Dr Nathalie Turpin (ST5). This article was first published in Anaesthesia News
The NHS is facing yet another difficult period in its relatively short life. Changing demands for healthcare, further technological developments and increasing patient expectations are coupled with huge financial challenges, such as the £20bn worth of savings that the NHS needs to make by 2015.
The King’s Fund performed a survey of 45 trust financial directors, of which 27 said that there was a very high risk that the NHS would not meet its saving’s target by the agreed date . This financial predicament will be an ongoing economic burden for the NHS to bear over the next couple of decades. It will require strong leadership and an innovative vision to steer it towards success.
But who is going to provide this leadership? Some doctors assume that it is only those in high profile leadership roles that have this responsibility. However, across all hospitals, groups of consultants command a great deal of clinical resources, and are already experiencing greater pressures to deliver clinically effective and cost-sustainable services. In the community, the UK parliament’s recent Health and Social Care Act put primary care clinicians in control of £60bn of the NHS budget for commissioning services . Changes to consultant contracts, as well as ongoing uncertainty about doctors pensions, provide continued challenges to staff morale. However, doctors are uniquely positioned to implement changes for the ultimate benefit and safety of patients. It requires strong leadership from within our profession to show doctors how important their contributions as leaders can be.
Many doctors consider themselves natural leaders by virtue of the fact that they spend their professional lives leading teams of other healthcare workers. Examples range from running a department to leading a ward round. In the course of a day at work, anaesthetists demonstrate many admirable leadership qualities; whether they are leading a cardiac arrest, running multiple theatre lists or supervising a trainee. There have been many nebulous descriptions of what a leader is meant to be. The old autocratic leadership style has been replaced with a variety of different types including a more ‘engaging’ leadership method. A more recent definition of leadership is that ‘it is primarily about setting a vision and then motivating people to want to achieve that vision’  rather than just telling them what to do. Modern leaders now often seek to engage others, so that they are able to make collective decisions and get the best results. In the simplistic example of a cardiac arrest situation, it is clear you need both types of leaders. An engaging leadership style would be the least useful in the first few minutes when people need to be assigned key roles and duties and perhaps told what to do. Further on into the arrest, the leader may need to engage others in deciding about whether to continue or stop resuscitation attempts.
Getting clinicians to engage in leadership and management has often proved difficult. There is a sort of tribalism in the NHS that can pit doctors against medical management and the leaders therein. This often stems from a misunderstanding on both sides about what the other ‘tribe’ is about. Some longer standing consultants will remember a time when there wasvery little medical management. The consultants on the wards were the natural leaders because they led a team of healthcare professionals towards making an individual or small group of patients better. Now we have an almost non-existent team-based atmosphere on the wards thanks to several factors, including the European working time directive, and we have layer upon layer of medical hierarchies in which we see non-medically trained personnel making many of the key decisions.
Doctors are not used to being told what do to, nor are they used to complex organisations or systems. They are excellent at figuring out the solution to an individual puzzle, but are less happy dealing with ‘problems’. It is often difficult for them to see ‘the bigger picture’ because they don’t fully understand the larger NHS culture in which they exist, and they are less strategic in their thinking because they are less inclined to think long-term. But doctors are highly intellectual, evidence-based creatures that excel in learning new things and making difficult decisions. They are, of course, in constant contact with the patients, so may make the best patient advocates. Both doctors and their non-clinical counterparts have much to learn in co-operation with each other.
The General Medical Council (GMC) already highlights that leadership is a part of a doctor’s professional work. The GMC’s Tomorrow’s Doctors states: ‘It is not enough for a clinician to act as a practitioner in their own discipline. They are expected to offer leadership and to work with others to change systems when it is necessary for the benefit of patients.’ 
To that end, the Medical Leadership Competency Framework (MLCF) was developed by collaboration between the Academy of Medical Royal Colleges, the NHS Institute for Innovation and Improvement and a variety of other stakeholders including the Royal Colleges. The MLCF is relevant to medical students and doctors throughout their training. At the heart of the MLCF lies the concept of ‘shared leadership’, meaning that this framework is not restricted to those in obvious leadership roles, rather that it can apply to anyone who shows a shared sense of responsibility for their organisation and its services . Therefore doctors, nurses and other multi-professional care workers within a Trust could benefit from its use. The MLCF curriculum is meant as a design tool to develop training curricula for different medical specialties and can inform the development of any trainee’s personal development plan.
The curriculum describes five domains within a leadership ‘wheel’ against which trainees can assess their performance. These domains describe the leadership competences that doctors need in order to become more actively involved in the planning, delivery and transformation of the health service.
The five domains are :
1. Demonstrating personal qualities
2. Working with others
3. Managing services
4. Improving services
5. Setting direction
Each domain is spit into four subsections, and each subsection has four competencies to be attained, all with examples at junior (core, ST1-2) and senior medical training levels (ST3+). For example, within the Managing Services domain, there are four subsections. As an example, one of them is called ‘Managing Resources’. It highlights four competencies :
1. Accurately identifying the appropriate type and level of resources required to deliver safe and effective services.
2. Ensure services are delivered within allocated resources
3. Minimise waste
4. Take action when resources are not being used efficiently and effectively.
A junior colleague would be expected to identify and highlight areas of potential waste to more senior colleagues, and may have already undertaken an audit in a particular area. A more senior trainee would be expected to take part in departmental team discussions about resource allocation and service improvement. However, to do this well, one requires knowledge about the structure and framework of the NHS, the requirements of running a department and an understanding of how financial pressures experienced by a department are managed. This is not something routinely learnt whilst on a medical rotation.
There are existing avenues in which a trainee can gain further leadership and management experience, from a one-day leadership course to a year-long fellowship such as the Fellowship in Clinical Leadership (old Darzi programme). But there is still an ‘extra-curricular’ feel to leadership. This needs to change so that these skills are embedded in the training of any future hospital consultant who is working within the NHS.
In North Central London, a group of senior trainee anaesthetists have formed a group called ‘Leadership Development for Anaesthetists’ (LDfA). Through deciphering the anatomy of the NHS to enhancing trainee interaction with leaders and managers within their trusts, the LDfA hopes to inspire a new generation of anaesthetic leaders. They will map their activity to that required by the MCLF and their movements will be coordinated by their website.
By flexing their leadership and management muscles, doctors may not only become more effective but also happier in their roles, by feeling a renewed sense of loyalty and ownership of the NHS. This would not only benefit our profession, but most importantly, the patients that we serve.
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