Making the case for medical leadership

The RCR recently submitted evidence to the Health and Social Care Committee’s Inquiry into NHS Leadership, Performance and Patient Safety. The latest of many such inquiries, the Committee are investigating the connection between leadership and both NHS performance and patient safety.  

We chose to firmly make the case for medical professionals to enter into leadership roles, arguing that this leads to better outcomes for patients and a more effective and rational service.  

It was important to highlight thee many barriers to medical leadership, such as: a lack of time allocated in job plans, a lack of proper administrative support, limited recognition and reward, and a lack of proper incentives to taking up such roles. 

We also argued that by far the largest factor influencing patient safety at present are persistent and growing workforce shortfalls – across the NHS, but specifically in the medical specialties. These shortfalls of course directly cause the barriers to medical leadership, as well as affecting the care patients can receive, despite medical professionals’ best efforts. 

Our recommendations for government included the need to put in place systems to properly value medical leadership and support doctors to enter into leadership roles; to ensure medical leaders receive the necessary training; to address crippling workforce shortfalls; to ensure job plans enable doctors to meet both their clinical commitments and leadership responsibilities; and to provide an update on progress made against the recommendations of previous reviews into this subject.  

Clinicians possess the skills, experience and knowledge necessary to drive improvements and uphold standards. It is essential that they are enabled and supported to do this crucial work.  

If you have any comments or questions, please contact [email protected].

Introduction

1. The Royal College of Radiologists (RCR) is the leading professional membership body for clinical radiologists and clinical oncologists. We support doctors throughout their career, providing training, setting out standards and clinical guidance and refining the latest research into relevant applications. Clinical radiologists interpret medical images to arrive at diagnoses and, as interventional radiologists, perform image-guided surgical treatments. Clinical oncologists treat cancer by prescribing radiotherapy and managing patients’ treatment.
2. Strong and effective leadership is needed to manage the challenges facing the NHS. This includes the need to ensure patient safety. Medical leadership, in particular, is essential, since clinicians very often possess the skills and knowledge required to drive service improvements and uphold standards.
3. Given our expertise as a professional membership body for doctors, our response to this consultation concerns primarily the role of medical leadership in the NHS. We would like to thank the Health and Social Care Committee for launching the Inquiry and enabling us to respond to this important topic.

Medical leadership improving patient outcomes

4. There are multiple ways in which the knowledge base and distinctive skills of senior doctors are important for maintaining and improving quality of care. One of these is in service design, where doctors may be especially well placed to understand the complex influences on patients’ needs across the entire healthcare system. Doctors also play key roles in better operational management, where their expertise may be critical for effective work system design and continuous improvement. The role of doctors optimising working environments is also critical, and includes nurturing positive cultures and behaviours, advising on workforce design and deployment, and enhancing professional development.[1] At their best, they can tackle behaviours that create risks, set clear standards, and communicate these clearly. Leaders also need to feel that they are themselves accountable for setting standards and ensuring these are met.[2]
5. There is evidence that medical organisations led by clinicians perform much better than others, including in terms of positive patient outcomes.[3] Positive associations have shown that having doctors in leadership roles or on boards of directors is correlated with higher levels of hospital performance.[4],[5]

Barriers to medical leadership

6. The right opportunities, support, and environment to secure the impacts of medical leadership in the NHS are lacking. In contrast with some other countries, most healthcare organisations are not led by a medically-qualified individual. Clinical lead roles in the UK are hard to fill, to the extent that doctors often have limited involvement in much strategic work and everyday management. These are important problems, especially given evidence that lack of professional diversity at senior levels can fuel interprofessional tensions and poor decision-making.[6]
7. Many of the barriers to medical leadership in the NHS are profoundly practical in character, and are linked to insufficient time in job plans, limited professional support, and poor recognition and reward.[7]

Lack of time allocated in job plans

8. The responsibilities associated with senior medical roles may be wide-ranging and extensive, requiring time, specific competencies and skills, and access to professional support in specialist areas. But those progressing to senior roles in organisations (e.g. Clinical Director) typically do not receive sufficient time allocation in their job plans for their duties.
9. One major reason for this lack of sufficient time are the persistent and growing workforce shortfalls across multiple staff groups. For instance, there is currently a 29% shortfall in clinical radiology, which will rise to 40% in five years if no action is taken.[8] Similarly in clinical oncology there is a shortfall of 15%, which is predicted to rise to 25% in five years.[9] These shortfalls mean the system lacks capacity to enable clinicians to spend sufficient time in leadership activities. It is a vicious cycle: the greater the shortfall, the less time there is available for leadership activities to improve services and doctors’ working lives, which in turn impacts morale and leads to greater shortfalls as staff reduce their hours or leave the NHS. Ultimately, it is patients who suffer.
10. Medical leaders with multiple competing responsibilities are left with insufficient time to build productive relationships with colleagues. This is a key problem because compassionate leadership requires that leaders have the ability to listen to their staff and understand the challenges they face, and moreover to offer both empathy and concrete support. Effective listening and understanding requires time and headspace.
11. Those in medical leadership positions may lack time needed to build coherent teams with an explicit shared purpose. The unfortunate consequence may be a tendency for teams to operate more as a group of autonomous individuals than as a cohesive unit.
12. There is some evidence to show that the current practice of not providing sufficient time for leadership responsibilities in job plans is detrimental to the performance of teams and services.[10],[11],[12]

Lack of support

13. Medical leaders may also receive far too little support to enable them to deliver effectively. Similarly, administrative and financial services support, including the sourcing of relevant and quality data, whilst essential, is also lacking.
14. Lack of time and specialist support to be able to deal promptly and effectively with performance and behavioural issues can be very high consequence. Failure to deal effectively with behavioural problems can have result in highly negative impacts on people’s experiences of and motivations for work and create dysfunctional or toxic working environments. Unchecked behavioural challenges may end up in significant effort and resource having to be diverted to service reviews, dealing with grievances and complaints, and employment tribunals.
15. Failure to deal effectively with behavioural problems can, of course, contribute to instances of increased risk of patient safety, or actual harm to patients. Often, poor communication are at the root of many patient incidents – whether this be poor communication between medical professionals or with patients, and especially between senior and less senior staff.

Limited recognition and reward

16. In other industries, competition and high demand for leadership roles are often the norm. For example, in law and accountancy, the typical career trajectory is focused around a clear and well-defined route towards becoming a partner in a practice, with growing financial reward and prestige throughout the journey. This is not the case for medicine.
17. Senior doctors progressing to management and leadership roles in the NHS are not generally awarded additional recompense or recognition that is commensurate with their additional responsibilities. For doctors, taking on a medical leadership role can in fact leave them worse off financially because the additional demands of the role preclude continuation with medico-legal or other independent work alongside their NHS role. In contrast, allied health practitioners and nurses are, rightly, rewarded financially, for example by going up a band when they progress to a management or leadership role from a primarily patient-facing role.
18. Medical leadership roles also lack prestige, meaning that non-monetary recognition may also be lacking. In some cases, this can lead to staff in these roles not wielding the authority they ought to have to perform the role well. While the NHS does invest significant money and time in supporting senior colleagues to undertake leadership training, doctors in senior clinical roles may nonetheless feel undervalued. As an example, they may have to take on multiple, often onerous, tedious, and emotionally demanding challenges with little support, yet get the blame when things go wrong. Similarly, inability to transform services may be framed as a professional failure on their part.

Unattractive nature of medical leadership roles

19. Overall, taking on senior management and leadership roles does not usually represent a career progression opportunity for doctors. Poor experience of leadership at a departmental level deters people from applying for more senior roles so the pipeline of future leaders is limited. Excellent candidates are deterred from applying for senior roles by the system-wide barriers to their ability to excel in role and make the difference the NHS so desperately needs. The unattractive nature of medical leadership positions and the often very difficult experiences of those who occupy them results in poor outcomes for everyone – an unsatisfactory experience for the individual manager/leader, a potential perceived lack of support for staff and ultimately poor patient outcomes.
20. Trainees may also not feel encouraged to pursue leadership roles. The latest GMC National Training Survey shows that 25% of trainees do not feel their rotas optimise their education and training opportunities. That same survey shows that only two thirds agreed their post gave them sufficient chance to develop their leadership skills.[13] This is likely due to a combination of trainees’ challenging workloads, a lack of capacity to provide training, and sub-optimal training programme design because of that lack of capacity. If we want to have the best leaders of the future, we need to retain talent and cultivate talent by creating a positive working culture for doctors.

Regulation and professional standards

21. As per the Kark and Messenger Reviews, better regulation of health service managers and the application of professional standards would drive improvements to all aspects of the health service, including patient safety.
22. It is important to note that doctors are already highly regulated by the General Medical Council and therefore that the regulatory requirements will differ somewhat between medical leaders and non-clinical managers and leaders.
23. The RCR produces guidance documents for clinical practice, much of which are relevant to leadership positions. For example, ‘Professional duty of candour – guidance for radiologists’ sets out guidelines for radiologists to follow to ensure they meet their duty of candour. This is the responsibility to be open and honest with patients when something goes wrong in their treatment and causes, or could cause, harm or distress.[14] Other relevant guidance includes those covering job planning and reporting standards.
24. There is therefore no shortage of high-quality material telling people how to best do things. What is needed is strong leadership to implement these standards and provide the frameworks for audit and regulation.
25. Some studies have shown that doctors who receive formal training in management or administration perform better in leadership roles. This supports the provision of formal training for all medical leaders in the NHS.[15] Leadership training for NHS leaders would be beneficial especially in terms of reinforcing positive behaviours and changing cultural attitudes. Training to break down tensions and misconceptions between staff groups and training to actively involve patients and their loved ones in their care would be worthwhile for all leaders.
26. A programme of consolidation and simplification of NHS regulation, without sacrificing rigour, may also be valuable. By one count, there are seventeen regulatory bodies that cover patient safety in the NHS.[16] This is arguably far too many to enable NHS leaders to understand what standards they must adhere to and to embed best practice against these standards.

Patient safety and NHS leadership

27. NHS leadership can only be as effective in encouraging a culture in which staff can raise concerns if leaders with the right skillsets and sufficient time and resource are in position. Where there is poor leadership, either due to a lack of specific skills or knowledge, or due to insufficient time and resources to dedicate to leadership role or specific aspects thereof, it is likely that staff or patient safety concerns either be not acted upon swiftly, or else not be raised at all.

Progress on previous Reviews

28. Recommendations from previous reviews of patient safety have only been implemented in a piecemeal fashion. Most clinicians on the ground are unlikely to have felt any difference since the Reviews were published. It is unfortunate that such excellent recommendations have not been properly implemented. This is a common problem in the NHS – much resource is spent developing such pieces of work, but very little is spent on implementation.
29. We note the fact that the Government committed to accepting the Messenger Review recommendations in full[17],[18].
30. We also acknowledge that the Government have acknowledged the need for national leadership programmes across healthcare. The commitment made to create a senior advisory group to plan a roadmap for this work is welcome.[19] We would like to see an update on the progress of this advisory group and how it has recommended the Government respond to the Kark and Messenger Reviews.
31. NHS England responded to the Kark Review in 2023 by publishing a new Fit and Proper Person Test (FPPT) framework, aiming to apply the recommendations made in that Review.[20] NHS England also published new learning resources and courses for NHS leaders in response to the Kark Review.[21] The RCR welcomes these initiatives. However, they should only be the beginning, and not the end, of the process. Much more needs to be done to embed the recommendations of the Kark Review and other Reviews and to ensure their recommendations are taken up across the board.
32. On the other hand, there is still little in the way of specific, accredited training for doctors who take on medical leadership roles in the NHS. Though NHS managers and Agenda For Change staff have clear career development pathways, this is not true for clinicians taking on leadership roles.

Recommendations

1. NHS staff are passionate about providing excellent care for patients, and it is a testament that there are so many excellent medical leaders – despite the many disincentives.
2. The time has come to address the challenges facing medical leadership in the NHS, and to redefine medical leadership roles recognising that medical leadership is a distinct expertise and if appropriately positioned could be capable of system-wide improvement through innovation and improved staff engagement.
3. The following solutions should be considered:
   1. Invest in thinking and consulting on “what good looks like” for senior teams and departmental leaders in healthcare organisations, to consider the role of doctors alongside other professions and managers.
   2. The government and the NHS should publish updates on their progress against the recommendations from the Messenger and Kark Reviews. If implemented fully, the recommendations of these two Reviews would have a significant positive impact in terms of advancing patient safety and improving patient outcomes.
   3. Rebalance the relationship between clinical commitments and leadership/management commitments, recognising that investing in people and ways of working is as important to building clinical capacity as the individual undertaking the work themselves. Specifically, doctors need more PAs in which to undertake their medical leadership roles.
   4. Devise an appropriate financial reward scheme for medical leadership roles.
   5. Ensure medical leaders have appropriate professional services support, including from staff with operational, administrative, HR, data, and finance specialist skills.
   6. Ensure medical leaders have the right training and expertise, with a core set of competencies that they are supported to develop. Professional bodies, such as medical Royal Colleges, should play a role in providing training and support to medical leaders.
   7. Create an environment where medical leadership is seen as a prestigious and valuable contribution so that the most able candidates compete to become leaders.
   8. Value the role of senior doctors in improving processes, systems, pathways and patient experience.
   9. Consider what can be learned from international models of medical leadership, and from the management models used by independent providers.

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References

1. NHS Institute for Innovation and Improvement and the Academy of Medical Royal Colleges, Engaging doctors: can doctors influence organisational performance? (2008). Available at: https://www.fmlm.ac.uk/sites/default/files/content/resources/attachments/49794%20Engaging%20Doctors%20-%20Can%20doctors%20influence%20organisational%20performance.pdf
2. Leonard M. and Frankel A. Health Foundation Thought Paper: How can leaders influence a safety culture? (May 2012). Available at: https://www.health.org.uk/sites/default/files/HowCanLeadersInfluenceASafetyCulture.pdf
3. Clay-Williams R, Ludlow K, Testa L, et al. Medical leadership, a systematic narrative review: do hospitals and healthcare organisations perform better when led by doctors? BMJ Open 2017;7:e014474. doi:10.1136/ bmjopen-2016-01447
4. Bai, G and Kirshnan, R. Do hospitals without physicians on the board deliver lower quality of care? American Journal of Medical Quality 2015, 30(1):58-65. doi:10.1177/1062860613516668
5. Veronesi, G. Kirkpatrick, I. and Vallascas, F. Clinicians on the board: what difference does it make? Social Science and Medicine 2013, 77:147-155. https://doi.org/10.1016/j.socscimed.2012.11.019
6. Ockenden, D Ockenden review: summary of findings, conclusions and essential actions (March 2022). Available at: https://www.gov.uk/government/publications/final-report-of-the-ockenden-review/ockenden-review-summary-of-findings-conclusions-and-essential-actions
7. Dickinson, H. et al. Are we there yet? Models of medical leadership and their effectiveness: an exploratory study (April 2013). Available at: https://www.nwpgmd.nhs.uk/sites/default/files/Dickinson%20et%20al%202013%20are%20we%20there%20yet.pdf
8. RCR, 2022 Clinical radiology workforce census report (June 2023). Available at: https://www.rcr.ac.uk/news-policy/policy-reports-initiatives/clinical-radiology-census-reports/
9. RCR, 2022 Clinical oncology workforce census report (June 2023). Available at: https://www.rcr.ac.uk/news-policy/policy-reports-initiatives/clinical-oncology-census-reports/
10. Kippist L, Fitzgerald A. Organisational professional conflict and hybrid clinician managers: the effects of dual roles in Australian health care organizations. J Health Organ Manag 2009;23:642–55
11. Quinn JF, Perelli S. First and foremost, physicians: the clinical versus leadership identities of physician leaders. J Health Organ Manag 2016;30:711–28.
12. Spehar I, Frich JC, Kjekshus LE. Clinicians in management: a qualitative study of managers' use of influence strategies in hospitals. BMC Health Serv Res 2014;14:14:1
13. GMC, National Training Survey 2023 results (July 2023). Available at: https://www.gmc-uk.org/education/how-we-quality-assure-medical-education-and-training/evidence-data-and-intelligence/national-training-surveys
14. RCR, Professional duty of candour – guidance for radiologists (June 2022). Available at: https://www.rcr.ac.uk/media/jbrpzjxc/rcr-publications_professional-duty-of-candour-guidance-for-radiologists_june-2022.pdf
15. Xirasagar S, Samuels ME, Stoskopf CH. Physician leadership styles and effectiveness: an empirical study. Med Care Res Rev 2005;62:720–40. doi:10.1177/1077558705281063
16. Sylvester, R. ‘Times Health Commission: A report into the state of health and social are in Britain today’ (2024). Available at: https://embed.documentcloud.org/documents/24398476-times-health-commission_report_2024/?embed=1&responsive=1&title=1. See page 53.
17. Hansard, House of Commons, Health and social care leadership review, Volume 715: debated on Wednesday 8 June 2022. Available at: https://hansard.parliament.uk/commons/2022-06-08/debates/E1DF8379-6BBF-4911-AF87-5DBB024D0531/HealthAndSocialCareLeadershipReview
18. Hansard, House of Lords, Health and social care leadership review, Volume 822: debated on Thursday 9 June 2022. Available at: https://hansard.parliament.uk/lords/2022-06-09/debates/2E899200-5D8B-468E-B5D4-844CBAB21F3F/HealthAndSocialCareLeadershipReview
19. UK Government, Government response to the House of Commons Health and Social Care Committee’s seventh report of session 2022 to 2023 on ‘integrated care systems: autonomy and accountability’ (June 2023). Available at: https://assets.publishing.service.gov.uk/media/6489a061103ca60013039f05/HSCC-and-hewitt-government-response-print-ready.pdf
20. NHS England, NHSE fit and proper person test framework for board members (updated January 2024). Available at: https://www.england.nhs.uk/publication/nhs-england-fit-and-proper-person-test-framework-for-board-members/
21. NHS England, Directory of board level learning and development opportunities (August 2023). Available at: https://www.england.nhs.uk/long-read/directory-of-board-level-learning-and-development-opportunities/