Possibilities and pitfalls for clinical leadership in improving service quality, innovation and productivity

Abstract

The idea that something called ‘clinical leadership’ is the favoured ‘answer’ to many of the huge challenges facing the NHS has been advanced with increasing intensity. Inter alia, Lord Darzi in the Next Stage Review emphasised the importance of clinical leadership; the Health and Social Care Act (2012) puts clinicians to the fore; and the Royal Colleges have accepted the need for Medical Leadership Competences to be defined and developed. Despite such emphasis and expectation, the reality of clinical leadership attempts to redesign services across the extant boundaries of the NHS and which reveal how the many barriers can be overcome, has not so far been studied. The overall research question was: What can be learned from the experience of enacting the Darzi model of clinical leadership in practice? What are the main enabling and constraining conditions for its effective realization and performance? Subsidiary research questions that feed-in to this main research question were: 1) What general lessons about its nature and its practice can be educed from a series of examples of effective clinical leadership in introducing more integrated models of care? What variations are required when enacting the model in very different service areas? 2) What are the enablers and the blockers of effective clinical leadership? 3) How do effective clinical leaders both initiate and lead service improvements while also engaging constructively with top-down service redesign and improvements initiatives? 4) How do service-level clinical leaders in acute and primary care develop and implement service quality improvements through achieving greater integration between primary and acute care? How do they go about mobilising other clinicians while also engaging with commissioners and managers? The main findings of the study were: 1. The obstacles to the exercise of the clinical leadership of cross-boundary service redesign within the context of the NHS are many. 2. Despite the extent and severity of the obstacles, we found some significant examples of clinical leadership of service redesign which were all the more impressive because of the challenges that had to be surmounted. 3. In general, clinical leadership was found to occur at multiple interlocking levels and the role of clinicians in shaping national policy should not be underestimated. Many of the important changes required national endorsement – and often funding – in order to put traction behind good ideas. 4. Successful clinical leadership requires the enactment of skilful practice across a number of constellations including collaborative working with a host of actors including managers, IT staff, project managers, estates and many others. 5. Clinical leaders were capable of being open to new ideas and new knowledge while also having the political wisdom to seek new reworked boundaries around which professional identity could be redefined and reformed. 6. Implementation leadership was important; it is the essential minimum for change. 7. Informal, lateral, leadership can mobilise and bring along clinical colleagues and conversely formal project planning on its own can be relatively ineffective but the most effective service redesigns were achieved when both of these processes worked in tandem