‘Don’t rubbish doctors for not always acting like managers’

Source: National Health Executive September/October 2014

Peter Lees, medical director and former founding director of the intercollegiate UK Faculty of Medical Leadership and Management, gives NHE his thoughts on medical engagement and developing leaders within the NHS. David Stevenson reports.

The King’s Fund recently highlighted that medical engagement should be an integral part of any NHS organisation’s culture, but that time is needed in order to evolve this and doctors must be motivated to take on greater responsibility.

NHE covered that in detail in our previous edition, but we wanted to catch up with Peter Lees, medical director at the Faculty of Medical Leadership and Management (FMLM), to get his thoughts too on just how important it is to develop leaders within the NHS via medical engagement.

“The fact that you are asking the question defines the problem really,” he said, adding that it is “ludicrous” to imagine that the health service could function without engaging with an important part of its core: doctors

Lees added that it is not all just about engaging with doctors on this topic, but “if you have a health service without engaged doctors you are going to be stuck”.

He stated that there is evidence from Michael West, who wrote one of the complementary reports for the King’s Fund, illustrating that ensuring doctors are engaged can help deliver high-quality, compassionate care (see box out).

Lees added that medical engagement is “incredibly” important, because it is good human resources practice with the major beneficiaries of this being the patients.

Encouraging engagement

The FMLM medical director stated that to encourage medical engagement, people really need to recognise it and work towards developing it. “We really need to mean it,” he said.

Stimulating medical engagement is easier said than done, he said, but is an absolute necessity nonetheless.

“We employ doctors to work in very complex environments, we train them in highly analytical skills so they can recognise patterns and not just take the patient coming in at face value – because if you take a patient at face value then you may miss actually what is really going on and the person who suffers then is the patient,” said Lees. “So we should not be surprised that the doctors have a particular persona, and behave in a particular way, and we certainly shouldn’t rubbish them for it.

“A lot of what people dislike about doctors is them applying the skills for which they were trained and employed to looking at other problems within the system.

“A caveat to that is that doctors have got to learn to be able to operate in all sorts of different environments, so when it comes to management decisions – and you actually pragmatically have got to make a decision – then endlessly pontificating doesn’t necessarily help the system.

“The system has got to ‘understand the animal’ and understand the value that doctors bring to the system at a clinical level; and doctors have got to understand to flex that style when they are facing different things, like leadership and management of the whole system.”

Funding engagement

In order to develop future leaders, NHE asked whether funding was an issue. Lees told us that, yes, NHS money is tight. However, he also stated that if we want to get out of this situation and deliver some clever solutions then, actually, engaging with some of the cleverest people in the system would be a good idea.

“If you were sitting in the private sector and you had this bunch of people who were pretty bright but, because you find them difficult to manage and difficult to understand, you ostracise them, your board might look at you and think you are completely barking mad,” said Lees.

“I don’t think any of this is complicated, I just think it is a question of understanding the people and working hard to get the best out of them, not saying ‘they are a difficult bunch, therefore, let’s not even try’.”

Changing the climate, not the culture

But rather than changing the ‘culture’ across the NHS, Lees said that he is in agreement with the health commentator Roy Lilley on this topic and instead believes we should change the ‘climate’.

“Roy Lilley argues that it is quite difficult to change a culture, but actually you can change the environment in which people work,” he said.

“So, for doctors, that is understanding the complexity of what they do, understanding how to get the best out of them, and supplying them with the support, training and development to get them there.”

Some people, when times are tight and budgets stretched, will want to disinvest in training to focus on urgent problems instead of long-term ones. But the long-term knock-on effects of such short-termism can be drastic, he said. “I remember going to Kaiser Permanente in California about 15 years ago and one person, without prompting, said ‘you have got to remember that in this organisation when we run into trouble, we invest in education’.”

Lees criticised what he called the ‘31 March’ mentality of focusing only on balancing the books for now and never investing to save in the future.

He said: “Of course, if you carry on and continuously do that, then in 12-18 months’ time, the problem is still there and it is probably that bit more difficult to deal with.”

Lees believes that taking a long-term view can help address issues before they become problems. “The NHS is a people business,” he said. “Yes, there are a few pieces of kit! But we should be thinking about how we invest in the people and how we get the people to think they are involved and engaged.”

He added that all the trusts cited in the recent King’s Fund report on medical engagement got their systems right by working hard. But it took time. “This is a slow burn issue,” says Lees.

Another point raised in that report was the importance of stable leadership – with chief executives being at the trusts for a long time and avoiding constant churn at the top of organisations. This has, for too long, been an unfortunate fact of life in the NHS. 

Looking ahead, he also noted that developing good relations between doctors and managers will be vital. “When we say ‘doctors are not engaged’, we need to ask the question: ‘what are they not engaged with?’”

This is because, he highlights, that a doctor will say: ‘I spend 60 hours a week in this organisation with patients and I am currently engaged with them’.

“What we are saying is that they are not engaged with the system, and also not particularly often engaged with managers,” said Lees, “and, again, one of the salient features of those trusts implementing good medical engagement was that they were engaged with the hospital managers and there was mutual respect.”

Developing collective leadership for healthcare

  • The most important determinant of the development and maintenance of an organisation’s culture is current and future leadership. Every interaction by every leader at every level shapes the emerging culture of an organisation.
  • Boards are responsible for ensuring their organisation develops a coherent, effective and forward-looking collective leadership strategy for their organisation and assuring themselves that it is implemented. This strategy comes from purposefully describing the leadership culture desired for that organisation.
  • Collective leadership means everyone taking responsibility for the success of the organisation as a whole – not just for their own jobs or work area. This contrasts with traditional approaches to leadership, which have focused on developing individual capability while neglecting the need for developing collective capability or embedding the development of leaders within the context of the organisation they are working in.
  • Collective leadership cultures are characterised by all staff focusing on continual learning and, through this, on the improvement of patient care. It requires high levels of dialogue, debate and discussion to achieve shared understanding about quality problems and solutions.
  • Leaders need to ensure that all staff adopt leadership roles in their work and take individual and collective responsibility for delivering safe, effective, high-quality and compassionate care for patients and service users. Achieving this requires careful planning, persistent commitment and a constant focus on nurturing leadership and culture.

Source: The King’s Fund – Developing collective leadership for health care; West et al 2014)

About Peter Lees

As well as his work with the FMLM, Peter Lees serves on the clinical governing body of West Hampshire CCG, the general advisory council of the King’s Fund and the NHS Leadership Academy steering group.

Over 20 years, he combined a career in neurosurgery with senior roles in operational management and leadership development.

This included experience at local, regional and national levels and in global health. Most recently he was the medical director, director of workforce and education and director of leadership at NHS South Central Strategic Health Authority; medical director of the NHS Top Leaders Programme; and senior lecturer in neurosurgery at the University of Southampton.

He is a graduate of Manchester and Southampton universities, a Fellow of the Royal College of Surgeons of England and a Fellow of the Royal College of Physicians, London.

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