01.08.14
Medical engagement should be integral in NHS cultures
Source: National Health Executive July/Aug 2014
Vijaya Nath, assistant director of leadership development at the King’s Fund, discusses the role of medical engagement in developing leadership within the NHS. David Evans, medical director at Northumbria Healthcare NHS Foundation Trust, identifies where his organisation has made changes to stimulate this; and Dr Andrew Goddard, the registrar at the Royal College of Physicians, assesses the issue and talks about maximising staff potential.
Medical engagement should be an integral part of any NHS organisation’s culture, from board to ward, a new King’s Fund report has concluded.
However, the ‘Medical engagement – A journey not an event’ study also highlighted that time is needed to evolve this and doctors must be motivated to take on greater responsibility.
The authors studied four foundation trusts – Northumbria Healthcare, Salford Royal, Southern Health and UCL Hospitals – to see how long-term stable leadership creates a firm foundation for cultural change.
Vijaya Nath, assistant director of leadership development at the King’s Fund, and one of the report authors, told NHE: “We thought it was important to profile organisations at different levels of medical engagement, so they are not all identical.
“Three of them, though, are advanced, compared to Southern Health which is still doing quite a lot of work. Medical engagement is a journey not an event. On both sides there have been things that have been preventing doctors getting into it.”
One particular issue is the autonomy of medical professionals, especially doctors. “If you look at the difference between some disciplines in health, and where their loyalties lie, for many they will see their employing organisation as where their loyalties are and where their energy should go,” Nath told us. “But many doctors see their autonomy coming from either the medical royal colleges or somewhere else, but not necessarily their employing organisation. I think these four organisations really cracked that in terms of doing what the Virginia Mason Institute (VMI) did, which involved taking the hard conversations with doctors and setting up compacts before roles were allocated.”
Autonomy or isolation
But Dr Andrew Goddard, registrar at the Royal College of Physicians (RCP) and a consultant physician at the Royal Derby Hospital, is not so sure. Although he admitted that consultants can feel like autonomous workers rather than fully loyal to their employer, he believes much of that is because they feel isolated and that there are barriers between them and medical management.
“That is a two-way communication programme, and one of our jobs as a royal college is to facilitate and encourage consultants to reach out to management. But this has to be a two-way process,” he said.
“There are people who feel disengaged in the NHS and feel it is very bleak; but there are also those out there who are extremely enthusiastic who, if you give them a little length on the leash, so to speak, could really fly and be real assets to the NHS.”
He said that striking the right balance in trying to maximise those with potential, while accepting you won’t get everybody engaged, “is the practical realism of the environment we’re in”.
The RCP registrar stated that the vast majority of consultants would “really love to do more and take a lead in running their services”.
Stretched resources
The King’s Fund report has come at a time when many people in the NHS feel stressed and stretched. However, the authors identified that where senior leaders have shown a commitment to medical engagement and leadership, positive changes have been made.
David Evans, medical director at Northumbria Healthcare NHS FT, one of the organisations reviewed in the report, said there is no ‘quick fix’ to suddenly achieve full medical engagement, and he doesn’t feel that sending people off for a course to become a medical leader works best either. “You need to build this internally and from the bottom up,” he said.
“It’s not about training people to become leaders, it is about creating an environment in which leaders can lead,” said Evans. “I’ve been medical director for 11 years, and in my first 18 months I had a series of newly-appointed consultants with problems, which we should have picked up on earlier in the way we recruited people. We don’t have that anymore.
“Instead, we take two days, we do psychometric profiles, we observe clinical scenarios and then we do a structured interview for over an hour against competencies and we use that with a weighted scoring grid.”
The trust has tied this in with a new consultancy programme – a ‘welcome to Northumbria’ where, within their first year, consultants meet their peers, discuss the rules and regulations at the trust, and how the trust’s business model works.
It has run a mentorship scheme for nearly 10 years, and almost a third of its consultants have been drawn into the trust through this method.
Evans stated: “Because we have three district general hospitals and six community hospitals, we need a lot of medical leadership time. So we’ve taken the decision to invest in that and I don’t think we could’ve achieved what we have without that commitment from the trust. It is a big bill, but it has really paid dividends for us.”
Nath agreed that board-level commitment to medical engagement is an absolute must. She was pleased to see that consistently, across the four trusts, an area where all of them succeeded was engaging with junior doctors.
“From the time a young doctor, or emerging leader, comes into one of the medical roles, these organisations have sought to make them part of the organisational culture,” she said. “And they see the value of new people coming in and bringing in new ideas.
“If we look at UCL Hospitals, they have managed to engage doctors just starting out in their first appointment – making sure people spend significant time on clinical training and quality improvement initiatives. They are saying that theirs is an organisation where it believes doctors have a leadership role, and they think junior doctors should have a leadership role early on.
“There is also a connection in that these organisations had had stable senior leadership. Given how, in the NHS, we churn over chief executives it is a factor that these organisations haven’t had to face.”
Calls for change
Dr Goddard praised the King’s Fund study and said it highlights important factors, including the point about stability at the top table; clinical engagement throughout the organisations; support in leadership development; and the importance of a patient focus.
“My one concern is that the report looks at three trusts that have done very well in the modern NHS, but the majority of trusts do not have the financial security that they have,” he said. “So many consultants are working in much harder financial conditions and also in organisations, because of that, which have higher turnover rates of managers.
“The example I would give is that in my 13-year consultancy career, I’ve had eight different managers. Most consultants would expect to be with an organisation for 25-30 years, so we’re in it for the long haul and there is a lot to be said about putting forward these people for leadership roles.”
Dr Goddard also feels that there needs to be a “big call from the top”, certainly from NHS England chief executive Simon Stevens and secretary of state Jeremy Hunt, to raise the argument that strong medical leadership in the NHS is vital to its success.
“I do believe this has to be a clear, concise message, because at the moment I’m not sure that is the case,” he noted. “We need to look at how we can make that work in a typical, busy trust which is trying to pay off a PFI, which has targets to meet and a full A&E and vacancies in their registrar rota – which is much, much harder.”
This can then be followed by a focus on trying to facilitate ways in which the management structure can involve clinicians in managerial roles, but that does require investment.
“There has to be an acceptance that focusing on leadership has an initial cost, but will reap huge dividends in the long run,” said Dr Goddard. “If you have a consultant for 30 years, it is going to cost a trust on average £3m over that time, if you pay them £100,000 per year. So investing a little bit in a high-level leadership programme, which usually costs around £2,000, seems a very worthy investment for the long-term picture.”
Northumbria’s Evans said his trust has had only two chief executives in 16 years, most of its executive directors have been in post for at least eight years and, in some cases, there are three generations of a family working for the trust.
He is also very keen about growing the trust’s own workforce. “For 14 years we have run our own in-house leadership development programme, which is multi-disciplinary, and runs over nine months. No-one takes on a leadership role unless they have done that programme,” said Evans. “So we have trained a sizeable pool of people, and there is a progression for people to move forward in the trust.”
Evans wants engaged clinicians to realise that “with extra responsibility comes accountability”.
Government help
Dr Goddard said that he hopes that in 10 years the situation will be very different, and more trusts will be medically led. The RCP’s Future Hospital Programme is also encouraging hospitals to be more outward facing and to integrate with the health community around them.
“That is one way in which consultants can engage and improve their leadership skills,” he said. “If we are going to engage and deliver healthcare in the NHS, doctors are going to have to be at the forefront of this and lead that.”
Nath agreed that financial stability cannot be ignored – it gives trusts the freedom to redefine workforce roles, which may not be so feasible when they are financially unsustainable.
“The government should help with this, because it can’t ‘just happen’,” she said. “If you have an organisation that is financially unstable, and you are asking them to make improvements, usually in order to make quality improvements, you need to inject some cash.
“If not, then you enter a downward spiral – and that’s partially how we ended up getting down to Mid Staffordshire.
“The government keeps saying we never want to see that again. So, therefore, there needs to be some motivators in the system for organisations to get behind medical engagement, and there needs to be some incentives rather than disincentives – that can be caused when everything is about targets and financial cost.”
Developing a ‘culture strategy’ where medical engagement is explicit is key to delivering change to the structure of leadership and management, she said.
Gender diversity is another important point, as raised by NHS England chief executive Simon Stevens.
Conclusion
“For the organisations we studied it was a long journey, but look at the examples – four years of consolidated work gets you to a place you could only have dreamed of if you didn’t do that work,” said Nath.
The report authors added: “The current generation of newly appointed doctors need to see that any investment in leading and managing innovation and quality improvement is an attractive, rewarding and valued proposition. It is too important to be left to chance.”
Common themes
The King’s Fund report found several common themes linked to strong medical engagement:
• Long-term stable leadership, creating a firm foundation for cultural change based around improving quality and safety;
• Clear strategies for improving quality of care and staff involvement in leadership roles;
• A strong medical leadership structure, with doctors in leadership roles at divisional and departmental levels with dedicated time to fulfil these roles;
• An emphasis on devolving authority to divisional and departmental leaders and creating a culture that encourages innovation;
• Recruitment of medical staff based on their values, not just their clinical expertise – this includes the use of psychometric tests and simulations against the organisation’s values and competency frameworks;
• Well-developed appraisal and revalidation processes with deeply ingrained talent management and succession planning and a broader focus on education and training;
• A focus on encouraging young talent and on junior doctors participating in service improvement initiatives; and
• An organisational willingness to learn from national and international examples of best practice.
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