Clinical Leadership Development in Postgraduate Medical Education and Training

© 2015 Aggarwal and Swanwick. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any furtherpermission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information onhow to request permission may be found at: http://www.dovepress.com/permissions.phpJournal of Healthcare Leadership 2015:7 109–122Journal of Healthcare Leadership Dovepresssubmit your manuscript | www.dovepress.comDovepress 109R e v i e wopen access to scientific and medical researchOpen Access Full Text Articlehttp://dx.doi.org/10.2147/JHL.S69330Clinical leadership development in postgraduatemedical education and training: policy, strategy,and delivery in the UK National Health ServiceReena Aggarwal1,2Tim Swanwick21women’s Health, whittington Health,London, UK; 2Health educationengland, North Central and eastLondon, London, UKCorrespondence: Reena Aggarwal women’s Health, whittington Health,Magdala Avenue, London N19 5NF, UK Tel [phone] email [e-mail]: Achieving high quality health care against a background of continual change,increasing demand, and shrinking financial resource is a major challenge. However, there issignificant international evidence that when clinicians use their voices and values to engagewith system delivery, operational efficiency and care outcomes are improved. In the UKNational Health Service, the traditional divide between doctors and managers is being bridged,as clinical leadership is now foregrounded as an important organizational priority. There are 60,000 doctors in postgraduate training (junior doctors) in the UK who provide the majorityof front-line patient care and form an “operating core” of most health care organizations. Thisgroup of doctors is therefore seen as an important resource in initiating, championing, anddelivering improvement in the quality of patient care. This paper provides a brief overviewof leadership theories and constructs that have been used to develop a raft of interventions todevelop leadership capability among junior doctors. We explore some of the approaches used,including competency frameworks, talent management, shared learning, clinical fellowships,and quality improvement. A new paradigm is identified as necessary to make a difference at alocal level, which moves learning and leadership away from developing “leaders”, to a moreinclusive model of developing relationships between individuals within organizations. Thisshifts the emphasis from the development of a “heroic” individual leader to a more distributedmodel, where organizations are “leader-ful” and not just “well led” and leadership is centeredon a shared vision owned by whole teams working on the frontline.Keywords: National Health Service, junior doctors, quality improvement, management, healthcare, leadership, fellowships, mentoringIntroductionHealth care has both scientific and social dimensions and is also the source of immensepolitical concern. Vast sums of gross domestic product are spent on health,1 the orga-nization of complex systems of health care provision is difficult, and governments areincreasingly judged on their ability to deliver high value services.2 In the UK, a NationalHealth Service (NHS) employs over 1.5 million people with a budget of around £115billion under the supervision of its departments of health. Notwithstanding its size,the NHS appears to be an effective system. In 2014, a Commonwealth Fund reportconcluded that in comparison with the health care systems of ten other countries(Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden,Switzerland, and USA), the NHS was the most impressive overall, although laggingbehind on health outcomes.3 By comparison, the USA has the most expensive healthcare system, yet ranked last in measures of health outcomes, quality, and efficiency.Journal of Healthcare Leadership downloaded from https://www.dovepress.com/ by 193.93.195.147 on 25-Aug-2018
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Journal of Healthcare Leadership 2015:7submit your manuscript | www.dovepress.comDovepressDovepress110Aggarwal and SwanwickDespite the UK’s high-ranking, significant shortcomingsexist in the quality and availability of care, as highlighted bya recent public inquiry by Sir Robert Francis. The “FrancisReport” detailed catastrophic failings in patient care occur-ring over a number of years in one particular NHS trust. Sig-nificantly, the report also identified a “learned helplessness”among medical and nursing staff, resulting in disengagementof health care professionals from management.4 Subsequentreviews of other NHS provider organizations have unearthedsimilar problems with a focus on targets and efficiency sav-ings dominating board agendas and organizations losing sightof the patient. This has been viewed widely as somethingthat needs fixing, and a significant element in the solutionhas been to invite clinicians to engage with system delivery,to use their voices and values in improving quality andproductivity, while simultaneously controlling the costs ofservice provision.4–6Clinicians, doctors in particular, have considerable influ-ence in relation to health care expenditure, occupy the moralhigh ground of patient advocacy, and have a large measureof autonomy by virtue of their training and professionalknowledge. Drawing upon the organizational theories ofMintzberg, health care organizations function as “profes-sional bureaucracies” in which the continually evolvingexpertise of skilled and knowledgeable workers exercisesa high degree of degree of control over the delivery ofservices.7 In a professional organization, workers’ autonomyis regulated by external professional bodies, contrastingwith a “machine bureaucracy”, where the organization itselfdesigns and enforces standards through strong line manage-ment structures. Professional bureaucracies create an invertedpower structure, where frontline staff have greater influenceover daily decision-making than those who, through formalpositions of authority, are responsible for managing the ser-vice.5,8 In such a system, the ability of managers to influenceclinical decision-making is constrained since clinical profes-sionals form the “operating core” of health organizations,thereby controlling the means of production.9According to Ham and Dickenson,10 this has three signifi-cant implications for health care organizations: key leader-ship roles are played by professionals; leadership is dispersedor distributed among staff and not limited to individuals informal managerial roles, and the system requires collectiveleadership, ie, teams that bring together leaders at differentlevels. In understanding the relationships and power dynam-ics within health care organizations, it becomes evident thatsignificant clinical change is impossible without the coop-eration and support of clinicians at all levels. The operatingcore of most health care organizations consists of a largebody of doctors in postgraduate training, resolutely engagedat the front line of patient care. “Junior” doctors, then, arethe perfect tool for initiating, championing, and deliveringchange and improvement in the quality of care.Postgraduate medical training inthe UKThere are around 60,000 junior doctors (In the UK, the term“junior doctor” is used to describe a qualified doctor who hasyet to be placed on the General Medical Council’s special-ist or general practice register. Junior doctors are normally“trainees” enrolled in a postgraduate training program andwork under the supervision of “seniors”, usually registeredconsultant specialists or general practitioners) in postgradu-ate training programs in the UK, with multiple agenciesresponsible for different aspects of the training. Setting andmonitoring professional standards is primarily a role of theGeneral Medical Council and Royal Colleges, funding iscontrolled centrally from the relevant Department of Healthand dispersed via various bodies such as Health EducationEngland or NHS Education for Scotland, and those deliveringthe training are situated in a variety of a community, inte-grated, and hospital settings. Unlike undergraduate students,postgraduate trainees do not have a university structure tomanage their placements, programs, or the progression ofindividuals. Historically therefore, a “deanery” has sat as“an organization in the middle”, providing an umbrella forpostgraduate medical education and training, controlling thefunding flows, ensuring training is delivered to curricularspecifications, and that quality standards are monitored andmaintained.There is broad agreement that the prime purpose ofpostgraduate medical training is “... to ensure that special-ized doctors competently address the medical needs of thecommunity” (p 3),11 an aim reiterated in a recent report onthe future of postgraduate medical education and training,The Shape of Training.12 Indeed, training structures in theUK have been in evolution since the publication, in the 1990s, of the Calman report.13 Predominantly concerned withimproving specialist hospital training, this report resultedin the introduction of specialist registrar posts with explicitcurricula, regular assessments of progress, and time-limitedspecialist training. Alongside this development was theimplementation of European Working Time Directive –later, European Working Time Regulations – restrictingjunior doctors to a maximum of 58 hours per week by 2004,with a further reduction to 48 hours by 2009. Many doctorsJournal of Healthcare Leadership downloaded from https://www.dovepress.com/ by 193.93.195.147 on 25-Aug-2018
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Journal of Healthcare Leadership 2015:7 submit your manuscript | www.dovepress.comDovepressDovepress111Leadership development in postgraduate medical education and trainingtraditionally worked much longer hours, and these changesreduced the degree to which the NHS could rely on doc-tors in training for service delivery and, correspondingly,decreased the amount of time doctors would have availablefor training.In order to address these issues, postgraduate training wasfurther reformed – under the banner of “Modernising MedicalCareers” – predominantly to accelerate the production ofcompetent specialists. “Modernising Medical Careers” led tothe creation of a 2-year foundation program, followed by basicspecialist training in a broad specialty grouping (eg, core med-ical training), and then higher specialist training in a specificspecialty (eg, neurology).14 The aim was to provide doctorswith wide initial breadth of training, which would ultimatelybe shorter by virtue of a more structured program later on.15 Explicit curricula for each specialty (there are 67 in the UKwith 35 subspecialties) were introduced alongside a wholesalerevision of training standards and accountabilities.Since then, there has been a gradual shift in curriculaemphases, from the dominance of technocratic expertise to theforegrounding of “nontechnical skills”.16,17 A range of genericcompetencies have found their way into postgraduate medicaleducation and training, particularly in the areas of leadership,research, and education. This recognition that doctors are anintegral part of a health care system, rather than isolated andautonomous clinical professionals, is further underscored byan increasing focus on quality improvement and populationhealth, and most recently a rediscovery of the patient at theheart of care, with attention turning to issues such as coproduc-tion, patient engagement, and supported self-management.18With these changes has come the recognition that thepotential of the trainee body (junior doctors), a large sectorof the NHS workforce, is largely untapped.19 Furthermore,there is a risk that this future generation of influential healthcare professionals may not be adequately engaged with the“business” of health care provision, with the consequencethat our professional bureaucracy continues to normalizearound professional rather than system drivers.Why engage junior doctors?At the heart of postgraduate medical education is a managedtension between service and training, with the learner alsoas employee.20 Junior doctors rotate frequently between dif-ferent service providers as part of their training in order toachieve their competency-based curricula, but also representthe front line of clinical service delivering, for example, 80% of ward-based activity.21 Due to their transient naturewithin organizations, junior doctors are often disconnectedfrom their employers and viewed as a temporary work-force providing service. However, this peripatetic group isexposed to a myriad of different working practices withina wide range of service providers and have the potentialto disseminate good practice as well the ability to identifyareas for change.22,23With recognition that today’s junior doctors will be tomor-row’s clinical leaders, the importance of the development ofmanagement and leadership has been highlighted in manypolicy documents, including an independent inquiry into“Modernising Medical Careers”,[...] the doctor’s frequent role as the head of the healthcareteam and commander of considerable resources requiresthat greater attention is paid to managerial and leadershipskills irrespective of specialism (p 90).21Many commentators have expressed concern that theability of doctors in training to influence change is notbeing harnessed and are an underused resource, which ifmobilized could significantly improve quality and safety ofpatient care.10,14,19,24 A recent survey of over 1,500 doctors intraining found that 91% had ideas for workplace improve-ment, but only 11% had been able to implement these.22,25 This is a waste. Leadership development of this group ofyouthful energetic junior doctors should be an essential partof “improving health, reducing its variation and doing so inan affordable way” (p 466).26What is clinical leadership?As understood in Anglo–American contexts,27 the terms “lead-ership” and “management” are sometimes used interchange-ably,28 but within the health care literature they tend to describedifferent approaches to how change can be achieved.Management is sometimes viewed as a pejorative term,particularly in the public sector, and the discourse of leader-ship provides a more attractive narrative for professionals,enabling policymakers to engage professionals into activi-ties they desire, such as service reform.29–31 While this maybe seen as a cynical tactic to co-opt professionals into theorganizational arena in order to control their activity,32 itmay also reflect a genuine recognition that to address the“wicked” problems faced by health and social care organi-zations, the particular knowledge and insight professionalsbring are crucial for effective negotiation, influence, andpersuasion with a variety of stakeholders in an increasinglycomplex system.33Definitions of leadership are many and contested, butmost commentators agree that leaders motivate, inspire, andJournal of Healthcare Leadership downloaded from https://www.dovepress.com/ by 193.93.195.147 on 25-Aug-2018
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Journal of Healthcare Leadership 2015:7submit your manuscript | www.dovepress.comDovepressDovepress112Aggarwal and Swanwickalign strategy to establish direction for individuals and thesystems in which they work, while managers are processdriven and use problem solving to direct individuals andresources to achieve goals already established by leader-ship.1,34,35 As described in an influential report from theKing’s Fund, leadership, management, and administrationare interdependent since ... without leadership there can beno effective management – because the organization will notknow what it is meant to be doing – and without good admin-istration management can be rendered ineffective (p 1).36If we accept Mintzberg’s theory that health care organi-zations exhibit an inverted power structure, a new leadershipparadigm emerges. Those providing front-line service havesignificant influence over the operational activities, result-ing in a range of patient- and population-related outcomescompared to those who occupy hierarchical positions ofauthority. Hence, clinical leadership becomes an inclusiveendeavor. By engaging champions of health care qualityat service-level, behaviors and attitudes on the front linecan be aligned with organizational vision, ensuring that theneeds of the patient are central in the organization’s aimsand delivery. This view of clinical leadership appeals toclinicians as it frames health care management around theleadership of change and improvement for the safety andquality of patient care. It is a discourse that also replaces theprevious one of professionals as the cause of problems inpublic service organizations and, crucially, begins to viewthem as part of the solution.Leadership models, trends, and contextsSwanwick and McKimm35 frame leadership as a socialconstruct, influenced by the preoccupations, sociopoliti-cal system, and cultural values of the time. The leadershiptheories and models espoused will influence the discoursesadopted and reflect societal views of how systems are orshould be organized. This is clearly crucial when we considerleadership development, as how leadership is conceptualizedwill profoundly influence approaches taken in the name ofits development. In the following sections, we summarizesome of the previous century’s most influential leadershipmodels and consider what might be needed for a 21st centuryhealth service.Trait theoryIn the first half of the 20th Century, “trait” theories emergedaround the ideal of the “Great Man” proposing that greatleaders (usually men, reflecting the position women had insociety at that time) had a defined collection of personalattributes, including ability, sociability, motivation, anddominance. This theory is attractive to doctors given theweight placed on key personal characteristics in their selec-tion process, but as Willcocks37 maintains, while many doc-tors may possess leadership qualities, these are not equallydistributed and some doctors may be able to employ thesein a clinical encounter, but not necessarily in the dynamicgroup context of leadership. Literature reviews in the 1970sfailed to consistently identify the personality traits thatdistinguish leaders from nonleaders, although one morerecent review has identified a weak positive correlationbetween successful leaders and three of the “big five” per-sonality factors – extroversion, openness to new experience,and conscientiousness.38 Additionally, leaders had a weaknegative correlation with neuroticism, but interestingly, norelationship was found to the extent to which the leader isagreeable. Another review in the context of school leader-ship found less emphasis or correlation on these “innatequalities” with successful leadership.39Leadership stylesFrom the 1950, greater emphasis began to be placedon leadership styles and behaviors rather than personalcharacteristics. In part, this was a reaction to the deficienciesof the trait approach and its failure to recognize the contextin which leadership occurred. The shift in theory focusedon two aspects – how leaders made decisions and on whatthey were focused. Many taxonomies for decision-makingstyles developed, but the most famous is perhaps that ofTannenbaum and Schmidt40 who describe a continuum ofleadership behavior from autocratic (“do as I say”) to abdi-catory (“do what you like”). Other styles embraced teammanagement, where leadership is focused on results or thepeople in the organization,41,42 or an authoritative mannerwhich mobilizes empathetically toward a vision.43 Thesestyles are attractive for clinicians in leadership roles as theyembrace balancing the needs of patients and team memberswithin an environment where resources are constrained andmanagement targets need to be met.Contingency theoriesIn order to recognize the complexity and context of differentsituations, contingency theories became popular in the 1960s,the concept being that leaders should adapt their style to thecompetence and commitment of followers, using a range ofinterventions, such as directing, coaching, supporting, anddelegating. Such an approach requires not only awareness ofJournal of Healthcare Leadership downloaded from https://www.dovepress.com/ by 193.93.195.147 on 25-Aug-2018
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