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15 Feb 2019

BY AMA VICE PRESIDENT DR CHRIS ZAPPALA 

As I look around me in the healthcare landscape I notice a progressive, enervating loss of good quality medical leaders – both in the public and private sectors as well as in community practices. Even more worrying is the perplexing trend for institutions/hospitals to marginalise medical administration and often hand duties over to non-medical professionals who have less formal training e.g. a FRACMA. Medical input is becoming more ‘advisory’ rather than the doctors having true responsibility and decision-making authority and strategic influence. This is a big problem for the profession – but also for institutions, practices and our patients. 

Is this worrying diminution and marginalisation of medical leadership because of our own torpor and misguided lack of desire to fill these posts (to our peril)? Perhaps we are fairly beaten in an open and transparent selection process? Does the wider medical profession wholeheartedly support doctors in leadership positions appropriately? Whatever the reason, I regard the loss of medical leadership as one of the most substantial threats currently facing the medical profession. Even when people agree, there seems perplexingly insufficient action from all doctors to improve our leadership prospects. I therefore want to spell out the strong case for medical leadership to be nurtured and reclaimed and point a pathway forward. 

Where we started to go wrong

Clinical governance is the framework through which organisations achieve and safeguard a high quality service. It is necessary to acknowledge that doctors provide a valuable contribution to the quality of patient care through diagnosis and treatment. By taking crucial decisions regarding clinical care and therefore resource utilisation, clinicians need to be at the heart of clinical governance1.  While doctors view clinical governance as essential, they are increasingly disillusioned and some are sceptical of the benefits. Not surprisingly, the knowledge and application, as well as perceived utility by medical professionals of clinical governance tools (e.g. risk management), are associated with the mortality rate of their units and with some efficiency indicators. However, the medical frontline staff seem to not consider homogeneously useful the clinical governance tools application on its own clinical practice1. We are vexingly dubious therefore of an integral component of enlightened medical leadership. 

The NHS has served as a microcosm of change since the Griffiths report in 1983. Doctors were challenged, threatened and removed by non-clinical or at least non-medical managers asserting commercial/business management and rules (there is much more to the post-Griffith reforms in which he also argued for medical leadership to become a much higher priority). It was perceived that doctors subsequently disengaged from the management and leadership of the NHS with the consequent alienation of the medical profession. Unfortunately, doctors then abrogated their responsibility and ‘retreated’ to clinical work alone2. We see this self-destructive attitude in Australia too. 

The ripple effects of this were felt everywhere. Nonetheless, a quiet body of work was building which showed that clinicians delivering high-quality health leadership, particularly in the USA, pointed the way towards improved patient outcomes. It is now recognised that a lack of clinician involvement hinders the achievement of progressive, high-quality care2. A younger generation of doctors demand a higher level of emotional intelligence and a corporate outlook, coupled with a patient-focused leadership style borne from a deep and wide understanding of the political, financial and business skills required to operate organisation successfully2. This can be difficult to find.

The Francis report which followed the Stafford Hospital scandal in the late 2000s highlighted that one of the factors behind patients dying unnecessarily or being harmed was the disengagement of doctors3. Several studies show a clear and positive relationship between medical engagement and organisational performance, reinforcing the view that involving doctors in leadership roles is not an optional extra, but central to raising standards of patient care3. In this we must be active participants and not over-emphasise the travail of medical leadership training and participation.

Clearly, to be a good clinician alone does not imply someone will be a good leader or medical administrator. In Scandinavia it was found that doctor-managers significantly based decision-making on personal professional experience, i.e. they still act as clinicians4. This effect was irrespective of their level within the structure or gender. Doctor leaders cannot therefore be chosen based on clinical prowess or the ‘last person standing’. 

The profession can however break free from its insouciance and enervating scepticism of management to become superlative, progressive participants that shape organisational culture and healthcare reform.

Can we do better with doctors in charge?

In daily practice, doctors have a significant impact on resource utilisation; deliver and influence the quality of medical care and; affect the speed and extent to which changes occur in medical practice5. Successful healthcare organisations must be able to leverage the unique perspective of medical leaders as these institutions strive to innovate and adapt in a competitive environment where their main business is providing clinical services to patients. Thus, developing medical leaders in medicine is essential, especially given the dynamic demands of the current health system. Critically, doctors develop greater organisational awareness through leadership courses e.g. financial, planning, human resources and marketing5. More on this later. Parts two and three of this discussion will appear in my subsequent columns.

 

References

  1. Sarchielli G et al. Is medical perspective on clinical governance practices associated with clinical unit performance and mortality? SAGE Open medicine 2016; 4:1-12.
  2. Nicol E et al. Perspectives on clinical leadership: a qualitative study exploring the views of senior healthcare leaders in the UK. J RSM 2014, 107(7):277-286.
  3. Ham C. Medical Leadership is vital for quality patient care. Health Services Journal. 2013.
  4. Elina V et al. Doctor-managers as decision makers in hospitals and health centres. Journal of health Organization and Management. 2006, 20(2):85-94.
  5. McAlearney AS et al. Developing effecting physician leaders: changing cultures and transforming organisations. Hospital Topics. 2005, 83(2):11-18.

 


Published: 15 Feb 2019