knew about outcomes, but Fielden demurred saying that perhaps they didn’t when they allowed tolerated unacceptable variations: X has a much higher rate of knee replacements than the average not because there’s greater need in X but because there’s a surgeon who likes operating on knees. He was insistent that clinician leaders must think about cost, something that doctors have in the past been reluctant to do.
Fielden, who led the consultants at the BMA from 2006-9, criticised doctors for not stepping forward when the NHS is in such difficult circumstances.
So if clinician leaders are so valuable why does the NHS have so few at a high level? Fielden pointed out that we have had for many years a pipeline for producing academic doctors but there is no pipeline for clinician leaders. Young doctors must piece a career path together themselves, and often they do so not only with no support from their colleagues but also with criticisms of “moving to the dark side.” The medical profession has simply not supported medical leaders as it should have done, so contributing to the present mess. Nursing has probably done better.
A clinician leader in the audience was very blunt about why he would not move to a higher level of leadership. There was little support and no more money. If you became a chief executive you joined a group with an average tenure of 18 months. You placed yourself not only in a stressful job that pays much less than a little private practice but you ran the risk of corporate manslaughter and being blamed publicly for any failings in the organisation. You were also likely to be reported to the GMC, a common tactic adopted by erring doctors you attempted to discipline.
Fielden emphasised that all those problems were just as bad—indeed, worse—for non-clinician leaders. The attributes needed by clinician and non-clinician leaders are similar, but the non-clinicians are likely to receive more opprobrium than the clinicians. The usual narrative, encouraged by politicians, is that doctors (“frontline staff”) are good and managers (“bureaucrats”) bad.
The meeting was stronger on the problems than the solutions. Somehow the clinical professions, particularly medicine, have to recognise the value of clinical leaders and support them. There need to be career paths and better rewards. The great reward, everybody agreed, is the chance to improve the health and care of large numbers, but more concrete rewards—like pay and support staff—are also needed. This response belongs to the government and health authorities.
Probably optimism next to resilience is the most important characteristic of leaders, and so Fielden and Perlin were optimistic for a better future for clinician leaders, but an old dog like me has been listening for a very long time to the song for more clinician leaders. I hope it happens because I’m convinced that it would good for patients, staff, the clinical professions themselves, and the NHS.
Note: Cambridge Health Network meetings are held under Chatham House rules, meaning that the main speeches are open but that comments in the discussion cannot be attributed.
Richard Smith was the editor of The BMJ until 2004. He is now chair of the board of trustees of icddr,b [formerly International Centre for Diarrhoeal Disease Research, Bangladesh], and chair of the board of Patients Know Best. He is also a trustee of C3 Collaborating for Health.