COMMENT
At the directorate level, clinical directors usually worked with a nurse manager and business manager. At the hospital level, a medical director was appointed, usually on a part-time basis, who worked along- side the other executives. Primary care was largely ignored initially by the changes that followed from the Griffiths Report, but this began to change with the introduction of the competitive internal market and GP Fund Holding in the early 1990s and the later establishment of Primary Care Groups and Trusts.
These arrangements continued throughout the 1990s and into this century with mixed success. Essentially, those doctors in posi- tional leadership roles offered advice and responded to general management direc- tives and initiatives. Nearly all the doctors in managerial and leadership positions in primary and secondary care were very slowly beginning to move from represen- tational to accountable roles but within a very strong general management culture.
As the Report from The King’s Fund Com- mission on Leadership and Management in the NHS (2011, p9) suggests: “The Re- port (Griffiths) is chiefly remembered for the introduction of general managers who, during the creation of the internal market in the 1990s, rapidly came to re-style them- selves as chief executives. It is too often for- gotten that Griffiths also saw a central role for doctors in management, both as chief executives and as critical managers of re- sources within clinical directorates.”
Over the past ten years or so, there has been a shift of emphasis with a stronger recognition that significant improvements in access, quality, safety, service delivery and productivity require stronger clini- cal (particularly medical) leadership and engagement. This was strongly reinforced by Lord Darzi’s review of the health system in England culminating in the publication of High Quality Care for All in 2008. He strongly advocated the importance of clini- cians, and particularly doctors, being more engaged in leading service improvements.
Over the past 60 years or so of the NHS’s life, doctors have often been criticised by their peers of moving to ‘the dark side’ if they reduce their clinical commitments and take on greater managerial and leader- ship roles.
However, doctors are now seen as ‘centre stage’ in the implementation of the cur- rent NHS (England) reforms. Doctors have increasingly responded to calls for their greater involvement in quality improve-
ment initiatives. Not surprisingly, this is a more attractive role than resource manage- ment to many doctors, given its closeness to their professional training and values. Indeed, many non-clinical managers can be thankful that clinical colleagues have helped them deliver centrally-imposed and challenging quality improvement targets!
Is the pendulum swinging from general management to medical leadership? Some commentators argue that appointing more doctors as chief executives will lead to even greater improvements in performance. The Government seems to feel that doc- tors leading, for example, the new Clinical Commissioning Groups, will be the answer to driving improvements in quality and productivity.
What is the evidence for such perspectives? To date, there is no evidence that medi- cal leaders are per se more effective than non-medical ones. There is strong evidence from studies in the USA and UK that se- curing greater medical engagement at all levels of any health service, organisation or system will generate greater clinical and financial performance. In the UK, the study led by the NHS Institute for Innovation and Improvement and The Academy of Medi- cal Royal Colleges confirmed that there is a strong relationship between the extent of medical engagement and performance.
What is the way forward for NHS Leader- ship? The King’s Fund Commission (2011) concluded that leadership is needed from the board to the ward and involves clini- cians as well as managers. Experience since the Griffiths Report suggests that the NHS and its patients will be better served by clinicians and managers working closely in partnership at all levels with common goals about improving quality. This re- quires more joint leadership development of clinicians and non-clinical managers.
The top-performing health organisations in the USA are typified by dualities or pair-
ings of clinicians and non-clinical manag- ers complementing each other and being jointly held to account for the delivery of desired goals.
We need therefore to create new compacts where doctors are encouraged to be more engaged in management, leadership and service improvement and where non-cli- nicians positively seek this involvement. It is not about whether we subscribe to the general management approach espoused in the Griffiths Report or the medical lead- ership movement currently being encour- aged by policy-makers.
The evidence firmly suggests we need a mix of greater medical engagement and leader- ship at all levels from dualities of clinicians and managers. This has implications for how we train and develop young doctors and managers and those already in leader- ship roles.
Perhaps we can use the evidence of nation- al and international health leadership and performance research to inform the most appropriate ways in which to organise the health system and within organisations. Recent high-profile and damning reports into failing hospitals and other health or- ganisations all confirm that good medical leadership and engagement, in conjunction with good general management, is criti- cal to quality of care. Let’s act on the evi- dence and ensure that our organisational arrangements and cultures are fit for the challenges of improved quality of care and productivity.
John Clark is a Senior Fellow, Leader- ship Development at The King’s Fund. He has held a number of senior posts within health academia and in the NHS, and has been chief executive of an acute hospital.
References
Spurgeon, P., Clark, J., and Ham, C. (2011) Medical Leadership: From the dark side to centre stage, Radcliffe Publishing, London
The King’s Fund (2011), The Future of Leadership and Management in the NHS: Report from The King’s Fund Commission on Leadership and Management in the NHS, The King’s Fund, London
Darzi, A (2008), High Quality Care for All: NHS next stage review final report, De- partment of Health, London
Academy of Medical Royal Colleges and NHS Institute for Innovation and Improve- ment (2011) Engaging Doc- tors: What can we learn from Trusts with high levels of medical engagement? NHS Institute, Coventry
John Clark FOR MORE INFORMATION
For further info on leadership development within health visit:
www.kingsfund.org.uk/
national health executive Nov/Dec 11 | 33
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