Medical leadership and management: essential for the modern physician

Published
12 Nov 2018

12 Nov 2018

Namita Kumar is a postgraduate dean, consultant physician and rheumatologist, and elected member of Council at the RCP.

It is plain to see that the NHS is underfunded, underdoctored and overstretched. To alleviate the pressure, should physicians just concentrate on seeing as many patients as they can, as quickly as they can? Perhaps not.

Physicians who engage in leadership and management roles, in addition to service improvement, contribute to a more efficient and higher quality system. In 2008, Professor John Tooke stated:

The doctor’s frequent role as head of the healthcare team and commander of considerable clinical resource requires that greater attention is paid to management and leadership skills ... An acknowledgement of the leadership role of medicine is increasingly evident. Role acknowledgement and aspiration to enhanced roles ... are likely to facilitate greater clinical engagement.1

The GMC states that it is not enough for a clinician to act as a practitioner in their own discipline. Each doctor must offer leadership, and ‘work with others to change systems when ... necessary for the benefit of patients’.2

From the 1960s to the late 1980s, hospitals were managed by clinicians. Compared to traditional management structures, these organisations were managed from the bottom-up, rather than top-down. As such, doctors had power to block organisational strategy and processes if they disagreed with management. However, market forces have increased competition and corporate governance pressures, and hospitals are now managed by non-clinician managers, who were not promoted from within the clinical profession. This model has been criticised for being too top-down in its approach, removing the dynamic and flexible nature of the traditional professional-run hospital.3

This has led to a loss of autonomy and decision-making for doctors, and results in some of the frustration and loss of morale observed in the workforce. 

There have been a number of initiatives trying to improve the participation of doctors in leadership and management, but appointment to top roles is still rare. There are many reasons for this and some doctors still don’t see the value. A common misconception is that a leadership or management role suggests an abandonment of being a ‘proper doctor’. Physicians are required to have an understanding of, and some training in, professional management skills. Both clinical and professional leadership could be provided in one role, improving patient care and providing high-quality outcomes. Physicians trained as managers not only have a positive impact on their patients, but on the organisation and system in which they work.


The evidence

The Commonwealth Fund is a private foundation that aims to promote a high performing healthcare system to improve access, quality, and efficiency, particularly for society’s most vulnerable. Their research has shown that clinical leadership makes a systemic impact on improving outcomes for patients. In its report Designing a High-Performing Health Care System for Patients with Complex Needs, it recommends that clinicians be engaged in training and supported to become leaders.4

The Kings Fund has also reported that organisations in which doctors are more engaged with maintaining and enhancing the performance of the organisation perform better financially and clinically.5 Further, the Harvard Business Review has stated that the best hospitals are managed by doctors.6

This does not change the commonly accepted role of a doctor to treat and provide medical care, but rather it allows the doctor to support and lead systems that have a far greater impact. The role of the doctor is to provide the best care in the interests of the patient, population, and in my opinion, the system. 

The Consensus statement of the role of the doctor states:
Doctors ... must be capable of regularly taking ultimate responsibility for difficult decisions in situations of clinical complexity and uncertainty ... The doctor’s role must be defined by what is in the best interest of patients and of the population served.7

The study and theory of management has been developed considerably in the past 50 years. Being a manager and sometimes a leader – be that in delivery of clinical service as medical directors, in education and training as postgraduate deans or within our professional organisations and bodies – allows those of us with the skills and inclination to make a huge impact on patient care and quality. It allows us to take clinical care and the profession forwards. As we gravitate to a specialisation,
so should we gravitate to management and leadership out of the clinical environment.

It’s not for everyone, but for those of us who choose to lead, the profession must be supportive. Physicians are influenced most from within the profession, and it is the role of the royal medical colleges to provide professional influence to support physicians who take up leadership and management roles. 

We cannot be bystanders in poor management systems and poor decision making. We must all understand leadership and management, and this can only be done with education and professional influence.


References

  1. Tooke J. Aspiring to excellence. Edinburgh: Scottish government, 2008.
  2. GMC. Tomorrow’s doctors. London: GMC, 2009.
  3. Loh E. Doctors as health managers: an oxymoron, or a good idea? JWAM 7:52–60.
  4. The Commonwealth Fund. Designing a High-Performing Health Care System for Patients with Complex Needs. 2017.
  5. Bohmer R. The instrumental value of medical leadership. London: The King’s Fund, 2012.
  6. https://hbr.org/2016/12/why-the-best-hospitals-remanaged-by-doctors
  7. AOMRC. Value of the Doctor in Training. London: AOMRC, 2014.