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Leadership Lessons

Putting the right leaders in strategic clinical leadership roles

Written by: Andrew Vincent, Medicology Ltd. Published: 3rd June 2010

When it’s time to volunteer for the role of Clinical Director, people often say “everyone took a step back but I was the slowest”. With comparatively few exceptions, some surgical specialities being notable, services the length and breadth of the country have a reluctant leader at the helm. When service ‘administration’ was the order of the day, this held comparatively little disadvantage but as we move towards strategic service leadership or indeed Service Line Management, this all too common finding potentially denies services the natural drive that is necessary to excel in a harsh, competitive economic climate. And that’s not the only problem...

Enabling leadership

Lord Darzi, the Tooke Report and about every major leader has emphasised the need for greater leadership at the clinical coalface. With significant levels of activity in leadership development existing in many organisations, few have addressed the issue of ‘who’ would make the right leader. Perhaps with so many taking the step back, organisations are just glad to have anybody, let alone the right person and yet successful services will need talented leaders equipped with the right skills and insight.

Organisations will need to devote greater attention to talent management in the new era but that very much begins with what we call ‘enabling leadership’. Enablement can be broken down into four facets:

• Will
• Skill
• Capacity
• Authority

Effective leadership relies on leaders that want to lead and have the right drive (will), have the necessary skills to lead effectively, are given the space in which to lead and in whom authority is placed, often termed ‘freedom to operate’. Focus is currently being placed on the ‘skill’ aspect of leadership, with little or no attention being placed in the others areas. Unless this is addressed, leadership will struggle to deliver the mandate being vested in it.

The will to lead

Looking at leaders throughout history, a defining factor amongst the majority is a passion for their chosen subject. In health, there are no shortages of doctors passionate about their field of medicine. However, this highly intellectual, often genuinely altruistic group entered medicine because they were passionate about medicine, not service leadership. Service leads that take up the role because of that driving passion often find themselves at odds with Trust senior managers, who are naturally focused on targets, performance, revenue, cost etc. In fact, many of those passionate individuals relinquish the service leadership role early, as the job requirements take them away from their chosen subject and lean them heavily towards ‘business’.

Besides this mismatched focus, there are many other factors that contribute to insufficient will to lead and Trusts need to consider them carefully. Firstly, the role of service leader is seen as an overwhelming role, administrative in nature and with comparatively little reward. Trusts need to consider carefully how service leaders are supported in their work and indeed how the work environment around service leadership is structured to bring out their best whilst avoiding making it so unpleasant that it’s just a matter of time before any enthusiasm drifts.

Service leaders often feel unprepared and out of depth when they take on the leadership role. In truth, the vast majority of service leaders have received no training in service leadership, let alone strategic leadership when they take up the role. Besides the obvious impact in the skills area, that has the potential to leave doctors feeling insecure or uncertain about their ability to lead effectively – in their eyes an unnecessary risk this far into a career and complete against the grain of medical development which develops first and releases second (at least that’s how it’s supposed to work). Trusts need to consider developing potential leaders, rather than just current leaders, with opportunities to develop skills, insight and mindset ahead of taking up the role.

The skills to lead

Service leaders need a heightened level of skill in leadership, certainly more than is acquired by osmosis and common sense, albeit the two most common development methods in leadership. For consistency across services, adoption of robust leadership models ensure that leaders understand how to act and can access support from other leadership peers when necessary. However, when considering skills of leadership, we have to go beyond the boundaries of leadership itself. To lead effectively in a competitive environment, leaders need knowledge skills and insight in three key areas (table 1).

Table 1 is not designed to be comprehensive but it does highlight the sheer weight of knowledge and skill that an effective service leader needs to have in order to thrive in the role. Moreover, a leader that is not equipped with these facets is being set up to fail not only the role of leadership itself but the service as a whole. It’s no small wonder that good doctors are reluctant to take on what can seem as an unpleasant, poisoned chalice.

The capacity to lead

Service leaders tend to retain many of their original functions. For instance, they continue to practise as doctors, teach students and trainees and engage in research. A typical service leader will be granted between 1 and 2 programme activities, effectively a day at best, in which fit service leadership. If we looked at the above development list alone it could take a service lead six months of their day per week (less holidays) just to get up to speed, let alone fully operational in the role. Besides affirming the vital necessity to grow service leaders ahead of the role, it highlights perhaps one of the greatest challenges facing service leaders – capacity to lead.

When asking so much of service leaders, we need to consider the ‘space’ in which they operate. The administrative side of service leadership often takes more than a day per week, especially in services with major initiatives under way. In fact, this aspect of service leadership is not leadership at all; it is management i.e. the implementation of direction, plans and performance, not the setting of it and leadership of people. Consequently, although all services need effective leadership, their leaders are granted no (zero, zip, diddly squat) time in which to lead. When leadership is concerned with setting strategic direction and keeping the people aligned and on board, it is no small wonder that the default position of many services is comparatively little more than reactive to today’s healthcare load, delivered by battle-weary, de-motivated staff with low morale. This is the almost guaranteed output of absent leadership.

This is a lesson that many Trusts will learn the hard way. In a competitive environment, the nimble and directed survive and thrive at the expense of the inert. Absent leadership within services will lead to those services constantly playing catch up i.e. they will evolve only when the cost to not evolving is so great and imminent that they have no choice. This is a weak position and will inevitably lead to service distress and demise.

The authority to lead

Senior doctors have seen a significant erosion of autonomy in recent years, contributed to by many factors, each undermining our natural need for significance and collectively leaving doctors feeling like worker bees and administrators after a career of aspiration to leadership. Negative factors include (table 2).

These factors leave doctors feeling that they are simply administrative pawns in an increasingly cruel system, which apart from undermining the will to lead, can leave them feeling that their authority is in title only. Leadership needs the mandate to act, in combination with the other facets of enablement, in order to breed passion, commitment and responsibility. Presently, service leaders can all too easily preside over service distress and account for this out of the environment and circumstances. Arguably the most prominent circumstance is the Trust’s failure to enable effective leadership and this is a lesson that needs learning early.

The right leaders

In summary, the right leader is one who desires the role and is equipped with the knowledge, skills and insight necessary to excel in the modern environment. Moreover, successful leaders will know their environment inside out, have the space in which to apply leadership practises effectively and the freedom to operate in order to make things happen. Doctors as service leaders is undoubtedly the right approach, as they have the intellectual capacity to marry complex clinical understanding with strategic insight, finance and business planning. However, if they are to excel, they need to have their non-clinical knowledge and skills developed to the same degree as their clinical ones and that has to be a focus of service leadership development going forward. So, rather than putting the right leaders in post, it is imperative on Trusts to create the conditions in which the right kind of leadership can flourish. Failure to achieve this risks an environment of well-meaning mediocrity in a marketplace that is unforgiving to the average.