Becoming a better medical leader
Peter Spurgeon and Bob Klaber, authors of Medical Leadership: A Practical Guide for Trainees and Trainers, together with Matt Green of the BPP University School of Health, explore the relevance of the Medical Leadership Competency Framework in modern day medicine and how it can be used as a guiding framework at every stage of a doctor’s career
The challenge of medical leadership
The familiar challenges facing most developed health systems (ageing population, costly new techniques, new patterns of disease, and rising public expectations) have intensified in the face of considerable financial constraints. The need for radical innovation and increased levels of productivity has probably never been greater. All healthcare staff will need to contribute significantly to this effort.
Previous experience has shown that widespread improvement of services and of patient safety requires a positively committed medical workforce and outstanding medical leadership. Early medical leaders, often pioneers in the field, were sometimes isolated from their colleagues and often ill prepared for the tasks facing them. Gradually, training materials and development courses began to emerge to support this relatively small subset of medical leaders. However, two key issues were not dealt with:
- How could the majority (not the minority) of doctors acquire the requisite management and leadership skills to play a full part in promoting service improvement?
- How could the culture surrounding medical managers and leaders be changed to support wider involvement in improving organisational performance and to make leadership a natural and normal part of the medical role?
Leadership: how everyone can contribute
Unfortunately, when many people think of leadership they think in terms of old fashioned and stereotypical concepts, bringing to mind rather isolated, charismatic, heroic leaders. Although such individuals have existed, and still do, they are by definition rare. It is unhelpful for people to consider themselves as leaders only if they possess such exceptional qualities.
A more modern and inclusive concept of leadership was embodied in the Enhancing Engagement in Medical Leadership project run jointly by the NHS Institute for Innovation and Improvement and the Academy of Medical Royal Colleges. This successful project has produced the Medical Leadership Competency Framework (figure).
Each of the framework’s five domains is further divided into four competency elements that doctors need to become more involved in the planning, delivery, and transformation of health services as a normal part of their role as doctors. The model is based on the concept of leadership rather than that of the individual leader: leadership is often described as shared or distributed, whereby each person can contribute leadership acts or behaviour according to their competence and the context or level at which they work.
The framework has been endorsed by the General Medical Council through its inclusion in Tomorrow’s Doctors —which prescribes the curriculum for all UK undergraduate medical schools—and also by the specialist medical royal colleges, which have incorporated it into their postgraduate curriculum.
The acquisition of competence in management and leadership is therefore a requirement for doctors throughout their training. The next section describes ways in which trainees can use everyday situations to learn these skills and also advises trainers and educational supervisors on how they can create learning opportunities and provide useful feedback.
Learning leadership in the workplace
To widen this leadership learning across all specialties, and at all levels of training, trainees need to seek out opportunities to learn and experience the different aspects of leadership and management within their workplace. The role of trainers or educational supervisors has to be as facilitator or enabler in helping this learning to happen.
Trainees and trainers can both use the Medical Leadership Competency Framework. Across the five domains are a total of 20 elements, each of which offers ideas and insight into competencies that need to be achieved. These might include, for example, work that focuses on developing self awareness, working within teams, managing resources, ensuring patient safety, or making decisions and then going on to evaluate the effects of change.
Another approach is to look at the different activities that occur within your practice or department. This might include meetings, discussions, or projects about quality and safety; patient safety; risk management; complaints; guidelines; audit; improving efficiency; improving training; or work on patient experience. These activities offer outstanding work based opportunities for learning, as well as having a considerable effect on the care given to patients. Historically, although audit and guideline work has involved trainees, many of the other activities have not, and this is an important missed learning opportunity that trainers and supervisors can relatively easily deal with. The culture change within a department or practice has to be that none of these activities goes ahead without the active involvement of a trainee.
Getting involved in improvement and change
There is considerable impetus in medicine to encourage trainees and trainers to move beyond a one dimensional emphasis on audit, which more often than not allows little opportunity for learning, is demotivating, and leaves patients no better off. The new approach encourages trainees to focus more on quality improvement and change (of which audit can be a part), with the desire to improve care for patients as the primary motivator. However, with trainees rotating through posts every few months, organisations have continuity problems, but there are also advantages. Where tutors are prepared to invest time in encouraging incoming trainees to contribute to the wider work of the department, the energy and imagination of the new doctors, alongside their recent experiences in other organisations or departments, can be a hugely important impetus for change.
As in learning clinical medicine, involvement in real cases, situations, and discussions is a powerful way to gain competence in management and leadership—and experiencing and supporting change is a key step in being able to lead change in the future.
The framework places considerable emphasis on working with and learning from others. Coaching and mentoring can support the development of leadership competencies, in addition to traditional support through educational supervision. Some programmes have successfully taken a formal approach to mentoring from senior leaders, while other doctors develop through informal mentoring relationships at different stages of their careers.
Opportunities for doctors and other clinicians to develop their leadership and management capabilities also occur through peer learning “buddying” schemes with managers. One example of this, “paired learning,” enabled considerable personal learning for the clinicians and managers who participated, as well as realising benefits for patients through the improvement work that was undertaken by the pairs. In this scheme, which paired senior trainees with service managers, the leadership learning came from four different components, all designed to support constructive clinician-manager conversations:
- Informal discussions between the manager and clinician in each pair
- Reciprocal work shadowing
- Leadership and improvement workshops, and
- Quality and service improvement projects.
The current challenges in healthcare provide many opportunities for work based learning in leadership. To achieve this learning, trainees need to use their energy, imagination, and determination to improve care for their patients through their work. Trainers and supervisors need to take on the role of enablers or facilitators to maximise chances of learning and success.
Competing interests: PS and BK’s book Medical Leadership: A Practical Guide for Trainees and Trainers is published by BPP Learning Media, whose medical publishing director is MG ( firstname.lastname@example.org).
- Spurgeon P, Mazelan PM, Barwell F. Medical engagement: a crucial underpinning to organizational performance. Health Serv Manage Res 2011;24:114-20.
- NHS Institute for Innovation and Improvement. Medical Leadership Competency Framework. 3rd ed. 2010. www.institute.nhs.uk/assessment_tool/general/medical_leadership_competency_framework_-_homepage.html.
- General Medical Council. Tomorrow’s doctors. www.gmc-uk.org/education/undergraduate/tomorrows_doctors.asp.
- Hillman T, Roueché A. Quality improvement. BMJ Careers 8 Apr 2011. http://careers.bmj.com/careers/advice/view-article.html?id=20002524.
- Bethune R, Roueché A, Hillman T. Is quality of care improving? Improvement efforts need to be targeted at junior doctors. BMJ 2011;342:d1323.
- Warren OJ, Carnall R. Medical leadership: why it’s important, what is required, and how we develop it. Postgrad Med J 2011;87:27-32.
- Klaber R, Lee J, Abraham R, Lemer C, Smith L. How pairing clinicians with managers could speed up clinical excellence. Health Serv J 20 Sep 2011. www.hsj.co.uk/resource-centre/best-practice/flexible-working-and-skills-resources/how-pairing-clinicians-with-managers-could-speed-up-clinical-excellence/5033381.article.
Peter Spurgeon director, Institute for Clinical Leadership, University of Warwick, Warwick, UK
Bob Klaber consultant paediatrician, Imperial Healthcare NHS Trust, London, UK
Matt Green medical publishing director, BPP Learning Media, London, UK