Medical Leadership

A Toolkit for Service Development and System Transformation

Jill Aylott, Jeff Perring, Ann Chapman, Ahmed Nassef, Jill Aylott, Jeff Perring, Ann Chapman, Ahmed Nassef

• Publisher: Routledge
• Year: 2018
• eBook ISBN:
  9781315440866
• Topic: Medicine
• Subtopic: Management

Today's health care systems need doctors and consultants to act as leaders, within the multi-disciplinary team, in addition to carrying out their clinical role. This book identifies the key elements of successful leadership through 'medically led' service development and systems transformation and shows how this benefits patient care, particularly when patients become partners in the process.

The authors provide a conceptual framework of medical leadership and a set of scientific methods and tools that make a significant contribution to advancing quality and transforming services in healthcare. On top of this, they present analytical tools which medical professionals can use to support their own improvement or system transformation strategy, including ways of measuring improvement and the returns on investment of medical leadership.

Woven throughout the book are real-life case studies from medical leaders across the world, providing students with valuable practical insights. Chapter summaries and reflections are provided to support learning.

Medical Leadership will be essential reading for students on medical and clinical leadership courses internationally as well as for all practising doctors, consultants and General Practitioners.

Part 1
A global emergent context for medical leadership

1
An introduction

Ahmed Nassef, Mathew Fortnam and Jill Aylott

‘Medical Leadership’ describes an additional set of skills and knowledge in leadership and management for doctors, who are then expected to apply and integrate this new learning into their everyday practice. There have been various attempts to explain and outline what these leadership and management skills are, usually by the introduction of competency frameworks in healthcare leadership and management, for example in the UK, The Medical Leadership Competency Framework (NHS Institute for Innovation and Improvement, 2013), the Clinical Leadership Competency Framework (NHS Leadership Academy, 2011), the Leadership Framework (The NHS Leadership Academy, 2011) and the Leadership and Management Standards for Medical Professionals (Faculty of Medical Leadership and Management, 2014). While doctors and other health professions are encouraged to develop skills in leadership, there is also an equivalent Leadership Qualities Framework for adult social care (National Skills Academy for Social Care, 2014) and a leadership competency framework for Nursing, Allied Health Professions and Managers with the Healthcare Leadership Model (NHS Leadership Academy, 2013) and a Healthcare Leadership Alliance Model in the United States and in the international global context (Stefl, 2008; The International Hospital Federation, 2015). But in the UK the competency frameworks have been insufficient to impact upon and prevent the reported failures in healthcare (Francis, 2010, 2013; Kirkup, 2015) and increases in clinical errors (Bulman and Deardon, 2017). The problems within healthcare continue, regardless of the plethora of leadership competency frameworks, with poor and average healthcare the norm, with extensive variations in healthcare and a lack of an organisational culture of improvement.

Part 1 of this book argues for a new framework for the development of international models of medical leadership to support access to Universal Health Care (UHC) for all, as championed by the World Health Organization (WHO, 2013, 2014, 2016). Globally, many people are unable to access healthcare, and the skills of healthcare workers are variable (WHO, 2013, 2014, 2016). Even where health systems are well developed and resourced, there is clear evidence that quality remains a concern (WHO, 2006) while the challenges for future healthcare systems across the world strive for a more sustainable, affordable and equitable healthcare system (Deloitte, 2016).

However, with a global shortage of healthcare workers estimated to be 12.9 million by 2035 (WHO, 2013), the fastest growing part of the healthcare workforce is and will continue to be the health assistant workforce (Imison et al., 2016), with the professions required to take a lead in professionalising workforce planning and to lead the training of the assistant workforce (Aylott and Montesci, 2017). This growth in demand for healthcare combined with a shortage of health workers will stimulate a growth in the ‘democratisation of professional knowledge’ inspired by the model developed in Mexico and worldwide by Dr Sanjeev Arora (Bornstein, 2014) to develop the assistant workforce to become competent to deliver quality healthcare. This will require a more engaged, informed and ‘conceptually different’ medical and clinical workforce, with all doctors accepting their need to grow and develop their non-clinical skills in ‘leadership’, ‘management’, ‘quality improvement’ and ‘health system transformation’. The future will require more collaboration between the professions, managers, assistants and patients, with less defensiveness about the ‘scope of professional practice’ and with less disputed professional boundaries (King et al., 2015; Aylott et al., 2017).

Chapter 2 outlined by Bolarinde Ola and Aishin Lok provides a chronology of the development of leadership theory and a critique of these theories and their relevance to doctors. The authors review key concepts such as ‘leadership’ and ‘management’ and critique how leadership theories have changed over time and evolved with a developed evidence base which has informed the development of new leadership theories. Perhaps the most striking evidence from leadership theory is the power of an awareness of ‘Emotional intelligence’. Emotional intelligence is an important indicator of a leader’s ability to succeed. Many studies link emotional intelligence with individual and group performances in the workplace. Evidence suggests that the best leaders and best ‘medical leaders’ will develop a heightened level of awareness of their ‘emotional intelligence’ and use the four styles – democratic, authoritative/visionary, affiliative and coaching – interchangeably according to the needs of individuals and team members. The styles of coerciveness and pace-setting are less likely to be effective and can create tension, a damaged culture and poor performance (Goleman et al., 2002). Goleman (2013) describes emotional intelligence as the foremost leadership skill, which harnesses four domains: self-awareness, self-management, social awareness and relationship management. Good leaders are aware of self and their physical and social environment, which facilitates how they influence people around them in a positive way. Demonstration of positive emotions like happiness, laughter and optimism can lift workers to achievements and progress; whereas negative emotions like anger, hostility, fear and anxiety can be demoralising to a workforce.

In Chapter 3, Rachael Baines explores the concept of ‘quality improvement’ and its origins, definition and application to healthcare. As ‘medical leadership’ develops within a contemporary global and emergent healthcare context, we argue that it is the goal of quality improvement and health system transformation in co-production with patients and the wider stakeholders, that requires the focus for current and future models of medical leadership.

Quality Improvement (QI), as a goal for healthcare, can unite clinicians and managers within ‘shared’, ‘distributed’ and ‘collective’ models of leadership to advance the quality of healthcare for patients and their families. It shares a common language and a common goal, however for QI to be effective it must embrace a new culture of working with patients and families as partners in all stages of the co-production of QI. Doctors are best placed to lead this process but are often unprepared, with a lack of integrated leadership and management skills developed throughout their medical training. However, all doctors are authoritative leaders because of their intensive training and experience in a clinical speciality, and without their engagement, healthcare will not transform. QI is required for all doctors regardless of their speciality alongside nurses, therapists, technicians and the assistant health workforce with support from managers in partnership with patients. Allowing patients to lead the Quality Improvement process is a challenging concept for all healthcare professionals, and future health systems depend on empowered patients managing their own healthcare conditions, with families which will lead to more ‘experience-based redesign’ of health and social care systems (Bate and Robert, 2006).

Much of the development of leadership programmes over time has developed with an absence of values (Moscrop, 2012). It is the ambition of this book to embed the core values of patient, service user and family engagement at the centre of reconceptualising ‘medical leadership’. We strongly believe that medical leadership should embody the core values of medical and clinical practice, and to this end, all leadership development should be patient focused. The patient experience particularly for the vulnerable patient presenting with complex and multiple comorbidities is not always a positive one. Future models of medical leadership will require different ways of working with patients to engage and support them in quality improvement using new mixed methods and qualitative approaches. In Chapter 4, Suvira Madan outlines hermeneutic inquiry, which focuses on what humans experience rather that what they consciously know. Heidegger used the term lifeworld to express the idea that individuals’ realities were invariably influenced by the world in which they were living. Being-in-the-world meant that humans could not abstract themselves from the world. Suvira Madan draws upon the life experience of elderly hip fracture patients to create new forms of knowledge and new forms of knowing to shape medical leadership learning about future healthcare scenarios. Where patients struggle to engage due to their vulnerability, we can learn from the patient experience to inform service improvement. All doctors as ‘medical leaders’ are unique in their proximity to the patients’ care and are best situated to lead this process and understand the potential impact of any policy changes to national healthcare structures and their funding mechanisms on patients’ care (Bohmer, 2012). Patient involvement is central to the most successful healthcare systems in the world, where integrated systems of service delivery focus on securing patient and carer involvement and embed ‘patient personas’ (please see the Institute for Health Improvement Esther project as an example (www.ihi.org/resources/Pages/ImprovementStories/ImprovingPatientFlowTheEstherProjectinSweden.aspx), which has been credited with being one of the main factors of success in Jonkoping, Sweden for sustainable Quality Improvement.

Medical Leadership within General Practice is a relatively recent emergence with guidance for doctors’ revalidation (RCGP, 2014) and its 2022 vision (RCGP, 2013). It is emphasised that “trainees must engage with systems of quality management and quality improvement in their clinical work and training” (see Royal College of General Practitioners website: www.rcgp.org.uk). In Chapter 5, Mathew Fortnam reviews the role of the General Practitioner in relation to the scope and practice of quality improvement and explores the future role of General Practice and Medical Leadership.

Within global austerity, healthcare quality cannot be separated from costs, and new ways of capturing the cost of healthcare while demand for services increases is urgently required (Porter and Lee, 2013). The increasing complexity and rising costs of modern healthcare has presented healthcare providers with difficult trade-offs as they try to balance the allocation of scarce resources to individual patient care and that of the population at large. Here, too, doctors find themselves being able to contribute and lead a debate, grounded in the core training of their values and commitment to patients through their Hippocratic oath and to make these trade-offs through a unique combination of specialist medical knowledge and insight into their organisations’ imperatives (Brook, 2010). Indeed, the creation of clinical commissioning groups with doctors positioned at the forefront of purchasing care has once again focused attention on the need for medical leadership (Bohmer, 2012).

Finally, Part 1 concludes with Chapter 6 by Ahmed Nassef, offering a conceptual model of Medical Leadership with underpinning theories of Adult Learning, Social Identity Theory, Self Determination Theory, co-production and communities of practice. This chapter concludes with the recommendation that medical leadership works better when it is ‘self-determined’ (Nassef and Aylott, 2016; Nassef et al., 2017; Giri et al., 2017) and when it is directly related to the interests and passions of the doctor at the individual level to pursue quality within the organisation. However, ‘self-determined’ medical leadership requires investment in the infrastructure of the organisation to support it, and in this book, we look for evidence of successful healthcare organisations that have embedded medical leadership and provide case studies to illustrate examples of this. The benefits of an engaged medical workforce reaps substantial organisational benefits including a more dynamic and engaged medical workforce who can deliver a better patient experience, with better outcomes, less clinical errors and lower absenteeism, and at the same time, results in engaged patients in the quality improvement process and in their own care (Clark et al., 2008; Rowling, 2011; Spurgeon et al., 2011a, 2014).

The advocacy of ‘medical leadership’ as a disaggregated and distinct entity, however, is neither to undermine the contribution of other healthcare professionals to the essential teamwork demanded by modern healthcare enterprises nor to imply that a doctor should necessarily be a better leader in all circumstances (Spurgeon et al., 2011b). It is merely a recognition that within any team, the professional identity, training and perspective of an individual is part of how the leadership role is enacted. Accordingly, Spurgeon et al. (2014) argue that doctors’ individualistic expertise, autonomy in practice and their differential power bases within the NHS all make for a unique perspective that in turn influences their role and contribution to the leadership process.

2
‘Leadership’ and ‘medical leadership’

Bolarinde Ola and Aishin Lok

‘Leadership’ vs ‘management’

Kotter (1996) differentiates between leadership and management, describing management processes as those that are concerned with planning, budgeting, organising staffing, controlling and problem solving and leadership processes as those that involve establishing direction, aligning people, motivating and inspiring (Kotter, 1996). However, leadership still requires considerable management skills. But it is more than just management, which might be concisely summarised as ‘getting the job done’. Leadership is differentiated from management in as much as managers seek to exert their control over an employee with the use of an employment contract, whereas leaders exert influence (Blom an...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Foreword
• Contributor bios
• Part 1 A global emergent context for medical leadership
• Part 2 Medical leadership
• Part 3 Improvement science, medical leadership and measurement for improvement
• Part 4 Service development
• Part 5 System transformation
• Index