Given the current workforce and financial issues facing the NHS, should physicians just concentrate on seeing as many patients as they can, as quickly as they can? Professor Namita Kumar says perhaps not.
Physicians who engage in leadership and management roles, in addition to service improvement contribute to a more efficient and higher quality system. In 2008, Professor John Tooke stated:
The doctor’s frequent role as head of the healthcare team and commander of considerable clinical resource requires that greater attention is paid to management and leadership skills regardless of specialism. An acknowledgement of the leadership role of medicine is increasingly evident. Role acknowledgement and aspiration to enhanced roles be they in subspecialty practice, management and leadership, education or research are likely to facilitate greater clinical engagement.
Further, the GMC states that doctors must participate in service improvement:
It is not enough for a clinician to act as a practitioner in their own discipline. They must act as partners to their colleagues, accepting shared accountability for the service provided to their patients. They are also expected to offer leadership and to work with others to change systems when it is necessary for the benefit of patients.
A common misconception is that a leadership or management role suggests an abandonment of ‘being a proper doctor’.
The RCP’s former president, Professor Dame Carol Black, referred to both these in the preface introduction of the Medical Leadership Competency Framework:
While the primary focus for doctors is on their professional practice, all doctors work in systems and within organisations. It is a vitally important fact that doctors have a direct and far-reaching impact on patient experience and outcomes. Doctors have a legal duty broader than any other health professional and therefore have an intrinsic leadership role within healthcare services. They have a responsibility to contribute to the effective running of the organisation in which they work and to its future direction.
From the 1960s to the late 1980s, hospitals were managed by clinicians. Compared to traditional management structures, these organisations were managed from the bottom-up rather than top-down. It was the doctors who were in charge. As such, doctors had power to block organisational strategy and processes, if they disagreed with management. But because of market forces, increasing competition and corporate governance pressures, hospitals have shifted to being managed by non-clinician managers trained in management who were not promoted from within the clinical profession itself. This model in hospitals has been criticised for removing the dynamic and flexible nature of the traditional professional-run hospital by being too top-down in its approach.
This has led to a loss of autonomy and decision making for doctors, and results in some of the frustration and loss of morale observed in the workforce.
There have been a number of initiatives trying to improve the participation of doctors in leadership and management roles, but appointment to top roles is still not high. There are many reasons for this, and some doctors still don’t see the value. A common misconception is that a leadership or management role suggests an abandonment of ‘being a proper doctor’. Physicians are required to have an understanding of and some training in professional management skills, both clinical and professional leadership could be provided in one role, improving patient care and providing high quality outcomes. Physicians trained as managers not only have a positive impact on their patients, but on the organisation and system they work within.
There is plenty of evidence to support this. The Commonwealth Fund is a private foundation that aims to promote a high performing healthcare system that improves access, quality, and efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children and elderly adults. This is done by supporting independent research on health care issues.
The Fund’s research has shown that clinical leadership makes system wide impact on improving outcomes for patients. In its report Designing a High-Performing Health Care System for Patients with Complex Needs: Ten Recommendations for Policymakers, it recommends that clinicians be engaged in training, and supported to become leaders:
Clinical leadership is key to delivering successful change, and the clinicians leading change need support from local managers to ensure that local administrative systems and budgetary arrangements do not stifle change. Clinicians may also benefit from formal leadership training and opportunities to meet with peers on a regular basis.
This does not change the commonly accepted role of a doctor to treat and provide medical care, but rather it allows the doctor to support and lead systems that have a far greater impact.
The King’s Fund has also reported that organisations in which doctors are more engaged with maintaining and enhancing the performance of the organisation, perform better financially and clinically. Further, the Harvard Business Review has stated that the best hospitals are managed by doctors.
This does not change the commonly accepted role of a doctor to treat and provide medical care, but rather it allows the doctor to support and lead systems that have a far greater impact. The role of the doctor is to provide the best care, in the interests of the patient, population, and in my opinion, the system.
The consensus statement of the role of the doctor states:
Doctors ... must be capable of regularly taking ultimate responsibility for difficult decisions in situations of clinical complexity and uncertainty...The doctor’s role must be defined by what is in the best interest of patients and of the population served.
The study and theory of management has been developed considerably in the past 50 years. As with any scientific advancement we must engage professionally or we risk being left behind. This is the case too, with leadership and management theory.
Being a manager and sometimes a leader, be that in delivery of clinical service as Medical Directors, in education and training as Postgraduate Deans or within our professional organisations and bodies, allows those of us with the skills and inclination to make a huge impact on patient care and quality that is system wide. It allows us to take clinical care and the profession forwards. It is not for everyone, but as we gravitate to a specialisation after considering our strengths and weaknesses, so should we gravitate to management and leadership out of the clinical environment.
For those of us who do, the profession must be supportive. Physicians are influenced most from within the profession, and it is the role of the royal medical colleges to provide professional influence to support physicians who wish to take up leadership and management roles.
We cannot be bystanders in poor management systems and poor decision-making.
For that very reason we must all understand leadership and management, and this can only be done by education and professional influence.
Professor Namita Kumar is a postgraduate dean, consultant physician and rheumatologist, and elected member of Council at the RCP. You can follow Namita on Twitter at @namita_1.
This article appears as part of the RCP's Our Future Health project, a year-long campaign to explore ways to tackle some of the most pressing issues facing our NHS today. It was published in the October issue of Commentary.