engaging doctors in leadership · 2018-06-06 · quality improvement programmes besides the...

Engaging Doctors in Leadership: What we can learn from international

experience and research evidence?

Chris Ham and Helen DickinsonHealth Services Management Centre

Contents

3Enhancing Engagement in Medical Leadership

Page

Executive Summary 4

Introduction 5

Acknowledgements 5

The NHS context 6

Health care organisations as professional bureaucracies 8

The role of medical leaders in the NHS 10

Evidence from quality improvement programmes 13

International Experience 14

Kaiser Permanente 14

Conclusion 16

References 17

Appendix 1 19

Enhancing Engagement in Medical Leadership

Executive Summary

4

The NHS ContextDoctors have enjoyed a large measure of clinicalautonomy since the inception of the NHS.

Clinical autonomy began to be challenged in the1980s following the Griffiths Report and theintroduction of general management.

The Griffiths Report started the process of doctorstaking on leadership roles as medical directors andclinical directors.

The research evidence suggests that doctors retainedsignificant autonomy even after the introduction ofgeneral management.

Professional bureaucraciesThese research findings are best understood byreference to Mintzberg’s analysis of health careorganisations as professional bureaucracies.

In professional bureaucracies, front line staff have alarge measure of control by virtue of their trainingand professional knowledge.

Leaders in professional bureaucracies have tonegotiate rather than impose new policies andpractices, and work in a way that is sensitive to theculture of these organisations.

Control in professional bureaucracies is achievedprimarily through horizontal rather than hierarchicalprocesses.

Three implications follow: professionals themselvesplay key leadership roles, leadership is oftendispersed and distributed in microsystems, andcollective leadership is important.

Followership is also important to avoid professionalbureaucracies becoming disconnected hierarchies ororganised anarchies.

Medical leaders in the NHSProgress has been made in appointing doctors asmedical directors and clinical directors but theeffectiveness of these arrangements is variable.

In some organisations there appears to be much greaterpotential for involving doctors in leading change; inothers there are difficulties in developing medicalleaders and supporting them to function effectively.

Part of the explanation of these findings is theresourcing put into medical leadership and the limitedrecognition and rewards for doctors who take onleadership roles.

Also important is the continuing influence ofinformal leaders and networks operating alongsideformal management structures.

Tribalism remains strongly ingrained in the NHS andstaff who occupy hybrid roles, like doctors who gointo leadership, face the challenge of bridgingdifferent cultures.

Quality improvement programmesThe research evidence suggests that there is a linkbetween the engagement of doctors in leadershipand quality improvement.

Quality improvement programmes that fail to engagedoctors and that are not sensitive to the nature ofmedical work tend to have a limited impact.

However, many factors influence the impact ofquality improvement programmes besides theengagement of doctors and medical leadership.

Medical leadership is therefore best seen as anecessary but not sufficient condition for qualityimprovement in health care.

International experienceAmong the countries we reviewed, Denmark standsout for its efforts to engage doctors in leadershiproles and to provide training and support.

In the United States, Kaiser Permanente is a goodexample of an integrated delivery system that hassucceeded in involving a high proportion of doctorsin leadership.

In Kaiser Permanente, there is close alignmentbetween the health plan and the medical group, andthis contributes significantly to the levels ofperformance that are achieved.

Change is led by doctors in a culture that has beencharacterised as one of commitment by physiciansthemselves to improve care rather than compliancewith external requirements.

ConclusionThe NHS has an opportunity to learn frominternational experience to become an exemplar inmedical leadership and its development.

The education and development of doctors asleaders needs to be linked to appropriate incentivesand career structures, and reward and recognitionfor those taking on leadership roles.

Introduction


In January 2007 the NHS Institute for Innovation andImprovement commissioned the Health ServicesManagement Centre at the University of Birminghamto carry out two reviews in support of the EnhancingEngagement in Medical Leadership project beingundertaken in association with the Academy ofMedical Royal Colleges.

The first review was a rapid survey of experience in anumber of countries of arrangements for medicalleadership and the training and support provided todoctors in leadership roles. Experts in these countrieswere commissioned to write papers for the review,and these were discussed at a workshop in May. Thepapers were subsequently revised and edited, and afull report on this work can be accessed atwww.institute.nhs.uk/medicalleadership. Appendix 1 provides a high level summary of the mainfindings of the international survey.

The second review focused on the literature on medicalleadership. The review sought to examine the use ofthe term medical engagement and the existence of anyempirical evidence for its linkage to organisational orclinical aspects of performance. It also reviewedapproaches to the measurement of levels of medicalengagement in leadership. In addition, the reviewexamined research on experience in the NHS ofinvolving doctors in leadership. A paper presenting theresults of the literature review can be accessed atwww.institute.nhs.uk/medicalleadership.

The aim of this paper is to summarise key points fromboth reviews. Much of the paper is based on publishedliterature drawn from peer reviewed journals. Itssummary of the evidence reflects the findings ofresearch into medical leadership undertaken during thelast twenty five years. This evidence provides asystematic and research based overview of theevolution of medical leadership and the reasons why aconcerted focus on the training and support fordoctors taking on leadership roles is needed. Fullreferences and sources for the material presented herecan be found in the background papers prepared forthis project.

Acknowledgements

Thanks are due to Jane Bryson, Jackie Cumming,Erling Madsen, Mats Brommels, Dung Ngo, SonjaJerak-Zuiderent, John Clark and Peter Spurgeon fortheir contributions to this paper.


The NHS context

6

Doctors have enjoyed a large measure of freedom topractise in the way they consider appropriate for muchof the history of the NHS. As the Department of Healthput it in 1978:

Clinical autonomy was based on the negotiations thattook place at the formation of the NHS and theconcessions the government made to the BritishMedical Association to secure the support of themedical profession. Rudolf Klein has described the dealthat was struck in the following way:

Phil Strong and Jane Robinson argue that as a result ofthis deal the NHS was ‘fundamentally syndicalist innature’ (1990: 15) in that the medical profession wasable to control and regulate its own activities withoutinterference from politicians or managers.

As Klein has emphasised, the bargain struck at theinception of the NHS was a temporary truce rather than

a final settlement. If, as Harrison and Pollitt maintain,the role of the manager until 1982 was to act as adiplomat, appointed ‘to provide and organise thefacilities and resources for professionals to get on withtheir work’ (1994: 36), then the financial pressuresfacing the NHS in the 1980s caused a fundamentalreappraisal of this role and the relationship betweenmanagers on the one hand, and doctors and the otherhealth professions on the other. These issues came to ahead with the publication of the report of the Griffithsinquiry into NHS management which argued for asystem of general management to be introduced inplace of consensus management. The Griffiths reportcontended that general management was needed toprovide the NHS with effective leadership and to ensureclear accountability for decision making. The report alsoargued that hospital doctors ‘must accept themanagement responsibility which goes with clinicalfreedom’ (Griffiths Report, 1983: 18).

To this end, a number of demonstration projects wereset up to test out what was termed ‘managementbudgeting’ and in 1986 this was superseded by theresource management initiative. Building on theseefforts, most NHS hospitals implemented a system ofmedical management centred on the appointment ofsenior doctors as clinical directors responsible forleading the work of different services within thehospital. Clinical directors combine their managementand leadership roles with continuing but reducedclinical duties. They usually work with a nurse managerand a business manager in a directorate managementteam known as a triumvirate. Clinical directors oftencome together as a group with the medical director andchief executive to advise on developments across thehospital as a whole. The involvement of hospital doctorsin management was influenced not only by the Griffithsreport but also by developments at Guy’s Hospitalwhich pioneered this approach, drawing on theexperience of Johns Hopkins Hospital in the UnitedStates (Chantler, 1999).

Evidence on the impact of general management foundthat a more active management style resulted in whichmanagers were increasingly involved in questioningmedical priorities (Flynn, 1991). The extent to which thisled to a shift in the frontier of control betweenmanagers and doctors is disputed with the balance ofevidence maintaining that change was limited and that

‘At the inception of the NHS, the Governmentmade clear that its intention was to provide a

framework within which the health professionscould provide treatment and care for patients

according to their own independent professionaljudgement of the patients’ needs. This

independence has continued to be a central featureof the organisation and management of healthservices. Thus hospital consultants have clinical

autonomy and are fully responsible for thetreatment they prescribe for their patients. They are

required to act within broad limits of acceptablemedical practice and within policy for the use of

resources, but they are not held accountable to NHSauthorities for their clinical judgements.’ (DHSS

evidence to the Normansfield Report, 1978: 424-5).

‘Implicit in the structure of the NHS was a bargainbetween the State and the medical profession.

While central government controlled the budget,doctors controlled what happened within that

budget. Financial power was concentrated at thecentre; clinical power was concentrated at the

periphery. Politicians in Cabinet made the decisionsabout how much to spend; doctors made thedecisions about which patient should get what

kind of treatment’ (Klein, 2006: 61).


doctors retained significant autonomy and influence(Harrison, 1988; Harrison and Pollitt, 1994; Strong andRobinson, 1990). As Steve Harrison summarised theevidence:

Likewise, research into organisational change concludedthat many of the transformational changes that hadbeen initiated were not well embedded, and thedominance of the medical profession remained largelyintact (Ferlie et al, 1996). These findings are reinforcedby the review of events leading up to the failures inpaediatric heart surgery at Bristol in the 1990s whichdescribed a hospital in which the chief executive(himself a doctor) delegated a large measure ofresponsibility to individual doctors and clinical directors,and a culture that emphasised the importance of clinicalautonomy (Kennedy Report, 2001).

This brief summary of the evidence highlights therobustness of established relationships of power andinfluence in the NHS, and the strength of ‘tribalism’, inthe face of attempts to make the NHS morebusinesslike and to bridge the divide betweenmanagers and doctors. As Phil Strong and JaneRobinson concluded in their ethnographic study of theimpact of general management, the Griffiths reportthrew down a radical challenge to the NHS, in particulara ‘challenge to the syndicalist notion that the clinicaltrades knew best’ (97), but it was only a partial breakwith the past. From this perspective, the changesinitiated by the Griffiths report are best seen as the startof a long term process of renegotiating the role of themedical profession in the NHS. This process was tocontinue into the introduction of the internal marketinto the NHS in the 1990s and beyond, and wastherefore more akin to a permanent revolution than asudden coup (Strong and Robinson, 1990: 100).

To help interpret the findings of research into generalmanagement, we now draw on the literature on healthcare organisations as professional bureaucracies, as thisliterature provides important insights into the challenges

involved in leadership in hospitals. Having highlightedthe way in which organisational theory can help inunderstanding the role of doctors and managers inhealth care organisations, we will then return to NHSexperience and focus more specifically on research intothe role of clinical directorates and medical leadership.‘…although managers are more clearly agents of

government than before, and although the frontierof control between government and doctors has

shifted a little, in favour of the former, there is as yetlittle evidence that managers have secured greater

control over doctors’ (Harrison, 1988: 122).


Health care organisations asprofessional bureaucracies

8

In the language of organisational theorists such asHenry Mintzberg, health care organisations areprofessional bureaucracies rather than machinebureaucracies (Mintzberg, 1979). One of thecharacteristics of professional bureaucracies is that frontline staff have a large measure of control over thecontent of work by virtue of their training and specialistknowledge. Consequently, hierarchical directives issuedby those nominally in control often have limited impact,and indeed may be resisted by front line staff.

In this respect, as in others, professional bureaucraciesare different from machine bureaucracies (such asgovernment departments). More specifically, they havean inverted power structure in which staff at thebottom of the organisation generally have greaterinfluence over decision making on a day to day basisthan staff in formal positions of authority. It follows thatorganisational leaders have to negotiate rather thanimpose new policies and practices, working in a waythat is sensitive to the culture of these organisations.The following observation from a study of the impact ofbusiness process reengineering in an English hospitalsummarises the challenge in this way:

Control in professional bureaucracies is achievedprimarily through horizontal rather than hierarchicalprocesses. These processes are driven by professionalsthemselves who use collegial influences to secure co-ordination of work. In health care organisations,professional networks play an important role inensuring control and co-ordination, both within andbetween organisations, alongside peer review and peerpressure. Collegial influences depend critically on thecredibility of the professionals at their core, rather than

simply the power of people in formal positions ofauthority.

An important feature of professional bureaucracies inMintzberg’s view is that they are oriented to stabilityrather than change. Not only this, but also they arecharacterised by tribalism and turf wars betweenprofessionals who often identify more strongly with‘their’ part of the organisation, than with theorganisation as a whole. Put another way, professionalbureaucracies are made up of collections of‘microsystems’, to adapt the language used by PaulBatalden and colleagues at Dartmouth, comprisingmulti-professional teams responsible for day to daywork (Batalden et al, 2003).

Three implications for leadership follow. First, inprofessional bureaucracies, professionals play keyleadership roles, both informally and where they areappointed to formal positions. Much more so than inmachine bureaucracies, the background of leaders andtheir standing among peers have a major bearing ontheir ability to exercise effective leadership, and to bringabout change.

Second, professional bureaucracies arecharacterised by dispersed or distributedleadership. In health care organisations, clinicalmicrosystems are a particularly important focus forleadership. It follows that in professional bureaucraciesthere is a need for large numbers of leaders fromclinical backgrounds at different levels. A focus onleadership only at the top or most senior levels risksmissing a central feature of these bureaucracies.

Third, much of the evidence highlights theimportance of collective leadership in health careorganisations. Collective leadership has twodimensions: first, it refers to the role of leadership teamsrather than charismatic individuals; and second, it drawsattention to the need to bring together constellations ofleaders at different levels when major changeprogrammes are undertaken, as demonstrated byempirical research into leadership in Canadian hospitalsundertaken by Jean-Louis Denis and his colleagues(Denis et al, 2001).

To draw out these implications is to underscore not justthe nature of leadership in professional bureaucraciesbut also the importance of ‘followership’. Put simply,the large measure of control that front line staff have

‘Significant change in clinical domains cannot beachieved without the co-operation and support of

clinicians. . . . Clinical support is associated withprocess redesign that resonates with clinical

agendas related to patient care, servicesdevelopment and professional development. . . .

To a large degree interesting doctors in re-engineering involves persuasion that is often

informal, one consultant at a time, and interactiveover time . . . clinical commitment to change,ownership of change and support for changeconstantly need to be checked, reinforced and

worked upon’ (Bowns and McNulty, 1999: 66–7)


over the content of work can result in professionalbureaucracies becoming disconnected hierarchies oreven organised anarchies. Appointing respected andexperienced professionals to leadership roles is oftenadvocated as the response to this challenge. Chantler isone of the foremost advocates of this approach,arguing that in Guy’s Hospital:

However, in itself this may not be sufficient toaddress the need for control, co-ordination andinnovation. As well, health care organisations haveincreasingly recognised the requirement tostrengthen the role of all staff as followers (Silversinand Kornacki, 2000, emphasise this in their workon medical leadership in the United States) byinvesting in organisation development and not justleadership development.

As a final comment on the organisational theoryliterature, it is worth noting the argument thatprofessional bureaucracies have been superseded bynewer organisational forms. Two such forms have beendescribed, namely the managed professional business(Cooper, Hinings, Greenwood and Brown, 1996) andthe quasi market hospital archetype (Kitchener, 1999).In both forms, it is argued that management structuresand business values have been superimposed onprofessional bureaucracies and changed their nature.As we show in the next section, the evidence for theascendancy of new kinds of professional organisationsis weak, and it is for this reason that we haveemphasised the continuing importance of Mintzberg’swritings in understanding leadership and relationshipsin health care organisations.

‘By giving significant responsibility for theorganisation to those who actually delivered the

service, we aimed to reduce the disconnection thatoccurs in hospitals, as pointed out by Mintzberg,

between those at the top who organise the strategyand those at the service end who deliver care to

patients’ (Chantler, 1999: 1179)


The role of medical leadersin the NHS

10

In our summary of the impact of the Griffiths report,we emphasised the importance of seeing the report asthe start of a long term process of renegotiating therole of the medical profession in the NHS. Subsequentresearch in this area has underlined the challenges ofchanging deeply entrenched relationships. While somehospitals have made progress in using clinicaldirectorates to engage doctors in leadership roles andto achieve improvements in performance, others haveexperienced difficulties. These difficulties are starklyillustrated in a detailed study of leadership in an NHShospital in the 1990s undertaken by Paul Bate (2000).

In this hospital, consultants did not accept thelegitimacy of management, and as a result were ableto undermine managerial power. The hospital wascharacterised by sub-cultures centred on microsystemsthat were isolated from each other. This wasproblematic when change was attempted involvingmore than one microsystem, as it led to tensions andoften gridlock. Doctors held power and managersbecame afraid to challenge doctors lest they shouldface a vote of no confidence. Progress only becamepossible when doctors and managers agreed toestablish a ‘network community’ (504) in place of thesystem of clinical directorates which was seen to havebeen ‘a failed experiment’ (509).

A more mixed picture emerged from a survey of clinicaldirectorates in Scotland conducted by Lorna McKee andcolleagues. This survey found wide variations in the waydirectorates were constructed and conducted theirbusiness. Three major directorate types were identified(McKee, Marnoch and Dinnie, 1999). The dominanttype was described as ‘traditionalist’ and this wascharacterised by a strong focus on operational issuesand limited scope for innovation and change.Relationships between clinical directors and clinicalcolleagues remained embedded in a collegiate clinicalnetwork and were based on consensus building andfacilitation.

The second type was described as ‘managerialist’ andwas characterised by a business oriented approachmore in line with the philosophy of the Griffiths report.Clinical directors in managerialist directorates had directlinks with top managers in the hospital and were betterplaced to influence overall strategy and direction thanthose in traditionalist directorates. The third type wasdescribed as ‘power-sharing’ and involved clinical

directors working across established specialtyboundaries and operating as a team with the businessmanager and nurse manager.

McKee and colleagues note that the variability betweenclinical directorates shows the ability of doctors to adaptmanagerial initiatives. More importantly, they emphasisethe overwhelming sense of continuity rather thanchange, and ‘few examples of trusts creating a newclimate in which clinical directors of the future werebeing spotted, nurtured or sustained’ (110).Furthermore, clinical management was very thinlyresourced, with many directorates run on a shoestring.The minority of directorates that were not traditionalistheld out the prospect that clinicians could be developed

into innovative leaders, but for this to happen: In many ways, this study reaffirmed evidence from theorganisational theory literature relating to the tendencyof professional bureaucracies to be oriented to stabilityrather than change, while also underlining the limitedprogress in moving from professional bureaucracies tomanaged professional businesses.

Further confirmation of the persistence of establishedrelationships comes from Kitchener’s study of theimpact of quasi-market reforms on NHS hospitals(Kitchener, 1999). Drawing on Mintzberg’s writings,Kitchener hypothesises that the NHS reforms are anattempt to replace the professional bureaucracy withthe quasi-market hospital archetype. In this newarchetype, the hospital is based around clinicaldirectorates and medical cost centres, and a morebusinesslike approach to management is adopted,centred on medical cost centres and using enhancedmanagement information systems. Kitchener found thatin practice the impact of this new archetype was limitedand warns that:

‘more, and more senior, doctors will have to begiven the incentive to get involved, the relevanceof management will have to be actively marketedand the clinical legitimacy of doctor-managers will

have to be safeguarded’ (112).


He concludes that the notion of the professionalbureaucracy continues to provide an appropriate basisfor understanding the nature of hospitals asorganisations.

The challenges facing clinical directors were highlightedin a survey of doctor-manager relationships in GreatBritain by Huw Davies and colleagues. This surveyfound that senior managers such as chief executivesand medical directors were more positive about theserelationships than managers at directorate level.Among all the groups surveyed, clinical directors werethe least impressed with management and the mostdissatisfied with the role and influence of clinicians.Davies and colleagues argued that unless thedivergence of views they found were addressed then itwould be difficult to engage medical leaders in thegovernment’s modernisation agenda (Davies, Hodgesand Rundall, 2003).

This conclusion echoes other work which concludedthat clinical directors and other doctors in leadershiproles occupied a ‘no man’s land’ between themanagerial and clinical communities (Marnoch, McKeeand Dinnie, 2000). It is also consistent with the researchof Degeling and colleagues (2003) which has describedthe differences that exist among staff groups in relationto individualist versus systematised conceptions ofclinical work, and in terms of conceptions of thefinancial and accountability aspects of clinical work. Theexistence of these differences confirms the persistenceof tribal relationships in hospitals and the difficultiesfacing staff like doctors who go into management rolesin bridging different cultures.

On a more positive note, one of the mostcomprehensive studies of medical managers notedevidence that clinical leaders can play an influential roleas promoters of change. However, Louise Fitzgerald andcolleagues observed that, notwithstanding theproliferation of clinical director and medical directorroles, and the establishment of the British Association ofMedical Managers (BAMM) as a professional

association, clinical managers lacked a coherent identityand accepted knowledge base. They commented that:

In its work, BAMM has reviewed the development ofmedical management roles in the NHS, and has set outa proposed career structure for medical managers suchas medical directors, clinical directors and associatemedical directors (BAMM, 2004). BAMM’s proposalsemphasise the need to properly reward and recognisethe part played by medical management, and to makeit an attractive career option for skilled and motivateddoctors. These recommendations underline the need tolink the development of medical leadership toappropriate incentives and career structures. As BAMMhas argued:

Primary care was largely bypassed by the changes thatflowed from the Griffiths report, and only recently havethere been moves to strengthen management andleadership in primary care. Work by Rod Sheaff andcolleagues (2003) has described the impact of thesemoves in primary care groups and trusts in England.Lacking any formal, hierarchical authority over GPs,primary care groups and trusts worked through GPs

‘The fact that some hospital doctors have acceptedmedical-manager roles within a more integratedformal structure should not…be conflated witheither a loss of their professional autonomy or a

replacement of key elements of the PB (professionalbureaucracy) interpretive scheme’ (197).

‘Externally, there is no recognition of clinicalmanagement as a specialty, with limited

opportunities or credentials – and an unwillingnessto undertake major training. Other medical

professionals do not consider clinical managementto represent a medical specialty – rather clinical

managers uncomfortably span themanagerial/clinical divide and are not full or

influential members of either occupational group’(Fitzgerald, Lilley, Ferlie, Addicott, McGivern and

Buchanan, 2006: 170).

‘It is essential that medical management isrewarded and supported in a way that will attract

the strongest applicants to the posts. Currentlythere are a number of major deterrents – for

example the relative difficulties in describing anddefining management activities. These activities can

be more difficult to define as coherent sessionsthan is the case for clinical work. The lack of aclear concept of where a medical management

career move will take the individual also proves tobe a major barrier’ (BAMM, 2004: 24).

Enhancing Engagement in Medical Leadership12

who took on the role of clinical governance leads, andmanagers exercised influence by proxy through theseleads. Sheaff and his co-authors argue that clinicalgovernance leads used a range of informal techniquesto implement clinical governance in primary care, andthey use the terms ‘soft governance’ and ‘softbureaucracy’ to describe the relationships andorganisations they studied.

In summary, research into medical leadership in the NHSsince the Griffiths report highlights the challengesinvolved in developing the role of medical managers.While progress has been made in appointing doctors asclinical directors and in establishing clinical directorateswithin hospitals, the effectiveness of thesearrangements is variable. If in some organisations thereappears to be much greater potential for involvingdoctors in leading change, in most there remaindifficulties in changing established ways of doing thingsand in supporting medical leaders to play an effectivepart in bridging the divide between doctors andmanagers. Part of the explanation of these findings isthe resourcing put into medical leadership and thelimited recognition and rewards for doctors who takeon leadership roles. Also important is the continuinginfluence of informal leaders and networks operatingalongside formal management structures. Summarisingthe mixed experience of clinical directorates, Marnochconcluded his assessment in the following way:

‘The means of controlling the operationalperformance of hospital doctors have advanced

somewhat since the introduction of generalmanagement in the 1980s. Nevertheless, the

Griffiths-inspired drive to push resource-consumingdecisions down to the level where they could best

be made is far from complete. A traditionalcentralised style of management has been used to

make the internal market work. This form ofcontrol remains constrained in its influence over

clinical behaviour. At worst, medical directors andclinical directors will be used as go-betweens in a

familiar book-balancing exercise that involvesclosing wards periodically, not filling vacancies andcancelling operations. At best they are the basis for

a new strategically led style of corporatemanagement in the NHS’ (Marnoch, 1996: 61)

Evidence from qualityimprovement programmes


While engaging doctors in leadership may be importantin its own right, it is usually seen as a means toimproving the quality of health care. Evidence from anumber of studies shows that there is a link betweenmedical leadership and organisational performance. Forexample, an evaluation of the introduction of totalquality management (TQM) into the NHS by RichardJoss and Maurice Kogan found that the impact of TQMvaried across the pilot sites. In explaining variations inimpact, the study concluded that the application ofTQM to the NHS had to be done in a way that madesense to staff and that engaged doctors fully in itsimplementation (Joss and Kogan, 1995).

These findings were echoed in a detailed analysis of theimpact of business process reengineering (BPR) at theLeicester Royal Infirmary by Terry McNulty and EwanFerlie (2002). As in the evaluation of TQM, this analysisshowed that BPR had variable impact in the hospital,with the authors emphasising the difficulty ofimplementing a programme of this kind in professionalbureaucracies. Despite the fact that there was topmanagement support for BPR, this was insufficient forwidespread organisational change. Of criticalimportance was the power of consultants in thehospital and their ability to promote or inhibit change.Implementation of BPR had to be sensitive to the natureof medical work, and the importance of negotiatingchange with consultants.

Similar conclusions were reached by Chris Ham andcolleagues in a study of the implementation of thenational booked admissions programme in 24 pilotsites. The study found substantial variation in progressbetween the sites. Some areas were more receptive tochange than others and the most successful pilots werethose with a combination of a chief executive whomade it clear that booking was a high priority for theorganisation and medical champions who were willingto lead by example and exert peer pressure on reluctantcolleagues (Ham et al, 2003).

Evidence from outside the UK confirms these findingsand also emphasises the range of factors that affect theimpact of quality improvement programmes. DavidBlumenthal and Ann Scheck reported on theapplication of total quality management to hospitals inthe United States, drawing on the work of variousresearchers to highlight the potential contribution ofTQM while also acknowledging the challenges of

engaging physicians in so doing (Blumenthal andScheck, 1995). Stephen Walston and John Kimberley’sreview of reengineering in United States hospitalssummarised the facilitators of change as: establishingand maintaining a consistent vision; preparing andtraining for change; planning smooth transitions in re-engineering efforts; establishing multiplecommunication channels; ensuring strong support andinvolvement; creating mechanisms to measure progress;establishing new authority relationships; and involvingphysicians (Walston and Kimberley, 1997).

In another review, Ewan Ferlie and Steve Shortell (2001)conclude that medical leadership is an important butnot exclusive contribution to the effort to lead qualityimprovement in health care. They emphasise also theinfluence of what they term core properties such asorganisational culture, team and microsystemdevelopment and information technology. As Ferlie andShortell argue, system wide quality improvement hingeson action at a number of different levels – theindividual, microsystem, organisational and largersystem – and is likely to result in pockets of innovationand change unless action at these levels and in relationto core properties is co-ordinated.


International Experience

14

Appendix 1 summarises at a high level the mainfindings from the review of international experiencethat we undertook, covering Australia, New Zealand,Denmark, Sweden, Finland, Norway, the Netherlandsand Germany. The table shows the variety ofarrangements between countries in the involvement ofdoctors in leadership roles.

While it is unusual for chief executives of health careorganisations to come from medical backgrounds, in allcountries it is common for medical directors to berepresented at board level, and for physicians to take onleadership roles within hospitals, analogous to the rolesof clinical directors in the NHS. Often this is as part of aleadership team or triumvirate comprising a physician,nurse manager and general manager. It appears thatmedical leadership in primary care is less welldeveloped, other than the leadership roles thatphysicians take on in their medical practices.

Denmark stands out in the review as the country wherethere is an explicit aim of increasing the involvement ofdoctors in leadership roles. Specifically, there are medicaldirectors on the boards of all hospitals, and clinicaldepartments are required to have a physician as leader.Doctors are supported to take on leadership rolesthrough mandatory training at the postgraduate levelthat is based on demonstrating core competences inseven roles (derived from CanMEDS approachdeveloped in Canada). The training includes a 10 dayleadership course provided by the Danish regions andthe National Board of Health. After appointment asconsultants, doctors are offered a five day leadershipcourse.

Arrangements in the other countries included in thereview are less well developed. In the Nordic countriesother than Denmark, there has been some weakeningof the traditionally dominant role of doctors inleadership, driven by reforms that have strengthenedthe role of managers and challenged professionalautonomy. In Australia and New Zealand, there is noexplicit policy to increase the involvement of doctors inleadership roles, and training to support medicalleadership is patchy (for example, in Australia training isfocused at the state level, and is heavily dependent onthe role of professional bodies rather than governmentagencies). Only in the Netherlands is there evidence of amore systematic approach with the CanMEDS approach

having recently been adopted as a framework forleadership development.

In none of the countries reviewed is leadership trainingincluded in the undergraduate curriculum, and in allcountries there is a range of voluntary provisionavailable to physicians in mid career, provided byuniversities, medical associations, and others.

Kaiser PermanenteA widely cited example of an organisation in whichmedical leadership is well developed is KaiserPermanente in the United States.

Kaiser Permanente comprises the Kaiser FoundationHealth Plan, Kaiser Foundation Hospitals, and thePermanente Medical Groups. The Permanente MedicalGroups have a mutually exclusive relationship with thehealth plan and this generates a high degree ofcommitment on the part of physicians to Kaiser’sperformance and success. This relationship means thatthe fate of the medical groups and the plan isintertwined, and there is therefore a strong incentive forworking in partnership. It is this close alignment ofinterests that lies behind Kaiser’s performance.

A high proportion of doctors take on leadership roles inthe medical groups and these groups are in effect selfmanaging medical guilds working under contract to thehealth plan. It is within the medical groups thatagreement is reached on how care should be deliveredto patients. Change and improvement occur throughthe commitment of physicians to deliver the care theybelieve to be appropriate, rather than compliance withan externally imposed standard.

The result is a culture in which the most powerful staffgroup has taken responsibility for the performance ofthe organisation. Peer accountability for performance isemphasised within this culture and doctors are expectedto engage with their colleagues in reviewing practiceand performance. A substantial commitment is made tocareer long education and professional development inorder to sustain this way of working.

There is a degree of self selection in the medical groupswhich tend to attract doctors who prefer workingwithin an organised framework rather than in officebased practice. Part of this organised framework is acommitment to team working and to practising in


collaboration rather than competition. After serving an‘apprenticeship’, doctors are elected by their peers intomembership of the medical groups, at which point theybecome shareholders in the groups.

Permanente physicians are paid market rates and someof their income is in the form of bonuses based onperformance in areas like quality outcomes and patientsatisfaction. The remuneration package on offer createsan incentive for doctors to stay within the groups fortheir entire career with pension entitlements beingenhanced as retirement is reached. There is a strongfeeling of all physicians working together and withmanagers in the organisation in a closely alignedrelationship.


Conclusion

16

For much of the history of the NHS, doctors haveenjoyed a large measure of freedom to practise inthe way they consider appropriate, and thedevelopment of clinical directorates since theGriffiths report in 1983 has met with only partialsuccess. Tribalism remains strongly ingrained in theNHS and staff who occupy hybrid roles, like doctorswho become clinical directors, face the challenge ofbridging different cultures. Research into the impactof clinical directors highlights the difficulties ofintroducing new ways of working into the NHS, thestrength of traditional relationships, and theorientation to stability rather than change. Theevidence also suggests that medical managementhas often been under resourced and the incentivesfor doctors to become involved in management havebeen weak.

The findings from empirical research confirm thepersistence of hospitals as professional bureaucraciesin which front line staff have a large measure ofcontrol by virtue of their training and specialistknowledge. Control and co-ordination are achievedprimarily through professional networks and collegialprocesses. In these bureaucracies, professionalsthemselves play key leadership roles, both informallyand where they are appointed to formal positions;leadership is dispersed and distributed; and collectiveleadership is critically important. In the absence ofhierarchical control, followership is also important inenabling leaders to function effectively, as is the roleof doctors who are leaders by virtue of their personalcredibility. The use of ‘soft governance’ techniquesby medical leaders is also relevant. There is littleevidence that professional bureaucracies have beensuperseded by newer organisational forms such asthe managed professional business and the quasimarket hospital archetype.

On the basis of the review of internationalexperience, it appears that there is most potential forlearning from Denmark and Kaiser Permanente. Thelearning from Kaiser Permanente relates not only toits investment in leadership development, importantas this is, but also to the creation of a system,shaped over many years, that is closely aligned withthe challenges of leadership in professionalbureaucracies. Key features of this system are theappointment of a large number of doctors to

leadership roles, an emphasis on horizontal orcollegial processes of control and co-ordination, anda culture in which autonomous professionals acceptthe need to work in partnership with their peers andwith managers.

One important caveat that needs to be registered isthat medical leadership in itself is unlikely to deliverthe transformational changes the NHS is seeking toimplement. As the review of the evidence shows,bringing about change and improvement in healthcare organisations is complex and hinges on theinteraction of several factors. Medical leadershipneeds to be developed alongside other strategiesand has to be supported and valued by strategicleaders at all levels in the NHS, including those at thevery top.

What our work also confirms is that there is anopportunity for the UK to use this learning and tobecome an exemplar in medical leadership and itsdevelopment, building on existing activities. With theexceptions noted here, none of the countries studiedappears to have made more progress on these issuesthan the UK, and the project being led by the NHSInstitute for Innovation and Improvement and theAcademy of Medical Royal Colleges has the potentialto position the UK at the leading edge ofinternational practice. As this project goes forward, itis important to learn from the experience that hasbeen gained in the 25 years that has elapsed sincethe Griffiths report, not least to ensure that arenewed commitment to the education anddevelopment of doctors as leaders is linked toappropriate incentives and career structures, andreward and recognition for those taking onleadership roles.

Chris Ham and Helen Dickinson

February 2008.


References

British Association of Medical Managers (2004)Making Sense – a career structure for medicalmanagement, Stockport: The British Association ofMedical Managers

Batalden, P.B., Nelson, E., Mohr, J.J., Godfrey, M.M.,Huber, T.P., Kosnik, L., and Ashling, K. (2003)Microsystems in health care: Part 5. How leaders areleading. Joint Commission Journal on QualityImprovement, vol. 29, pp.297-308

Bate, P. (2000) Changing the culture of a hospital:from hierarchy to networked community. PublicAdministration, vol. 78, pp.485-512

Blumenthal, D. and Scheck, A. (eds.) (1995),Improving Clinical Practice, San Francisco: Jossey-Bass

Bowns, I. R. and McNulty, T. (1999), ReengineeringLeicester Royal Infirmary: an independent evaluationof implementation and impact, Sheffield: School ofHealth and Related Research, University of Sheffield

Chantler, C. (1999) ‘The role and education of doctorsin the delivery of health care’ Lancet, vol. 353,pp.1178-81

Cooper, D.J., Hinings, C.R., Greenwood, R., andBrown, J.L. (1996) Sedimentation and transformationin organisational change: the case of Canadian lawfirms. Organisation Studies vol. 17, pp.623-647.

Davies, H.T.O., Hodges, C., and Rundall, T. (2003)Views of doctors and managers on the doctor-manager relationship in the NHS. British MedicalJournal, vol. 326, pp.626-628

Degeling, P., Maxwell, S., Kennedy, J. and Coyle, B.(2003) Medicine, management and modernisation: a‘danse macabre’? British Medical Journal, vol. 326,pp.649-52

Denis, J.-L., Lamothe, L., and Langley, A. (2001) Thedynamics of collective leadership and strategicchange in pluralistic organisations. Academy ofManagement Journal, vol. 44, pp.809-937

Ferlie, E., Ashburner, L., Fitzgerald, L., and Pettigrew,A. (1996) The New Public Management in Action,Oxford: Oxford University Press

Ferlie, E.B. and Shortell, S. (2001) Improving thequality of health care in the United Kingdom and theUnited States: a framework for change. The MilbankQuarterly, vol. 79, pp.281-315

Fitzgerald, L., Lilley, C., Ferlie, E., Addicott, R.,McGivern, G., and Buchanan, D.A. (2006) Managingchange and role enactment in the professionalisedorganisation. Report to the National Co-ordinatingCentre for NHS Service Delivery and OrganisationR&D (NCCSDO), London

Flynn, R. (1991) ‘Coping with cutbacks andmanaging retrenchment in health’ Journal of SocialPolicy, vol. 20 (2), pp.215-36

Griffiths Report (1983) NHS Management Inquiry,London: Department of Health and Social Security

Ham, C., Kipping, R., and McLeod, H. (2003)Redesigning work processes in health care: lessonsfrom the National Health Service. The MilbankQuarterly, vol. 81, pp.415-439

Harrison, S. (1988) Managing the National HealthService, London: Chapman and Hall

Harrison, S. and Pollitt, C. (1994) Controlling HealthProfessionals, Buckingham: Open University Press

Joss, R. and Kogan, M. (1995) Advancing quality:TQM in the NHS. Buckingham: Open University Press

Kennedy Report (2001) The Report of the PublicInquiry into children’s heart surgery at the BristolRoyal Infirmary 1984-1995, Cm 5207 (1) Norwich:The Stationery Office

Kitchener, M. (1999) ‘All fur coat and no knickers’:contemporary organisational change in UnitedKingdom hospitals, in Brock, D, Powell, M andHinings, C., Restructuring the ProfessionalOrganisation, London: Routledge

Klein, R. (2006) The New Politics of the NHS, fifthedition, Oxford: Radcliffe Publishing

McKee, L., Marnoch, G., and Dinnie, N. (1999)Medical managers: puppetmasters or puppets?Sources of power and influence in clinicaldirectorates. In A.Mark and S.Dopson (Eds)Organisational behaviour in health care: the researchagenda. Basingstoke: Macmillan Press Ltd


McNulty, T. and Ferlie, E. (2002) Re-engineeringHealth Care: the complexities of organisationaltransformation. Oxford: Oxford University Press

Marnoch, G. (1996) Doctors and Management in theNational Health Service, Buckingham: OpenUniversity Press

Marnoch, G., McKee, L. and Dinnie, N. (2000)Between Organisations and Institutions. Legitimacyand Medical Managers. Public Administration, vol.78, pp.967-87

Mintzberg, H. (1979) The Structuring ofOrganisations: a synthesis of the research,Englewood Cliffs, NJ: Prentice Hall

Normansfield Report (1978) Report of the Committeeof Inquiry into Normansfield Hospital, Cmnd 7357,London: HMSO

Sheaff, R., Rogers, A., Pickard, S., Marshall, M.,Campbell, S., Sibbald, B., Halliwell, S., & Roland, M.(2003) A subtle governance: 'soft' medicalleadership in English primary care. Sociology ofHealth and Illness, vol. 25, pp.408-428

Silversin, J. and Kornacki M. J. (2000) LeadingPhysicians Through Change, Tampa Fl: AmericanCollege of Physician Executives

Strong, P. and Robinson, J. (1990) The NHS UnderNew Management, Milton Keynes: Open University Press

Walston, S. and Kimberley, J. (1997) ReengineeringHospitals: Evidence from the Field, Hospital andHealth Services Administration, vol. 42 (2), pp.143-63


Summary of FindingsAppendix 1

1.

Ho

w a

re p

hys

icia

ns

invo

lved

in le

ader

ship

ro

les

in h

osp

ital

s?

a)

Are

ho

spit

al c

hie

f ex

ecu

tive

s u

sual

ly f

rom

med

ical

bac

kgro

un

ds?

Un

ited

Kin

gd

om

D

enm

ark

Swed

enFi

nla

nd

No

rway

Net

her

lan

ds

Ger

man

yN

ew Z

eala

nd

Au

stra

lia

Occ

asio

nally

, but

not

as a

gen

eral

rule

in m

ost

stat

es.

Que

ensla

nd a

ndW

este

rn A

ustr

alia

are

enco

urag

ing

the

appo

intm

ent

ofch

ief

exec

utiv

esfr

om m

edic

alba

ckgr

ound

s fo

rm

ajor

hos

pita

ls.

They

can

be

from

med

ical

back

grou

nds,

but

ther

e is

nore

quire

men

t fo

rC

EOs

to b

e fr

omm

edic

alba

ckgr

ound

s bu

tno

r is

ther

e an

yre

ason

why

the

yca

nnot

be

from

such

bac

kgro

unds

.

In p

rivat

e ho

spita

lsth

ey a

re u

sual

lyfr

om a

fin

anci

alan

d bu

sine

ssba

ckgr

ound

. In

univ

ersi

ty,

publ

ican

d no

n-fo

r-pr

ofit

hosp

itals

it v

arie

s.

CEO

s m

ay c

ome

from

med

ical

back

grou

nds

but

do n

ot u

sual

ly d

oso

.

Two

out

of f

our

regi

onal

hea

lthen

terp

rise

CEO

san

d si

x ou

t of

twen

ty-s

even

loca

len

terp

rise

CEO

sar

e ph

ysic

ians

.

One

out

of

twen

tyof

the

pre

sent

CEO

s is

a ph

ysic

ian.

CEO

s ar

e on

lyoc

casi

onal

lyph

ysic

ians

.

The

maj

ority

of

chie

f ex

ecut

ives

do n

ot h

ave

am

edic

alba

ckgr

ound

. In

200

7 it

is o

neou

t of

ten

CEO

s.

Very

few

CEO

sco

me

from

am

edic

alba

ckgr

ound

.

b)

Do

ho

spit

als

hav

e m

edic

al d

irec

tors

wh

o s

it o

n t

he

bo

ard

?

Un

ited

Kin

gd

om

D

enm

ark

Swed

enFi

nla

nd

No

rway

Net

her

lan

ds

Ger

man

yN

ew Z

eala

nd

Au

stra

lia

Yes,

usu

ally.

Not

as

a fo

rmal

arra

ngem

ent

whe

re a

med

ical

dire

ctor

is o

n th

ebo

ard

ex o

ffic

io.

How

ever

, som

ecl

inic

ians

are

elec

ted

to t

heir

DH

B go

vern

ing

Boar

d or

to

othe

rD

HB

Boar

ds.

In u

nive

rsity

,pu

blic

and

non

-fo

r-pr

ofit

hosp

itals

they

do;

in p

rivat

eho

spita

ls t

hey

dono

t as

the

man

agem

ent

stru

ctur

e is

mor

ebu

sine

ss o

rient

ed.

Alm

ost

all h

ospi

tal

boar

ds c

onsis

t of

two

or t

hree

boa

rdm

embe

rs, i

nclu

ding

a m

edic

al d

irect

or.

Med

ical

dire

ctor

sar

e m

embe

rs o

fth

e m

anag

emen

tte

am,

but

they

have

no

“pro

duct

ion

resp

onsi

bilit

y”(t

hey

hand

lequ

ality

, sa

fety

,pa

tient

com

plai

nts

and

med

ical

negl

igen

ce is

sues

).

Hos

pita

l med

ical

dire

ctor

s ar

em

embe

rs o

f th

em

anag

emen

tte

am, b

ut t

hey

have

no

“pro

duct

ion

resp

onsib

ility

” (th

eyiss

ue c

linic

algu

idel

ines

and

supe

rvise

prac

titio

ners

, and

hand

le p

atie

ntco

mpl

aint

s an

dm

edic

al

negl

igen

ce is

sues

).

Med

ical

dire

ctor

sar

e m

embe

rs o

fth

e m

anag

emen

tte

am,

but

they

have

no

“pro

duct

ion

resp

onsi

bilit

y”(t

hey

hand

lequ

ality

, sa

fety

,pa

tient

com

plai

nts

and

med

ical

negl

igen

ce is

sues

).

Yes,

the

med

ical

dire

ctor

s si

t on

the

boar

d of

dire

ctor

s,of

ten

as o

ne o

utof

thr

ee:

the

CEO

,nu

rsin

g di

rect

oran

d th

e m

edic

aldi

rect

or.

Med

ical

dire

ctor

s do

not

serv

e on

the

polit

ical

gov

erni

ngbo

ards

.

Yes,

thi

s is

are

quire

men

t, an

dth

ere

is an

incr

easin

g te

nden

cyfo

r m

edic

al d

irect

ors

to b

e re

crui

ted

exte

rnal

ly.


c)

Do

ph

ysic

ian

s h

ave

lead

ersh

ip r

ole

s w

ith

in h

osp

ital

, e.g

. as

lead

ers

of

clin

ics

and

div

isio

ns?

Un

ited

Kin

gd

om

D

enm

ark

Swed

enFi

nla

nd

No

rway

Net

her

lan

ds

Ger

man

yN

ew Z

eala

nd

Au

stra

lia

Yes.

The

re is

usua

lly a

med

ical

/clin

ical

dire

ctor

role

and

dire

ctor

s of

clin

ical

divi

sions

.

Yes.

The

re is

gene

rally

a C

hief

Med

ical

Off

icer

role

whi

ch is

oft

en p

art

of t

he e

xecu

tive

team

of

the

hosp

ital;

and

clin

ical

lead

ers

oper

atin

g at

clin

ican

d di

visio

n le

vels.

In u

nive

rsity

, pub

lican

d no

n-fo

r-pro

fitho

spita

ls th

ey d

o;m

ainl

y as

med

ical

head

s of

clin

ical

depa

rtm

ents

(Che

färz

te).

Alo

ngsid

e th

eir

clin

ical

tas

ks t

hey

are

incr

easin

gly

invo

lved

inm

anag

eria

l and

finan

cial

asp

ects

of

thei

r de

part

men

tsan

d ho

spita

l. In

priv

ate

hosp

itals

phys

icia

ns a

relim

ited

to t

heir

clin

ical

tas

ks a

ndar

e no

t in

volv

ed in

man

ager

ial a

spec

ts(th

ey c

an b

ein

volv

ed in

man

agem

ent,

but

not

as p

hysic

ians

).

Yes,

lead

ersh

ipro

les

at a

ll le

vels

ofth

e ho

spita

lor

gani

satio

n.

Mos

t di

visi

on a

ndde

part

men

t he

ads

are

phys

icia

ns b

utth

e po

sts

are

open

to o

ther

prof

essi

onal

s al

so.

Mos

t di

visio

n an

dde

part

men

t he

ads

are

phys

icia

ns, b

utm

unic

ipal

re

gula

tions

requ

iring

a m

edic

alqu

alifi

catio

n w

ere

abol

ished

dur

ing

the

1990

s.

Man

y di

visi

on a

ndde

part

men

t he

ads

are

phys

icia

ns,

but

a le

gal

requ

irem

ent

rese

rvin

g th

ose

post

s fo

rph

ysic

ians

was

abol

ishe

d in

199

4.

Yes,

man

y D

anis

hph

ysic

ians

are

lead

ers

of c

linic

san

d di

visi

ons.

Onl

yve

ry f

ew n

on-

phys

icia

ns a

rele

ader

s of

divi

sion

s at

larg

eho

spita

ls a

nd o

nly

phys

icia

ns a

rele

ader

s of

clin

ics.

Yes,

the

y ta

ke o

n a

rang

e of

role

s,of

ten

as c

linic

al o

rdi

visio

nal d

irect

ors.

Oth

ers

may

tak

e on

som

e co

rpor

ate

role

s e.

g. c

linic

algo

vern

ance

,ed

ucat

ion

and

trai

ning

, res

earc

han

d de

velo

pmen

t.

1.

Ho

w a

re p

hys

icia

ns

invo

lved

in le

ader

ship

ro

les

in h

osp

ital

s?


2.

Ho

w a

re p

hys

icia

ns

invo

lved

in le

ader

ship

ro

les

in p

rim

ary

care

?

a)

Do

pri

mar

y ca

re o

rgan

isat

ion

s h

ave

chie

f ex

ecu

tive

s w

ho

co

me

fro

m m

edic

al b

ackg

rou

nd

s?

Un

ited

Kin

gd

om

D

enm

ark

Swed

enFi

nla

nd

No

rway

Net

her

lan

ds

Ger

man

yN

ew Z

eala

nd

Au

stra

lia

The

divi

sions

of

Gen

eral

Pra

ctic

eus

ually

hav

e a

chie

fex

ecut

ive

with

am

edic

alba

ckgr

ound

.

This

is no

t a

requ

irem

ent;

and

no re

sear

ch h

asbe

en d

one

on t

his

issue

; how

ever

,so

me

Prim

ary

Hea

lthca

reO

rgan

isatio

ns(P

HO

s) m

ay h

ave

CEO

s w

ith m

edic

alba

ckgr

ound

s.

Prim

ary

care

isty

pica

lly b

ased

on

phys

icia

ns in

sol

opr

actic

es r

un a

ssm

all b

usin

esse

s.

Hea

lth c

entr

es a

reru

n by

CEO

s w

ithan

eco

nom

ican

d/or

adm

inist

rativ

eba

ckgr

ound

. Mos

tpr

imar

y ca

re is

prov

ided

by

GPs

eith

er in

sol

opr

actic

e or

sm

all

grou

ps. G

Pspr

ovid

e th

ele

ader

ship

in t

hese

prac

tices

.

Mun

icip

al“h

ealth

care

dire

ctor

s”,

who

lead

pub

lic h

ealth

and

prim

ary

care

are

very

sel

dom

phys

icia

ns.

Prim

ary

care

phys

icia

ns a

repr

ivat

e pr

actit

ione

rsco

ntra

cted

by

the

mun

icip

ality

.

Man

y pr

imar

y ca

rece

ntre

CEO

s,es

peci

ally

in s

mal

lan

d m

iddl

e siz

eor

gani

satio

ns, a

re“c

hief

phy

sicia

ns”

(med

ical

dire

ctor

s).

Very

sel

dom

inpu

blic

ly o

wne

dpr

imar

y ca

rece

ntre

s. P

rivat

eor

gani

satio

ns a

reof

ten

phys

icia

n-ow

ned

and

lead

.

In D

enm

ark

we

have

no

sepa

rate

prim

ary

care

orga

nisa

tions

.Pr

imar

y ca

re is

man

aged

by

the

five

Regi

ons,

inw

hich

the

Dire

ctor

s fo

rPr

imar

y C

are

are

non-

phys

icia

ns.

Very

few

CEO

sco

me

from

am

edic

alba

ckgr

ound

.

b)

Do

pri

mar

y ca

re o

rgan

isat

ion

s h

ave

med

ical

dir

ecto

rs w

ho

sit

on

th

e b

oar

d?

Un

ited

Kin

gd

om

D

enm

ark

Swed

enFi

nla

nd

No

rway

Net

her

lan

ds

Ger

man

yN

ew Z

eala

nd

Au

stra

lia

Yes

– on

the

Boar

ds o

f D

ivisi

ons

of G

ener

al P

ract

ice.

Aga

in, t

here

is n

ofo

rmal

rese

arch

on

this

issue

, but

it is

likel

y th

at s

ome

PHO

s ha

ve m

edic

aldi

rect

ors

who

sit

on t

heir

boar

ds o

rat

leas

t ha

vem

edic

al e

xper

ienc

eon

the

boa

rd (e

g,re

pres

entin

g th

ein

tere

sts

of G

Ps).

No.

Gen

eral

ly n

ot.

No.

The

chie

f ph

ysic

ian

is a

mem

ber

of t

hem

anag

emen

tte

am.

The

med

ical

dire

ctor

fun

ctio

n is

usua

lly o

rgan

ised

on t

he c

ount

y le

vel

(cou

nty

heal

thca

reor

gani

satio

nsin

clud

e pr

imar

yca

re).

We

have

no

med

ical

dire

ctor

sfo

r pr

imar

y ca

re.

Yes,

on

the

boar

dsof

prim

ary

care

trus

ts.


c)

Do

ph

ysic

ian

s h

ave

oth

er le

ader

ship

ro

les

wit

hin

pri

mar

y ca

re o

rgan

isat

ion

s?

Un

ited

Kin

gd

om

D

enm

ark

Swed

enFi

nla

nd

No

rway

Net

her

lan

ds

Ger

man

yN

ew Z

eala

nd

Au

stra

lia

Not

obv

ious

ly, t

heem

phas

is in

prim

ary

care

is o

nth

e G

P.

Yes,

alth

ough

thi

sis

not

wel

ldo

cum

ente

d.

They

may

do

inla

rger

par

tner

ship

and

med

ical

uni

tsbu

t th

ere

is no

rese

arch

into

the

lead

ersh

ip r

oles

of

phys

icia

ns in

the

seor

gani

satio

ns.

The

mai

nle

ader

ship

role

of

phys

icia

ns in

prim

ary

care

is in

runn

ing

thei

r ow

npr

actic

es.

No,

see

abo

veQ

2a).

But

mun

icip

alhe

alth

care

orga

nisa

tions

are

requ

ired

by la

w t

osa

lary

a m

edic

alof

ficer

res

pons

ible

for

infe

ctio

usdi

seas

e co

ntro

lan

d th

em

anag

emen

t of

acut

e ca

re a

nden

viro

nmen

tal

heal

th.

All

“hea

lthst

atio

ns”

(sur

gerie

s)of

a p

rimar

y ca

reor

gani

satio

n ar

e le

dby

“he

adph

ysic

ians

”.

Abo

ut h

alf

of t

hepr

imar

y ca

rece

ntre

man

ager

sar

e ph

ysic

ians

(th

eot

her

half

bein

gnu

rses

).

Man

y ph

ysic

ians

run

a on

e-pe

rson

ente

rpris

e in

prim

ary

care

,w

here

the

y ta

keca

re o

f da

ilyle

ader

ship

of

secr

etar

y an

dnu

rse.

So

me

prim

ary

care

phys

icia

ns a

regr

oupe

d to

geth

erat

the

sam

elo

catio

n. In

the

sepl

aces

one

of

the

phys

icia

ns lo

oks

afte

r th

e da

ilym

anag

emen

t an

dle

ader

ship

.

Som

e do

ctor

s w

illha

ve le

ader

ship

role

s in

prim

ary

care

trus

ts, e

.g. c

linic

algo

vern

ance

,ed

ucat

ion

and

trai

ning

, res

earc

han

d de

velo

pmen

t,an

d m

any

are

lead

ers

in t

heir

own

prac

tices

. So

me

are

posit

ivel

y em

brac

ing

the

new

lead

ersh

ipop

port

uniti

esaf

ford

ed b

yPr

actic

e-Ba

sed

Com

miss

ioni

ng.

2.

Ho

w a

re p

hys

icia

ns

invo

lved

in le

ader

ship

ro

les

in p

rim

ary

care

?


Un

ited

Kin

gd

om

D

enm

ark

Swed

enFi

nla

nd

No

rway

Net

her

lan

ds

Ger

man

yN

ew Z

eala

nd

Au

stra

lia

No

(not

fed

eral

ly).

The

only

Sta

tepo

licy

initi

ativ

esth

at c

ome

clos

e to

this

are

the

clin

ical

netw

ork

arra

ngem

ents

inm

any

Stat

es.

Not

real

ly. T

here

are

stat

emen

tsab

out

the

bene

fits

of c

linic

ians

inle

ader

ship

role

s bu

tno

off

icia

l pol

icy

that

we

are

awar

eof

.

A f

irst

atte

mpt

ism

ade

from

the

Ger

man

Med

ical

Ass

ocia

tion

(Bun

desä

rzte

kam

mer

) with

the

deve

lopm

ent

ofth

e cu

rric

ulum

on

med

ical

lead

ersh

ip.

But

they

are

repr

esen

ting

one

voic

e, t

he in

tere

sts

of p

hysic

ians

, of

man

y vo

ices

in t

hede

cent

ralis

ed a

ndfr

agm

ente

d se

lf-go

vern

ing

heal

thca

re s

yste

m o

fG

erm

any.

Not

exp

licitl

y, b

utim

plic

itly.

In t

hene

w c

urric

ula

phys

icia

ns a

retr

aine

d to

‘mas

ter’

all c

ompe

tenc

es o

fth

e C

anM

EDS

mod

el. L

eade

rshi

pan

d m

anag

emen

t is

only

one

of

the

com

pete

nces

and

isth

eref

ore

not

seen

as t

he p

rimar

y ai

m.

No.

No.

No.

Yes,

alre

ady

twen

ty f

ive

year

sag

o th

eim

port

ance

of

gett

ing

doct

ors

mor

e in

volv

ed in

the

lead

ersh

ip o

fho

spita

ls w

asac

know

ledg

ed.

Aft

er t

hat

med

ical

dire

ctor

s w

ere

appo

inte

d in

to t

hebo

ards

of

dire

ctor

sat

all

hosp

itals

.A

lso

the

curr

ent

heal

th p

olic

yap

prov

es t

hat

acl

inic

alde

part

men

tsh

ould

hav

e a

phys

icia

n as

ale

ader

.

Yes,

thi

s ha

s be

enan

obj

ectiv

e sin

ceth

e G

riffit

hs re

port

of 1

983,

and

has

rece

ntly

bee

nre

itera

ted

both

by

the

Secr

etar

y of

Stat

e in

The

Nex

tSt

age

Revi

ew a

ndby

the

chi

efex

ecut

ive

of t

heN

HS.

3.

Is it

an

exp

licit

aim

of

hea

lth

po

licy

to in

crea

se t

he

invo

lvem

ent

of

do

cto

rs in

lead

ersh

ip r

ole

s?


Un

ited

Kin

gd

om

D

enm

ark

Swed

enFi

nla

nd

No

rway

Net

her

lan

ds

Ger

man

yN

ew Z

eala

nd

Au

stra

lia

The

new

Aus

tral

ian

Cur

ricul

umFr

amew

ork

for

Juni

or D

octo

rsim

plie

s th

is w

ill b

eth

e ca

se b

utcu

rren

tly p

ract

ice

isun

clea

r.

Aus

tral

ian

Med

ical

Stud

ents

Ass

ocia

tion

(AM

SA) h

as a

Nat

iona

l Lea

ders

hip

Dev

elop

men

tse

min

ar, a

ndm

ento

ring

for

med

ical

stu

dent

s.C

onte

nt m

ore

focu

sed

onun

ders

tand

ing

and

influ

enci

ng t

hehe

alth

sys

tem

and

polit

ical

sys

tem

. A

ustr

alia

nIn

dige

nous

Doc

tors

Ass

ocia

tion

(AID

A)

and

Roya

lA

ustr

alas

ian

Col

lege

of

Phys

icia

ns (R

AC

P)m

ento

ring

for

indi

geno

us m

edic

alst

uden

ts.

Non

e of

the

sein

itiat

ives

ass

ess

com

pete

nce,

how

ever

one

expe

cts

that

the

curr

icul

umfr

amew

ork

wou

ldre

quire

som

eas

sess

men

t of

com

pete

nce.

Ther

e is

no s

uch

form

al t

rain

ing

offe

red.

Not

in g

ener

al;

alth

ough

the

re a

rein

crea

singl

yre

form

-cur

ricul

aw

hich

tak

e th

isas

pect

into

acco

unt.

Und

ergr

adua

test

uden

ts d

o no

tre

ceiv

e an

y tr

aini

ngat

all

conc

erni

ngle

ader

ship

role

s.

Med

ical

sch

ool

curr

icul

a va

ry.

Usu

ally

pub

liche

alth

,co

mm

unity

med

icin

e an

dfo

rens

ic m

edic

ine

cour

ses

cove

r th

eba

sics

of

the

heal

thca

re s

yste

m,

legi

slat

ion,

the

prof

essi

onal

rol

e,re

spon

sibi

litie

san

d du

ties

ofhe

alth

care

prac

titio

ners

and

the

impo

rtan

ce o

fte

amw

ork.

No

spec

ific

lead

ersh

iptr

aini

ng.

Med

ical

sch

ool

curr

icul

a va

ry.

Usu

ally

pub

liche

alth

, com

mun

itym

edic

ine

and

fore

nsic

med

icin

eco

urse

s co

ver

the

basic

s of

the

heal

thca

re s

yste

m,

legi

slatio

n, t

hepr

ofes

siona

l rol

e,re

spon

sibili

ties

and

dutie

s of

hea

lthca

repr

actit

ione

rs a

ndth

e im

port

ance

of

team

wor

k. N

osp

ecifi

c le

ader

ship

trai

ning

.

Med

ical

sch

ool

curr

icul

a va

ry.

Usu

ally

pub

liche

alth

, co

mm

unity

med

icin

e an

dfo

rens

ic m

edic

ine

cour

ses

cove

r th

eba

sics

of

the

heal

thca

re s

yste

m,

legi

slat

ion,

the

prof

essi

onal

rol

e,re

spon

sibi

litie

s an

ddu

ties

ofhe

alth

care

prac

titio

ners

and

the

impo

rtan

ce o

fte

amw

ork.

No

spec

ific

lead

ersh

iptr

aini

ng.

The

med

ical

stud

ents

will

not

get

any

form

altr

aini

ng f

or f

utur

ele

ader

ship

rol

es.

Dur

ing

thei

rcl

inic

al t

rain

ing

inth

e ho

spita

lde

part

men

tsst

uden

ts w

ill m

eet

cons

ulta

nts,

clin

ical

dire

ctor

san

d m

edic

aldi

rect

ors,

all

ofw

hom

in t

heir

lead

ersh

ipbe

havi

our

as r

ole

mod

els

som

ehow

will

influ

ence

the

way

med

ical

grad

uate

s lo

okin

to m

edic

alle

ader

ship

. C

ompe

tenc

e is

not

asse

ssed

.

Not

in g

ener

al,

alth

ough

the

foc

uson

pro

fess

iona

lism

at t

heun

derg

radu

ate

leve

lco

vers

som

e as

pect

sof

med

ical

lead

ersh

ip.

4. A

t th

e u

nd

erg

rad

uat

e le

vel,

wh

at t

rain

ing

an

d p

rep

arat

ion

do

ph

ysic

ian

s re

ceiv

e fo

r le

ader

ship

ro

les?

Wh

at is

th

e co

nte

nt

of

this

tra

inin

g?

Wh

op

rovi

des

it?

Is c

om

pet

ence

ass

esse

d a

nd

if s

o h

ow

?


Un

ited

Kin

gd

om

D

enm

ark

Swed

enFi

nla

nd

No

rway

Net

her

lan

ds

Ger

man

yN

ew Z

eala

nd

Au

stra

lia

Prac

tice

is no

tco

nsist

ent

natio

nally

.

Prof

essio

nal

deve

lopm

ent

ofre

gist

rars

nat

iona

lpr

ogra

mm

epi

lote

d.

Con

tent

foc

used

on p

ract

ical

tea

mm

anag

emen

t,m

ento

ring,

com

mun

icat

ion

and

self

man

agem

ent

skill

s.

Com

pete

nce

does

not

appe

ar t

o be

asse

ssed

.

Ther

e is

very

litt

lefo

rmal

post

grad

uate

trai

ning

off

ered

.So

me

priv

atel

yfu

nded

cou

rses

are

offe

red,

disc

usse

din

the

pap

er.

Com

pete

nce

does

not

appe

ar t

o be

asse

ssed

.

No.

Com

pulso

rytr

aini

ng a

ndpr

epar

atio

n ba

sed

on t

he s

even

com

pete

nces

of

the

Can

MED

S m

odel

,an

d pr

ovid

ed b

yun

iver

sity

depa

rtm

ents

inco

llabo

ratio

n w

ithre

gion

al in

stitu

tes.

St

uden

ts’

com

pete

nces

are

asse

ssed

by

usin

gse

vera

l ass

essm

ent

form

s.

Hou

se o

ffic

ers

may

tak

e el

ectiv

eco

urse

s on

man

agem

ent

and

lead

ersh

ip o

ffer

edby

som

eun

iver

sitie

s.Re

gist

rars

hav

e a

one-

wee

km

anda

tory

cou

rse

on “adm

inis

trat

ion

and

lead

ersh

ip”.

Hou

se o

ffic

ers

have

a m

anda

tory

six

teen

hour

cou

rse

on t

hehe

alth

care

sys

tem

and

legi

slatio

n as

wel

l as

soci

alin

sura

nce.

Reg

istra

rsha

ve a

tw

enty

hour

s m

anda

tory

cour

se in

“he

alth

adm

inist

ratio

n”,

whi

ch a

lso c

over

sth

e sp

ecia

list’s

role

as t

he le

ader

of

acl

inic

al t

eam

or

unit.

The

cour

ses

are

orga

nise

d by

med

ical

sch

ools

(dep

artm

ents

of

publ

ic h

ealth

). N

ode

fined

“co

recu

rric

ulum

” or

form

al a

sses

smen

tof

com

pete

ncy.

Som

e el

ectiv

eco

urse

s ar

e of

fere

dto

reg

istr

ars

bysp

ecia

lty

asso

ciat

ions

or

med

ical

sch

ools

.N

o de

fined

“co

recu

rric

ulum

” or

form

al a

sses

smen

tof

com

pete

ncy.

Dur

ing

spec

ialit

ytr

aini

ng it

ism

anda

tory

tha

tfu

ture

med

ical

spec

ialis

ts

can

docu

men

t co

reco

mpe

tenc

es in

seve

n ba

sic

role

s.Th

ese

are

asse

ssed

by e

duca

tion

talk

sw

ith t

heir

peer

supe

riors

. Th

etr

aini

ng in

clud

es a

ten

day

man

dato

ry c

ours

ein

“Le

ader

ship

,ad

min

istr

atio

nan

dco

llabo

ratio

n”,

prov

ided

by

the

Dan

ish

Regi

ons

(hos

pita

l ow

ners

)an

d th

e N

atio

nal

Boar

d of

Hea

lth.

Opt

iona

l tra

inin

g is

prov

ided

, mai

nly

thro

ugh

the

post

grad

uate

dean

erie

s. T

heco

urse

s on

off

er a

rem

ainl

y di

dact

ic in

orie

ntat

ion

and

may

also

incl

ude

asse

ssm

ent

of a

proj

ect.

Vario

us M

edic

alRo

yal C

olle

ges

doof

fer

som

ele

ader

ship

prog

ram

mes

as

wel

las

priv

ate

trai

ning

com

pani

es.

5.

At

the

po

stg

rad

uat

e le

vel,

wh

at t

rain

ing

an

d p

rep

arat

ion

do

ph

ysic

ian

s re

ceiv

e fo

r le

ader

ship

ro

les?

Wh

at is

th

e co

nte

nt

of

this

tra

inin

g?

Wh

o p

rovi

des

it?

Is c

om

pet

ence

ass

esse

d a

nd

if s

o h

ow

?


Un

ited

Kin

gd

om

D

enm

ark

Swed

enFi

nla

nd

No

rway

Net

her

lan

ds

Ger

man

yN

ew Z

eala

nd

Au

stra

lia

Gen

eral

ly t

rain

ing

is vo

lunt

ary,

alth

ough

part

icip

atio

n in

som

e pr

ogra

mm

esw

ill f

orm

ally

cou

ntto

war

ds c

ontin

uing

prof

essio

nal

deve

lopm

ent.

Con

tent

isge

nera

lly s

elf

awar

enes

s,st

rate

gic

thin

king

,m

anag

emen

t sk

ills,

som

eun

ders

tand

ing

ofle

ader

ship

conc

epts

.

Ass

essm

ent

ofco

mpe

tenc

e va

ries

acco

rdin

g to

the

prov

ider

. Mos

tlyth

ere

will

be

nofo

rmal

ass

essm

ent.

The

exce

ptio

n is

RAC

MA

who

do

asse

ss c

ompe

tenc

eof

ten

thro

ugh

viva

,or

pre

cept

orre

port

.

Ther

e is

very

litt

lefo

rmal

post

grad

uate

trai

ning

off

ered

.So

me

priv

atel

yfu

nded

cou

rses

are

offe

red,

as

disc

usse

d in

the

pape

r.C

ompe

tenc

e do

esno

t ap

pear

to

beas

sess

ed.

The

curr

icul

um o

nm

edic

al le

ader

ship

as o

ne p

rogr

amm

eou

t of

the

man

yan

d m

ainl

ym

edic

ally

foc

usse

dco

ntin

uing

med

ical

educ

atio

npr

ogra

mm

esof

fere

d by

the

Med

ical

Ass

embl

ies

(Län

derä

rzte

kam

mer

).Th

e co

mpe

tenc

e is

not

asse

ssed

; the

requ

irem

ents

of

the

prog

ram

me

are

fulfi

lled

byco

mpl

etin

gpr

evio

usly

agr

eed

task

s et

c.

Volu

ntar

y tr

aini

ngan

d de

velo

pmen

tpr

ogra

mm

es a

repr

ovid

ed b

yin

divi

dual

inst

itute

s.M

ost

com

mon

are

shor

t-te

rmm

anag

emen

tco

urse

s, s

uch

asho

spita

lm

anag

emen

t,ho

spita

l fin

ance

san

d he

alth

car

ela

w. H

owev

er,

com

pete

nces

are

gene

rally

not

asse

ssed

.

In-h

ouse

lead

ersh

ipde

velo

pmen

tor

gani

sed

byhe

alth

ent

erpr

ises

.H

ealth

ent

erpr

ises

offe

r jo

intly

a “

top

lead

ersh

ippr

ogra

mm

e” o

ver

four

mon

ths

tose

nior

lead

ers

ofal

l pro

fess

ions

, th

ecu

rric

ulum

cov

er-

ing

stra

tegi

c an

dfin

anci

alm

anag

emen

t a

ndan

inte

rnat

iona

lm

odul

e w

ith s

tudy

tour

s to

Sw

eden

and

Den

mar

k.

In-h

ouse

lead

ersh

ipde

velo

pmen

tor

gani

sed

byho

spita

ls or

mun

icip

aliti

es. N

ode

fined

“co

recu

rric

ulum

” or

form

al a

sses

smen

tof

com

pete

ncy.

A t

hree

-leve

lm

ultip

rofe

ssio

nal

lead

ersh

ipde

velo

pmen

tpr

ogra

mm

e w

ith a

natio

nal c

urric

ulum

will

sta

rt in

the

autu

mn

of 2

007.

Cou

rse

orga

nise

rsw

ill b

e m

edic

alsc

hool

s in

coop

erat

ion

with

othe

r fa

culti

es(b

usin

ess,

pol

itica

lsc

ienc

e). F

orm

alex

amin

atio

ns w

illbe

per

form

ed.

In-h

ouse

lead

ersh

ipde

velo

pmen

tor

gani

sed

byco

untie

s. N

ode

fined

“co

recu

rric

ulum

” or

form

al a

sses

smen

tof

com

pete

ncy.

Cou

rses

are

als

oof

fere

d by

cons

ulta

ncy

firm

san

d bu

sine

sssc

hool

s.

Aft

er r

egis

trat

ion

as s

peci

alis

ts t

hey

are

offe

red

a fiv

eda

y ba

sic

lead

ersh

ip c

ours

ein

the

prog

ram

me:

“Edu

catio

n fo

rPh

ysic

ian

Lead

ersh

ip a

ndM

anag

emen

t”.

The

mai

n is

sues

are

lead

ing

prof

essi

onal

s,qu

ality

, ch

ange

,le

ader

ship

in a

polit

ical

con

text

and

pers

onal

lead

ersh

ip.

Prov

ided

by

the

Dan

ish

Regi

ons

and

the

Dan

ish

Med

ical

Ass

ocia

tion

(the

empl

oyee

sor

gani

satio

n).

Com

pete

nces

are

asse

ssed

in o

wn

orga

nisa

tion

bym

anda

tory

yea

rlyta

lks

with

supe

riors

.

This

is va

riabl

e. A

nin

crea

sing

num

ber

of N

HS

trus

tspr

ovid

e tr

aini

ng in

-ho

use,

and

som

edo

ctor

s m

ay c

hoos

eto

tak

e a

Mas

ters

degr

ee w

hich

incl

udes

ele

men

tsof

lead

ersh

ip. T

heBr

itish

Ass

ocia

tion

of M

edic

alM

anag

ers

offe

rs a

rang

e of

lead

ersh

ipde

velo

pmen

tin

terv

entio

ns.

A n

umbe

r of

Roy

alC

olle

ges,

univ

ersit

ies,

tra

inin

gor

gani

satio

ns a

ndco

nsul

tanc

yco

mpa

nies

also

offe

r a

rang

e of

clin

ical

lead

ersh

ippr

ogra

mm

es.

6.

Wh

at t

rain

ing

an

d d

evel

op

men

t in

lead

ersh

ip d

o p

hys

icia

ns

rece

ive

afte

r re

gis

trat

ion

? W

hat

is t

he

con

ten

t o

f th

is t

rain

ing

? W

ho

pro

vid

es it

? Is

com

pet

ence

ass

esse

d a

nd

if s

o h

ow

?


Un

ited

Kin

gd

om

D

enm

ark

Swed

enFi

nla

nd

No

rway

Net

her

lan

ds

Ger

man

yN

ew Z

eala

nd

Au

stra

lia

Not

nat

iona

lcu

rren

tly.

Gen

eral

ly le

ft t

oSt

ate

heal

thde

part

men

ts,

Are

aH

ealth

Ser

vice

s &

hosp

itals

, m

edic

alan

d pr

ofes

sion

alco

llege

s/as

soci

atio

ns.

Ther

e is

a na

tiona

lle

ader

ship

prog

ram

me

offe

red

by D

istric

t H

ealth

Boar

ds N

ewZe

alan

d (D

HBN

Z)bu

t at

tend

ance

and

fund

ing

is le

ftto

indi

vidu

alho

spita

ls an

dpr

imar

y ca

reor

gani

satio

ns.

The

trai

ning

isor

gani

sed

on a

fede

ral a

ndLä

nder

-leve

l; bu

t it

is le

ft t

o th

ein

divi

dual

phy

sicia

nif

she

/ he

wan

ts t

ofo

llow

suc

h a

prog

ram

me

or n

ot.

Ther

e ar

e no

man

dato

ryst

anda

rds

to d

o so

.In

priv

ate

hosp

itals

the

situa

tion

isdi

ffer

ent;

but

also

ther

e it

is ve

rym

uch

unde

r th

edi

scre

tion

of t

hesp

ecifi

c ho

spita

lho

w t

o pr

ovid

ead

ditio

nal t

rain

ing

on le

ader

ship

.

It is

prov

ided

on

anin

divi

dual

bas

is.Se

e pr

evio

usan

swer

.Se

e pr

evio

usan

swer

.Se

e pr

evio

usan

swer

.Tr

aini

ng c

ours

esar

e pr

ovid

ed o

n a

natio

nal b

asis

.Th

e co

urse

dur

ing

spec

ialit

y tr

aini

ngis

fre

e an

d pa

id b

yth

e N

atio

nal

Boar

d of

Hea

lth.

The

five

day

lead

ersh

ip c

ours

eaf

ter

spec

ialit

yre

gist

ratio

n ar

ele

ft f

or in

divi

dual

hosp

itals

to

take

care

of

and

pay

for.

A r

ough

guid

elin

e is

tha

tne

w s

peci

alis

ts a

resu

ppos

ed t

oat

tend

dur

ing

the

first

tw

o-th

ree

year

s af

ter

first

appo

intm

ent.

Trai

ning

is n

otpr

ovid

ed o

n an

ysy

stem

atic

bas

isna

tiona

lly a

nd is

am

atte

r fo

r in

divi

dual

hosp

itals

and

heal

thca

re o

rgan

isatio

ns.

7. A

fter

reg

istr

atio

n, i

s tr

ain

ing

pro

vid

ed o

n a

nat

ion

al b

asis

or

is it

left

to

ind

ivid

ual

ho

spit

als

and

pri

mar

y ca

re o

rgan

isat

ion

s?


8. D

oes

a n

atio

nal

co

mp

eten

cy f

ram

ewo

rk e

xist

fo

r m

edic

al m

anag

emen

t an

d le

ader

ship

an

d c

om

pet

ency

?

Un

ited

Kin

gd

om

D

enm

ark

Swed

enFi

nla

nd

No

rway

Net

her

lan

ds

Ger

man

yN

ew Z

eala

nd

Au

stra

lia

No.

No;

how

ever

, it

may

be

that

thi

s is

incl

uded

inup

com

ing

deve

lopm

ent

of a

natio

nal

com

pete

ncy

fram

ewor

k fo

rdo

ctor

s.

The

curr

icul

um o

nle

ader

ship

can

be

cons

ider

ed a

s a

com

pete

ncy

fram

ewor

k; b

ut it

is vo

lunt

ary

and

not

com

pulso

ry.

Sinc

e 20

07 t

heC

anM

EDS

2000

mod

el h

as b

een

intr

oduc

ed. O

ne o

fth

e co

mpe

tenc

esw

ithin

thi

s m

odel

focu

ses

on m

edic

alm

anag

emen

t an

dle

ader

ship

.

No.

No.

No.

Yes

as p

art

of t

hedo

cum

enta

tion

ofco

re c

ompe

tenc

esdu

ring

spec

ialit

ytr

aini

ng.

One

of

the

seve

nco

mpe

tenc

es is

bein

g a

good

lead

er a

ndad

min

istr

ator

with

focu

s on

prio

ritie

s,m

anag

emen

t of

reso

urce

s, r

atio

nal

man

agem

ent

ofcl

inic

, ec

onom

ym

anag

emen

t an

dpe

rson

alle

ader

ship

with

prio

rity

of o

wn

use

of t

ime.

The

Briti

shA

ssoc

iatio

n of

Med

ical

Man

ager

sha

s de

velo

ped

ale

ader

ship

com

pete

ncy

fram

ewor

k –

asy

llabu

s fo

r D

octo

rsin

Man

agem

ent

and

Lead

ersh

ipPo

sitio

ns in

Hea

lthca

re.

The

join

t N

HS

Inst

itute

and

Aca

dem

y of

Med

ical

Roy

alC

olle

ges

proj

ect

has

deve

lope

d a

med

ical

lead

ersh

ipco

mpe

tenc

yfr

amew

ork

for

all

doct

ors

in t

heir

prac

titio

ner

role

s.


Un

ited

Kin

gd

om

D

enm

ark

Swed

enFi

nla

nd

No

rway

Net

her

lan

ds

Ger

man

yN

ew Z

eala

nd

Au

stra

lia

The

heal

th s

yste

mfr

agm

enta

tion

and

com

plex

itym

ay m

ake

itha

rder

for

an

indi

vidu

al t

o be

seen

to

lead

fro

mw

ithin

it.

Inst

itutio

nal

mec

hani

sms,

like

clin

ical

net

wor

ks,

seem

to

be m

ore

popu

lar

toen

cour

age

enga

gem

ent

inle

ader

ship

tha

ned

ucat

ion.

Med

ical

lead

ersh

ip(a

s w

ith le

ader

ship

in h

ealth

car

e in

NZ

gene

rally

) is

serio

usly

unde

rdev

elop

ed in

New

Zea

land

.Th

ere

is ba

sical

lyno

nat

iona

l pol

icy

on t

he is

sue,

and

the

trai

ning

is v

ery

ad h

oc.

Diff

eren

ce in

man

agem

ent

stru

ctur

e be

twee

npr

ivat

e ho

spita

lson

the

one

han

dan

d un

iver

sity,

publ

ic a

nd p

rivat

eho

uses

on

the

othe

r ha

nd;

tren

d to

war

dsas

simila

tion

ofm

anag

emen

tst

ruct

ures

inun

iver

sity,

pub

lican

d no

n-fo

r-pro

fitho

spita

ls to

priv

ate

hosp

itals

thro

ugh

incr

easin

gpr

ivat

isatio

n of

hosp

itals.

Med

ical

lead

ersh

ipis

com

mon

inal

mos

t al

l Dut

chho

spita

ls. H

owev

er,

only

sin

ce t

here

stru

ctur

ing

of t

hepo

stgr

adua

tecu

rric

ula

phys

icia

nsre

ceiv

e(c

ompu

lsory

)le

ader

ship

tra

inin

gan

d m

anag

emen

tde

velo

pmen

tco

urse

s.

The

2001

and

2002

ref

orm

s re

-es

tabl

ishe

d G

Ps a

spr

ivat

e en

trep

rene

urs

and

intr

oduc

edge

nera

lm

anag

emen

t in

toho

spita

ls,

whi

chde

mon

stra

bly

show

ed t

hede

clin

e of

the

prev

ious

ly v

ery

stro

ng m

edic

alin

fluen

ce in

Nor

weg

ian

heal

thca

re.

New

legi

slatio

n on

impr

oved

acc

ess

toca

re t

hat

intr

oduc

ed n

atio

nal

trea

tmen

tin

dica

tions

for

80

% o

f el

ectiv

epr

oced

ures

has

high

light

ed t

hele

gal r

espo

nsib

ility

of m

edic

al d

irect

ors

and

clin

ical

depa

rtm

ent

head

sto

ove

rsee

the

adhe

renc

e to

clin

ical

gui

delin

es“r

eins

tatin

g” a

med

ical

hie

rarc

hy.

Incr

easi

ngco

ncer

ns a

mon

gpo

litic

al d

ecis

ion-

mak

ers

and

adm

inis

trat

ors

rega

rdin

g th

e di

ffic

ultie

s to

recr

uit

phys

icia

nle

ader

s.

It is

wel

lac

know

ledg

ed in

the

med

ical

com

mun

ity t

hat

educ

atio

n an

dtr

aini

ng f

orm

edic

al le

ader

ship

is n

eces

sary

and

man

dato

ry f

orbe

ing

a go

odph

ysic

ian

lead

er o

fa

depa

rtm

ent

orcl

inic

al d

irect

or.

Itis

not

eno

ugh

just

bein

g a

med

ical

expe

rt s

ince

mor

ebr

oad

com

pete

nces

are

requ

ired

for

ago

od m

edic

alle

ader

ship

.

The

impo

rtan

ce o

fm

edic

al le

ader

ship

is in

crea

singl

yre

cogn

ised

as is

the

need

to

do m

ore

tosu

ppor

t do

ctor

s to

take

on

lead

ersh

ipro

les

and

tost

reng

then

tra

inin

gin

lead

ersh

ip.

9. P

leas

e lis

t an

y o

ther

sig

nif

ican

t fe

atu

res

on

med

ical

lead

ersh

ip in

yo

ur

cou

ntr

y?

© Copyright NHS Institute for Innovation and Improvement 2008.

Engaging Doctors in Leadership: What we can learn from international experience and research evidence? ispublished by the NHS Institute for Innovation and Improvement, Coventry House, University of Warwick Campus,Coventry, CV4 7AL

This publication may be reproduced and circulated by and between NHS England staff, related networks andofficially contracted third parties only, this includes transmission in any form or by any means, including e-mail,photocopying, microfilming, and recording.

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