THE INTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT
Int J Health Plann Mgmt 2014; 29: 280–291. Published online 17 March 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/hpm.2245
Whither the elephant?: the continuing development of clinical leadership in the UK National Health Services John Duncan Edmonstone1,2* University of Keele – Centre for Health Planning & Management, Newcastle-under-Lyme, Staffordshire, UK 2 MTDS Consultancy, Ripon, North Yorkshire, UK 1
SUMMARY The paper revisits the theme of clinical leadership in UK countries, following an earlier (2009) review. It examines the competency-based approach; considers the emerging voices of clinical leaders; explores the results of evaluation research studies; identifies learning from intra-UK and international comparisons and considers the issue of leader development versus leadership development. It concludes that there is little conceptual clarity; that there continues to be a major disconnect between clinicians and managers; that different approaches to developing clinical leaders are emerging in different parts of the UK and that the major challenge remains to develop leadership, rather than leaders. Copyright © 2014 John Wiley & Sons, Ltd. KEY WORDS: clinical leadership; competences; evaluation research; international and UK comparisons; leader development and leadership development
INTRODUCTION Background Over the last 10 years, the various versions of the National Health Service operating in the four countries of the UK have focused increasingly on the importance of clinical leadership. A review of this development (Edmonstone, 2009a) proposed that clinical leadership comprised ‘leadership of clinicians by clinicians’, where the term ‘clinician’ was an inclusive one, involving doctors, nurses, allied health professionals and others. The prime focus of such clinical leadership was on the patient, client group, clinical specialty or service and on improvement in local frontline patient care outcomes. Clinical leaders typically retained some ‘hands-on’ clinical role but also took part in issues such as strategic direction, resource management and engagement in collaborative working with other healthcare professions, *Correspondence to: J. D. Edmonstone, University of Keele – Centre for Health Planning & Management, Darwin Building, University of Keele, Newcastle-under-Lyme, Staffordshire ST5 5BG, UK. E-mail: john. [email protected]
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with healthcare managers and with other agencies (typically social care). Such leaders could be selected and/or elected into leadership roles. This working definition effectively excluded those clinicians who worked corporately at board level. The clinical leadership approach was marked by the use of persuasion rather than hierarchical power as a means of managing the tension between the clinical ‘expert system’ and the healthcare managerial hierarchy. It exhibited a preference for an incremental, evidence-based, planned and evaluated approach to change involving clarification, choice of options and consultation. Clinical leaders needed to enjoy the respect and trust of their professional colleagues based upon their perceived credibility and integrity, and to that extent, clinical leadership could also be termed as ‘influence-ship’. Clinical leadership therefore took the patient/client/specialty viewpoint and was largely based upon ‘personal power’—credibility, respect, trust and the ability to influence, persuade, debate and negotiate. It stood in contrast to healthcare managerial leadership, which always took the corporate or organisational viewpoint and was largely based upon ‘position power’ or place in the hierarchy. Clinical leadership was seen to be important because healthcare organisations were professional organisations where frontline staff possessed a high degree of control over clinical work, where the ability of managers to directly influence clinical decision making was constrained and contingent and where clinical decision making was typically collegiate in nature, with a premium on professional clinicians leading change. The review noted the growing profile of clinical leadership through an expansion of internal and external clinical leadership development programmes, a growing number of undergraduate and postgraduate degrees in clinical leadership and the creation of a Medical Leadership Competency Framework. It concluded that clinical leadership was ‘the elephant in the room’—an obviously important entity often ignored or unaddressed for the convenience of other interested parties; principally general managers and politicians of all persuasions who (consciously or unconsciously) operated to a command-and-control model of leadership. This paper updates the earlier review and examines clinical leadership under a number of headings: • • • • • •
The competency saga, The emerging voice of clinical leaders, The results of research and evaluation studies, International comparisons, Emerging country differences and The challenge of leader development versus leadership development.
The competency saga In the UK, the most adopted approach to leadership and management development in healthcare is based upon the notion of leadership competences (Edmonstone, 2011a). In early 2000, the Hay Group management consultancy was commissioned to undertake work for the NHS in England, which led to the identification of a core set of leadership qualities associated with success at chief executive and executive director levels. This work entailed the following: Copyright © 2014 John Wiley & Sons, Ltd.
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• desk research of 23 existing leadership and management competency frameworks in use in various public sector and private sector organisations, • interviews and focus groups to consult and test the emerging approach with over 200 NHS leaders and managers in England and • refining of this information to produce an overarching model that claimed to capture and embody a template of all the qualities required by all managerial and clinical leaders in the NHS. It identified 15 leadership qualities arranged in three clusters—personal qualities, setting direction and delivering the service. This Leadership Qualities Framework (LQF) essentially conflated both leadership and management, despite the fact that it is now well established that they pertain to conceptually distinct phenomena but with an overlap in practice. For example, leadership is quite clearly exercised by both managerial and clinical leaders. The LQF was launched in the NHS in England in 2002 and was subsequently reviewed and amended in 2006. Variants of the LQF are also used in the healthcare systems of the other UK nations. The growing recognition of the importance of medical engagement in leadership led to the creation of the Enhancing Engagement in Medical Leadership project— a joint initiative between the then NHS Institute for Innovation and Improvement and the Academy of Medical Royal Colleges (AoMRC). From the work of this project emerged the Medical Leadership Competency Framework (MLCF) between 2006 and 2009, which was intended to describe the leadership competences doctors needed to become more actively engaged in the planning, delivery and transformation of health services (Spurgeon et al., 2011). Intended to apply to all medical students and doctors throughout their training and career, the MCLF was created to inform the design of leadership development programmes, appraisal and recruitment and to assist doctors with personal development planning and career progression. In 2011, a vehicle for taking forward the MCLF was created by the AoMRC—the Faculty of Medical Leadership and Management, aimed at promoting the advancement of medical leadership, management and quality improvement at all stages of the medical career. Subsequently, a further project was commissioned by the then National Leadership Council for the NHS in England to extend the applicability of the MLCF to other clinical professions—the Clinical Leadership Competency Framework. However, in 2011, a single NHS leadership framework (LF) was once again deemed to be applicable to everyone in healthcare in England, whatever their professional discipline, role or function and working at whatever level, in order to create a common approach to leadership development across the professional, regulatory and educational sectors of the NHS. It was claimed that the MLCF and the Clinical Leadership Competency Framework were both ‘embedded’ within the LF, although the latter also includes two additional domains that are designed solely to support those in senior leadership roles—effectively confining clinical/medical leadership to a more subordinate and operational focus. This plethora of initiatives and bodies involved would appear to offer ample scope for confusion and also seem to embody a tension between, on the one hand, uniformity (a desire for a generic or universal approach) and, on the other, diversity Copyright © 2014 John Wiley & Sons, Ltd.
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(a more local, contextual and clinically based approach). They can also be interpreted as an attempt by senior healthcare organisational leaders to exercise and reassert clarity and control—to ‘hold things together’ in the face of the volatile and virtual environments of healthcare organisations in the 21st century—with new organisational forms such as strategic alliances, clinical networks, joint ventures, partnership arrangements, remote working, matrix working, project management and team working—all of which have led to a blurring of organisational identity and boundaries and given rise to feelings of fragmentation and loss of central command and control (Child and Rodrigues, 2002; Kallinokos, 2003; Bolden and Gosling, 2006). Although competency frameworks may be useful in enabling agreement on core leadership desidirata and in providing a language about which to speak of leadership activity, they do not provide the whole picture, particularly in considering contextualised performance. The competency approach, as claimed, contains fundamental flaws—it supports and reinforces ‘personality trait’ views of leadership; it diminishes leadership to a reductionist set of fragmented skills; it focuses on past or current performance and hence has little predictive value, and it struggles to take account of situational or complex organisational factors (McKimm and Swanwick, 2011). The notion of a single one-size-fits-all LF applicable to everyone, no matter what their discipline, has recently been labelled as ‘ridiculous’, especially when applied to such a large and complex organisational context as the NHS. It is seen instead as a symptom of a poor understanding of the emotions and politics that inform and underpin attempts to learn about leadership. It does not account for everyday power relations and their consequences for service delivery. It is claimed that it is solely focused on individual development and takes no account of the contradictions that are generated within such a highly political context (Vince, 2012). It has also been suggested (Swanwick and McKimm, 2011) that leadership competency frameworks in healthcare should not be seen as a comprehensive recipe for personal and organisational success but rather as a ‘lexicon’ with which individuals, organisations and others can debate the nature of leadership and the associated value relationships within their organisations—although this seems a far cry from the original intentions of NHS LFs. The emerging voice of clinical leaders One result of the growth of development programmes for clinical leaders has been that many of the clinical leaders who took part in such programmes began themselves to reflect on and write about clinical leadership ‘from the inside’. As a result of the ‘Darzi’ Clinical Leadership Fellowship schemes pioneered in parts of England, the experience of such clinical leadership fellows came to be shared (Stanton et al., 2010). A very different approach to clinical leadership development in the NHS in Scotland was also expressed (Robertson, 2010). Many of those active in designing and delivering programmes also offered their experience (Stanley, 2011; Swanwick and McKimm, 2011; Weir-Hughes, 2011). Although the content of these publications varies enormously, they do seem to contain a number of common themes: Copyright © 2014 John Wiley & Sons, Ltd.
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• A historical perspective on the development of clinical (by which many actually mean solely medical) leadership, • An identification of the necessary “tools and techniques” needed to be an effective clinical leader and • ‘Practical tips’ for clinicians. The publications therefore somewhat disappointingly represent a form of ‘how to do it’ advice from existing to next-generation clinical leaders, rather than any critical or analytical consideration of clinical leadership as an emerging phenomenon. Evaluation and research studies As a range of clinical leadership development programmes have been initiated, many of these have been subject to formal evaluation studies. The Darzi Clinical Leadership fellow programmes, for example, generated several studies (Stoll et al., 2010, Miller and Dalton, 2011, Sinha et al., 2011) while other unrelated programmes also offered useful learning from the evaluation process (Edmonstone, 2009b, McIntosh and Tolson, 2009, Haycock-Stuart et al., 2010, Pearson and Machin, 2010). The learning from these studies can be summarised as follows: • For the Darzi programmes, a number of common features were identifiable: - the use of an underlying competency framework, such as the LQF or MLCF, both of which use a 360° personal feedback tool, - a personal development focus, including the use of psychometric tests for diagnostic purposes, the creation of personal development plans, provision of one-to-one coaching and mentoring and support and challenge to programme participants through membership of action learning sets, - a service-improvement focus in which participants worked on a serviceimprovement project or projects across the duration of the programme and - academic input through which participants were introduced to theories, skills and techniques relevant to their role and to service improvement delivered through workshops and masterclasses. In some instances, participants also worked towards a masters qualification (Malby et al., 2011). • Evaluation of the Darzi programmes confirmed that there was indeed significant disengagement between clinicians and healthcare managers and that time and effort was required in order to bridge this divide. For these programmes, major organisational barriers (both within and between organisations and professions) existed to working and learning together, which often served to undermine engagement. Such barriers included insufficient protected time, restricted access to funding, limited provision of space and varying levels of autonomy and opportunity (Sinha et al., 2011). The local workplace context was highly variable in the extent to which it was experienced as developmental for programme participants. Key local players were chief executives, executive directors (especially medical and nursing directors) and local mentors and coaches. Where work towards an academic qualification was a major component of the programme, the completion of academic work Copyright © 2014 John Wiley & Sons, Ltd.
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alongside that of normal clinical work demanded created real challenges. Space and time for adequate reflection on working with people from diverse professional backgrounds encouraged dialogue and allowed people to examine their established ways of working and enabled new ideas and behaviours to emerge (Miller and Dalton, 2011). • The other studies emphasise the necessity of adequate initial preparatory development for those in new clinical leadership roles and then continuing support in the early stages of working in those roles. Coaching, mentoring and action learning were seen as key to this. Nonetheless, for many clinicians, leadership was still perceived as top-down and hierarchical, and the ‘default position’ for development was still identified as the off-site, in-house short course to which access was limited. Finally, those taking on new clinical leadership roles typically experienced confusion over future career paths (McIntosh and Tolson, 2009, Haycock-Stuart et al., 2010, Pearson and Machin, 2010). • A caveat on what can be learned from such evaluation studies has also been made (Hayward and Voller, 2010). Although noting that a range of human resource factors (including leadership development) when effectively implemented have a positive effect on organisational performance, it has not proved possible to identify the individual impact of such practices, and this does not, therefore, amount to causality. The problem of proving attribution can, of course, be due to intervening variables but also because attempts to measure impact have typically come from a scientific, experimental mindset with requirements for control groups, standardisation, repeat experiments and elimination of extraneous variables—all issues that are nigh on impossible to overcome in the messy and complex reality of organisational life. Hayward and Voller also note that the bulk of recent evaluation studies is derived from the public sector and especially from healthcare. They suggest that the emphasis on evidence-based decision making in healthcare plus a requirement to demonstrate value for public investment and also commercial sensitivity in the private sector are the reasons why the latter was dramatically under-represented. They concluded that although there was substantial evidence that leadership development does make a positive impact on organisational performance, it remains beyond most organisations’ assessment capabilities to demonstrate any causal link between the two. Finally, it is also clear that leadership development works as much through ‘generative’ causation (creating the conditions where things can change and move on to destinations as yet unknown) as through ‘successionist’ causation (achieving predictable and pre-known outcomes) (Thorpe et al., 2008). • Other research since the original article was written offers a series of useful insights: - The ‘disaggregated’ nature of clinical leadership noted in the 2009 article revealed that different clinical professions diverged significantly in their attitudes towards reform in the NHS. A recent review of clinician–manager relationships supports this insight, with medical clinicians broadly opposing managerial reforms, senior (corporate) medical managers offering some support, nurse Copyright © 2014 John Wiley & Sons, Ltd.
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Figure 1. Three archetypes of clinical leadership
managers providing broad support and nurse clinicians generally opposed (Greener et al., 2011). The authors asserted that these differences in perception and an associated opposition to attempts to introduce multidisciplinary teamworking meant that considerable ‘tribal’ behaviour still seemed to predominate. - Mountford and Webb (2009) developed a useful model of three ‘archetypes’ of clinical leaders, as shown in Figure 1 Given the working definition being used in this paper, service leaders and frontline leaders (as defined by Mountford and Webb) would be seen as clinical leaders, whereas institutional leaders would be seen as part of the corporate managerial world. International comparisons A number of recent studies have attempted to relate developments in clinical leadership in the UK with similar developments in other countries. Ham and Dickinson (2008) highlighted the importance of adequately resourcing the development of medical leadership and ensuring recognition and reward (including in career terms) for those taking on leadership roles. More usefully, Neogy and Kirkpatrick (2009) in Copyright © 2014 John Wiley & Sons, Ltd.
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a Europe-wide survey that focused solely on leadership in a hospital context noted that although all countries were marked by attempts to involve doctors in management, the perception remained that medical practice was still not fully engaged with the managerial perspective. Four factors were identified as shaping the response of doctors to new management roles: • the extent to which such roles provided some degree of real authority, as well as responsibility, to make decisions, • the timing of reform changes, • the nature of incentives for doctors to get involved in management and • the training and development opportunities available to prepare individuals for new roles. These reviews, useful in themselves, tend to ignore one obvious difference that the healthcare systems in the UK nations display in relation to other countries. In most developed and developing countries, there has been, and continues to be, an expectation that the most senior organisational roles will be taken by people with a clinical (usually medical) background. The issue in these countries is then how such people can best develop adequate leadership and management capability in order to undertake such roles. From the instigation of the National Health Service in the UK in the 1940s, a marked division between doctors on the one hand and administrators/managers on the other has been a continuing feature of the healthcare system. The UK has one of the lowest proportions of clinically qualified managers in any healthcare system—58% compared with 74% in the USA and 93% in Sweden (Dorgan et al., 2010). This may well have been exacerbated by the introduction of general management into the NHS in the 1980s, the appointment of administrators/managers to chief executive roles and the resultant antagonism demonstrated to such changes by the doctors’ trades union the British Medical Association. This is embodied, perhaps, in the problematic role of the medical director. Recent research on this role indicates that it is a profoundly ambiguous one as identification with corporate general management is typically constructed negatively from the perspective of doctors. The importance for medical directors of maintaining clinical credibility secures their identity with clinical colleagues and so distinguishes the medical director from the taint associated with the pejorative managerial identity that many doctors construct of managers (Joffe and MacKenzie-Davey, 2012). As a result, the UK countries are somewhat atypical, and the concomitant challenges faced in developing clinical leadership are, while not unique, at least distinctive in nature. Emerging country differences The original paper (Edmonstone, 2009a) noted that clinical leadership was taking different forms in all four UK countries as their healthcare systems increasingly diversified as a result of devolution (Greer, 2004; Greer and Rowland, 2008). Within the NHS in England, ‘managers and the market’ were said to be the guiding forces; whereas in Scotland, the clinical professions were seen as being in the driving seat. Copyright © 2014 John Wiley & Sons, Ltd.
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The paper proposed that, as a result, the nature and profile of clinical leadership in Scotland would, over time, differ considerably from that in England. This has indeed proved to be the case. In England, the Health & Social Care Act of 2012 introduced by the Coalition government abolished pre-existing organisational arrangements and introduced GP commissioning of services from ‘any qualified provider’—potentially leading to the contracting-out of services to private sector and social enterprise providers. The Scottish Government has set its face firmly against such measures, as have the other devolved administrations in Wales and Northern Ireland. In the field of clinical leadership development, Scotland launched an 18-month-long multi-professional annual development programme for strategic clinical leaders in 2005 that was focused on leadership practice and designed and delivered by a small team (Edmonstone, 2011b; Upton et al., 2013). By contrast, it was not until the Darzi report of 2008 that clinical leadership in England began to show such a high profile, and as demonstrated earlier, work on the Medical Leadership Competency Framework between 2006 and 2009 only later added the other clinical professions as something of an afterthought, before being subsumed into a more generic framework. The NHS Leadership Academy for England has recently launched a whole suite of (increasingly multi-professional) programmes, but the emphasis is on postgraduate qualifications at certificate and masters levels, run in partnership between higher education institutions and international management consultancies. Described by the Leadership Academy as a ‘professionalised and standardised’ approach to leadership, possession of such qualifications is intended to become essential criteria for those applying for future leadership roles. The challenge of leader development versus leadership development A growing critique has emerged of in relation to leadership in healthcare, which pits ‘leader development’ versus ‘leadership development’ (Edmonstone, 2011c). The former focuses on the development of individual leaders through the enhancement of their personal attributes, qualities, behaviours, knowledge and skills—the creation of individual ‘human capital’. It is founded on a basic assumption that leadership exists within individuals, rather than in the relationships between them. Leadership is seen to be the property of the leader alone, divorced from the situational context in which it occurs. It assumes that leadership can be developed by increased self-insight and has a working metaphor of the leadership journey. There is also an inherent assumption that the personal development of many individual leaders will lead to improved social and organisational learning and, in addition to enhanced individual human capital, to the creation of ‘social capital’, although this may occur as much by accident as by design. In contrast, the alternative viewpoint claims that it is impossible to develop leadership without paying attention to the context in which it takes place. It places great emphasis on the importance of local history and culture as a prime influence on what is possible in leadership terms. Leadership is seen as a social influence process balancing order and change and conducted through the making and mending of relationships and is therefore a collective or shared activity, rather than an individual one. Enhancing social capital therefore means developing the quantity and quality of the connections and relationships in an organisation, network or system. Copyright © 2014 John Wiley & Sons, Ltd.
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Despite this emerging critique, which is not confined to healthcare (Hartley and Benington, 2011), almost all leadership activities in the NHS have been and are concerned with the development of individual healthcare leaders, rather than with that of healthcare leadership—a much more challenging and complex problem.
CONCLUSION Since the original 2009 paper was published, there has been a wealth of clinical leadership development initiatives, research and publications. From this, it is possible to arrive at the following conclusions: • There is a continuing lack of conceptual clarity as to what clinical leadership is and what it is for. For example, the previous and current papers used the term to cover what Mountford and Webb called service and frontline leaders, while it is clear that others use the term to also encompass institutional (or corporate) clinical leaders, such as medical and nursing and allied health professions directors. • Although leadership competency-based approaches are now the conventional wisdom, there has emerged a powerful critique with regard to the value of such an approach. It is also unclear whether such competencies are intended solely as a ‘lexicon’ for stimulating continuing dialogue and debate on leadership issues or whether they are intended as a one-size-fits-all prescription and thus a means of ‘soft’ control. • The voices of clinical leaders themselves resemble the dog in the Sherlock Holmes story that did not bark in the night-time. There is disappointingly little evidence of self-reflection or of a more critical and analytical consideration of clinical leadership emerging from these quarters. • What research has been undertaken on clinical leadership has largely focused on the evaluation of a range of clinical leadership development programmes, rather than on the nature of clinical leadership itself. This research has served to highlight the degree of continuing disengagement between clinicians and healthcare managers, together with the challenges of resourcing the development of leaders and leadership and the preference for work-based development approaches such as coaching, mentoring and action learning. • International comparisons serve to reinforce the development challenges mentioned earlier and also the importance of providing clinical leaders with real authority to make changes rather than the cosmetic tokenism highlighted in the earlier paper. Internationally, the UK healthcare systems have differed from the majority of countries by recruiting administrators, managers and financial experts to the most senior leadership positions. The current chief executive of NHS England once went on record as saying that he wanted a clinician on the short list for every local chief executive position that arose. One step beyond this would be to aim for the bulk of chief executives to derive from the clinical professions. Recent research (Ham et al., 2010, Veronesi et al., 2012) do show that strong representation at board level Copyright © 2014 John Wiley & Sons, Ltd.
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can make a significant difference to the challenges of clinical engagement (and disengagement). • Within the four nations of the UK, the divergence in healthcare policy and in approaches to clinical leadership and its development has increased and seems to be increasing further. This is especially evident in the preparation for clinical leadership roles where the NHS in England seems intended on ensuring that this is based upon higher education-based qualifications, whereas the approach adopted in Scotland seems much more practice-based. • Finally, all the approaches adopted have largely concentrated on leader development, rather than on leadership development. A focus on leadership development would concentrate on teams, networks and relationships and on work-related practice—what has been described as the ‘extraordinisation of the mundane’ (Alvesson and Sveningsson, 2003). It would also increasingly see leadership development as a multi-professional and multi-agency concern, rather than being confined to single professions and organisations. Certainly, as Albert Einstein is alleged to have remarked, ‘we cannot solve our problems with the same thinking we used when we created them’.
CONFLICT OF INTEREST The authors have no competing interests.
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Int J Health Plann Mgmt 2014; 29: 280–291. Published online 17 March 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/hpm.2245
Whither the elephant?: the continuing development of clinical leadership in the UK National Health Services John Duncan Edmonstone1,2* University of Keele – Centre for Health Planning & Management, Newcastle-under-Lyme, Staffordshire, UK 2 MTDS Consultancy, Ripon, North Yorkshire, UK 1
SUMMARY The paper revisits the theme of clinical leadership in UK countries, following an earlier (2009) review. It examines the competency-based approach; considers the emerging voices of clinical leaders; explores the results of evaluation research studies; identifies learning from intra-UK and international comparisons and considers the issue of leader development versus leadership development. It concludes that there is little conceptual clarity; that there continues to be a major disconnect between clinicians and managers; that different approaches to developing clinical leaders are emerging in different parts of the UK and that the major challenge remains to develop leadership, rather than leaders. Copyright © 2014 John Wiley & Sons, Ltd. KEY WORDS: clinical leadership; competences; evaluation research; international and UK comparisons; leader development and leadership development
INTRODUCTION Background Over the last 10 years, the various versions of the National Health Service operating in the four countries of the UK have focused increasingly on the importance of clinical leadership. A review of this development (Edmonstone, 2009a) proposed that clinical leadership comprised ‘leadership of clinicians by clinicians’, where the term ‘clinician’ was an inclusive one, involving doctors, nurses, allied health professionals and others. The prime focus of such clinical leadership was on the patient, client group, clinical specialty or service and on improvement in local frontline patient care outcomes. Clinical leaders typically retained some ‘hands-on’ clinical role but also took part in issues such as strategic direction, resource management and engagement in collaborative working with other healthcare professions, *Correspondence to: J. D. Edmonstone, University of Keele – Centre for Health Planning & Management, Darwin Building, University of Keele, Newcastle-under-Lyme, Staffordshire ST5 5BG, UK. E-mail: john. [email protected]
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with healthcare managers and with other agencies (typically social care). Such leaders could be selected and/or elected into leadership roles. This working definition effectively excluded those clinicians who worked corporately at board level. The clinical leadership approach was marked by the use of persuasion rather than hierarchical power as a means of managing the tension between the clinical ‘expert system’ and the healthcare managerial hierarchy. It exhibited a preference for an incremental, evidence-based, planned and evaluated approach to change involving clarification, choice of options and consultation. Clinical leaders needed to enjoy the respect and trust of their professional colleagues based upon their perceived credibility and integrity, and to that extent, clinical leadership could also be termed as ‘influence-ship’. Clinical leadership therefore took the patient/client/specialty viewpoint and was largely based upon ‘personal power’—credibility, respect, trust and the ability to influence, persuade, debate and negotiate. It stood in contrast to healthcare managerial leadership, which always took the corporate or organisational viewpoint and was largely based upon ‘position power’ or place in the hierarchy. Clinical leadership was seen to be important because healthcare organisations were professional organisations where frontline staff possessed a high degree of control over clinical work, where the ability of managers to directly influence clinical decision making was constrained and contingent and where clinical decision making was typically collegiate in nature, with a premium on professional clinicians leading change. The review noted the growing profile of clinical leadership through an expansion of internal and external clinical leadership development programmes, a growing number of undergraduate and postgraduate degrees in clinical leadership and the creation of a Medical Leadership Competency Framework. It concluded that clinical leadership was ‘the elephant in the room’—an obviously important entity often ignored or unaddressed for the convenience of other interested parties; principally general managers and politicians of all persuasions who (consciously or unconsciously) operated to a command-and-control model of leadership. This paper updates the earlier review and examines clinical leadership under a number of headings: • • • • • •
The competency saga, The emerging voice of clinical leaders, The results of research and evaluation studies, International comparisons, Emerging country differences and The challenge of leader development versus leadership development.
The competency saga In the UK, the most adopted approach to leadership and management development in healthcare is based upon the notion of leadership competences (Edmonstone, 2011a). In early 2000, the Hay Group management consultancy was commissioned to undertake work for the NHS in England, which led to the identification of a core set of leadership qualities associated with success at chief executive and executive director levels. This work entailed the following: Copyright © 2014 John Wiley & Sons, Ltd.
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• desk research of 23 existing leadership and management competency frameworks in use in various public sector and private sector organisations, • interviews and focus groups to consult and test the emerging approach with over 200 NHS leaders and managers in England and • refining of this information to produce an overarching model that claimed to capture and embody a template of all the qualities required by all managerial and clinical leaders in the NHS. It identified 15 leadership qualities arranged in three clusters—personal qualities, setting direction and delivering the service. This Leadership Qualities Framework (LQF) essentially conflated both leadership and management, despite the fact that it is now well established that they pertain to conceptually distinct phenomena but with an overlap in practice. For example, leadership is quite clearly exercised by both managerial and clinical leaders. The LQF was launched in the NHS in England in 2002 and was subsequently reviewed and amended in 2006. Variants of the LQF are also used in the healthcare systems of the other UK nations. The growing recognition of the importance of medical engagement in leadership led to the creation of the Enhancing Engagement in Medical Leadership project— a joint initiative between the then NHS Institute for Innovation and Improvement and the Academy of Medical Royal Colleges (AoMRC). From the work of this project emerged the Medical Leadership Competency Framework (MLCF) between 2006 and 2009, which was intended to describe the leadership competences doctors needed to become more actively engaged in the planning, delivery and transformation of health services (Spurgeon et al., 2011). Intended to apply to all medical students and doctors throughout their training and career, the MCLF was created to inform the design of leadership development programmes, appraisal and recruitment and to assist doctors with personal development planning and career progression. In 2011, a vehicle for taking forward the MCLF was created by the AoMRC—the Faculty of Medical Leadership and Management, aimed at promoting the advancement of medical leadership, management and quality improvement at all stages of the medical career. Subsequently, a further project was commissioned by the then National Leadership Council for the NHS in England to extend the applicability of the MLCF to other clinical professions—the Clinical Leadership Competency Framework. However, in 2011, a single NHS leadership framework (LF) was once again deemed to be applicable to everyone in healthcare in England, whatever their professional discipline, role or function and working at whatever level, in order to create a common approach to leadership development across the professional, regulatory and educational sectors of the NHS. It was claimed that the MLCF and the Clinical Leadership Competency Framework were both ‘embedded’ within the LF, although the latter also includes two additional domains that are designed solely to support those in senior leadership roles—effectively confining clinical/medical leadership to a more subordinate and operational focus. This plethora of initiatives and bodies involved would appear to offer ample scope for confusion and also seem to embody a tension between, on the one hand, uniformity (a desire for a generic or universal approach) and, on the other, diversity Copyright © 2014 John Wiley & Sons, Ltd.
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(a more local, contextual and clinically based approach). They can also be interpreted as an attempt by senior healthcare organisational leaders to exercise and reassert clarity and control—to ‘hold things together’ in the face of the volatile and virtual environments of healthcare organisations in the 21st century—with new organisational forms such as strategic alliances, clinical networks, joint ventures, partnership arrangements, remote working, matrix working, project management and team working—all of which have led to a blurring of organisational identity and boundaries and given rise to feelings of fragmentation and loss of central command and control (Child and Rodrigues, 2002; Kallinokos, 2003; Bolden and Gosling, 2006). Although competency frameworks may be useful in enabling agreement on core leadership desidirata and in providing a language about which to speak of leadership activity, they do not provide the whole picture, particularly in considering contextualised performance. The competency approach, as claimed, contains fundamental flaws—it supports and reinforces ‘personality trait’ views of leadership; it diminishes leadership to a reductionist set of fragmented skills; it focuses on past or current performance and hence has little predictive value, and it struggles to take account of situational or complex organisational factors (McKimm and Swanwick, 2011). The notion of a single one-size-fits-all LF applicable to everyone, no matter what their discipline, has recently been labelled as ‘ridiculous’, especially when applied to such a large and complex organisational context as the NHS. It is seen instead as a symptom of a poor understanding of the emotions and politics that inform and underpin attempts to learn about leadership. It does not account for everyday power relations and their consequences for service delivery. It is claimed that it is solely focused on individual development and takes no account of the contradictions that are generated within such a highly political context (Vince, 2012). It has also been suggested (Swanwick and McKimm, 2011) that leadership competency frameworks in healthcare should not be seen as a comprehensive recipe for personal and organisational success but rather as a ‘lexicon’ with which individuals, organisations and others can debate the nature of leadership and the associated value relationships within their organisations—although this seems a far cry from the original intentions of NHS LFs. The emerging voice of clinical leaders One result of the growth of development programmes for clinical leaders has been that many of the clinical leaders who took part in such programmes began themselves to reflect on and write about clinical leadership ‘from the inside’. As a result of the ‘Darzi’ Clinical Leadership Fellowship schemes pioneered in parts of England, the experience of such clinical leadership fellows came to be shared (Stanton et al., 2010). A very different approach to clinical leadership development in the NHS in Scotland was also expressed (Robertson, 2010). Many of those active in designing and delivering programmes also offered their experience (Stanley, 2011; Swanwick and McKimm, 2011; Weir-Hughes, 2011). Although the content of these publications varies enormously, they do seem to contain a number of common themes: Copyright © 2014 John Wiley & Sons, Ltd.
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• A historical perspective on the development of clinical (by which many actually mean solely medical) leadership, • An identification of the necessary “tools and techniques” needed to be an effective clinical leader and • ‘Practical tips’ for clinicians. The publications therefore somewhat disappointingly represent a form of ‘how to do it’ advice from existing to next-generation clinical leaders, rather than any critical or analytical consideration of clinical leadership as an emerging phenomenon. Evaluation and research studies As a range of clinical leadership development programmes have been initiated, many of these have been subject to formal evaluation studies. The Darzi Clinical Leadership fellow programmes, for example, generated several studies (Stoll et al., 2010, Miller and Dalton, 2011, Sinha et al., 2011) while other unrelated programmes also offered useful learning from the evaluation process (Edmonstone, 2009b, McIntosh and Tolson, 2009, Haycock-Stuart et al., 2010, Pearson and Machin, 2010). The learning from these studies can be summarised as follows: • For the Darzi programmes, a number of common features were identifiable: - the use of an underlying competency framework, such as the LQF or MLCF, both of which use a 360° personal feedback tool, - a personal development focus, including the use of psychometric tests for diagnostic purposes, the creation of personal development plans, provision of one-to-one coaching and mentoring and support and challenge to programme participants through membership of action learning sets, - a service-improvement focus in which participants worked on a serviceimprovement project or projects across the duration of the programme and - academic input through which participants were introduced to theories, skills and techniques relevant to their role and to service improvement delivered through workshops and masterclasses. In some instances, participants also worked towards a masters qualification (Malby et al., 2011). • Evaluation of the Darzi programmes confirmed that there was indeed significant disengagement between clinicians and healthcare managers and that time and effort was required in order to bridge this divide. For these programmes, major organisational barriers (both within and between organisations and professions) existed to working and learning together, which often served to undermine engagement. Such barriers included insufficient protected time, restricted access to funding, limited provision of space and varying levels of autonomy and opportunity (Sinha et al., 2011). The local workplace context was highly variable in the extent to which it was experienced as developmental for programme participants. Key local players were chief executives, executive directors (especially medical and nursing directors) and local mentors and coaches. Where work towards an academic qualification was a major component of the programme, the completion of academic work Copyright © 2014 John Wiley & Sons, Ltd.
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alongside that of normal clinical work demanded created real challenges. Space and time for adequate reflection on working with people from diverse professional backgrounds encouraged dialogue and allowed people to examine their established ways of working and enabled new ideas and behaviours to emerge (Miller and Dalton, 2011). • The other studies emphasise the necessity of adequate initial preparatory development for those in new clinical leadership roles and then continuing support in the early stages of working in those roles. Coaching, mentoring and action learning were seen as key to this. Nonetheless, for many clinicians, leadership was still perceived as top-down and hierarchical, and the ‘default position’ for development was still identified as the off-site, in-house short course to which access was limited. Finally, those taking on new clinical leadership roles typically experienced confusion over future career paths (McIntosh and Tolson, 2009, Haycock-Stuart et al., 2010, Pearson and Machin, 2010). • A caveat on what can be learned from such evaluation studies has also been made (Hayward and Voller, 2010). Although noting that a range of human resource factors (including leadership development) when effectively implemented have a positive effect on organisational performance, it has not proved possible to identify the individual impact of such practices, and this does not, therefore, amount to causality. The problem of proving attribution can, of course, be due to intervening variables but also because attempts to measure impact have typically come from a scientific, experimental mindset with requirements for control groups, standardisation, repeat experiments and elimination of extraneous variables—all issues that are nigh on impossible to overcome in the messy and complex reality of organisational life. Hayward and Voller also note that the bulk of recent evaluation studies is derived from the public sector and especially from healthcare. They suggest that the emphasis on evidence-based decision making in healthcare plus a requirement to demonstrate value for public investment and also commercial sensitivity in the private sector are the reasons why the latter was dramatically under-represented. They concluded that although there was substantial evidence that leadership development does make a positive impact on organisational performance, it remains beyond most organisations’ assessment capabilities to demonstrate any causal link between the two. Finally, it is also clear that leadership development works as much through ‘generative’ causation (creating the conditions where things can change and move on to destinations as yet unknown) as through ‘successionist’ causation (achieving predictable and pre-known outcomes) (Thorpe et al., 2008). • Other research since the original article was written offers a series of useful insights: - The ‘disaggregated’ nature of clinical leadership noted in the 2009 article revealed that different clinical professions diverged significantly in their attitudes towards reform in the NHS. A recent review of clinician–manager relationships supports this insight, with medical clinicians broadly opposing managerial reforms, senior (corporate) medical managers offering some support, nurse Copyright © 2014 John Wiley & Sons, Ltd.
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Figure 1. Three archetypes of clinical leadership
managers providing broad support and nurse clinicians generally opposed (Greener et al., 2011). The authors asserted that these differences in perception and an associated opposition to attempts to introduce multidisciplinary teamworking meant that considerable ‘tribal’ behaviour still seemed to predominate. - Mountford and Webb (2009) developed a useful model of three ‘archetypes’ of clinical leaders, as shown in Figure 1 Given the working definition being used in this paper, service leaders and frontline leaders (as defined by Mountford and Webb) would be seen as clinical leaders, whereas institutional leaders would be seen as part of the corporate managerial world. International comparisons A number of recent studies have attempted to relate developments in clinical leadership in the UK with similar developments in other countries. Ham and Dickinson (2008) highlighted the importance of adequately resourcing the development of medical leadership and ensuring recognition and reward (including in career terms) for those taking on leadership roles. More usefully, Neogy and Kirkpatrick (2009) in Copyright © 2014 John Wiley & Sons, Ltd.
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a Europe-wide survey that focused solely on leadership in a hospital context noted that although all countries were marked by attempts to involve doctors in management, the perception remained that medical practice was still not fully engaged with the managerial perspective. Four factors were identified as shaping the response of doctors to new management roles: • the extent to which such roles provided some degree of real authority, as well as responsibility, to make decisions, • the timing of reform changes, • the nature of incentives for doctors to get involved in management and • the training and development opportunities available to prepare individuals for new roles. These reviews, useful in themselves, tend to ignore one obvious difference that the healthcare systems in the UK nations display in relation to other countries. In most developed and developing countries, there has been, and continues to be, an expectation that the most senior organisational roles will be taken by people with a clinical (usually medical) background. The issue in these countries is then how such people can best develop adequate leadership and management capability in order to undertake such roles. From the instigation of the National Health Service in the UK in the 1940s, a marked division between doctors on the one hand and administrators/managers on the other has been a continuing feature of the healthcare system. The UK has one of the lowest proportions of clinically qualified managers in any healthcare system—58% compared with 74% in the USA and 93% in Sweden (Dorgan et al., 2010). This may well have been exacerbated by the introduction of general management into the NHS in the 1980s, the appointment of administrators/managers to chief executive roles and the resultant antagonism demonstrated to such changes by the doctors’ trades union the British Medical Association. This is embodied, perhaps, in the problematic role of the medical director. Recent research on this role indicates that it is a profoundly ambiguous one as identification with corporate general management is typically constructed negatively from the perspective of doctors. The importance for medical directors of maintaining clinical credibility secures their identity with clinical colleagues and so distinguishes the medical director from the taint associated with the pejorative managerial identity that many doctors construct of managers (Joffe and MacKenzie-Davey, 2012). As a result, the UK countries are somewhat atypical, and the concomitant challenges faced in developing clinical leadership are, while not unique, at least distinctive in nature. Emerging country differences The original paper (Edmonstone, 2009a) noted that clinical leadership was taking different forms in all four UK countries as their healthcare systems increasingly diversified as a result of devolution (Greer, 2004; Greer and Rowland, 2008). Within the NHS in England, ‘managers and the market’ were said to be the guiding forces; whereas in Scotland, the clinical professions were seen as being in the driving seat. Copyright © 2014 John Wiley & Sons, Ltd.
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The paper proposed that, as a result, the nature and profile of clinical leadership in Scotland would, over time, differ considerably from that in England. This has indeed proved to be the case. In England, the Health & Social Care Act of 2012 introduced by the Coalition government abolished pre-existing organisational arrangements and introduced GP commissioning of services from ‘any qualified provider’—potentially leading to the contracting-out of services to private sector and social enterprise providers. The Scottish Government has set its face firmly against such measures, as have the other devolved administrations in Wales and Northern Ireland. In the field of clinical leadership development, Scotland launched an 18-month-long multi-professional annual development programme for strategic clinical leaders in 2005 that was focused on leadership practice and designed and delivered by a small team (Edmonstone, 2011b; Upton et al., 2013). By contrast, it was not until the Darzi report of 2008 that clinical leadership in England began to show such a high profile, and as demonstrated earlier, work on the Medical Leadership Competency Framework between 2006 and 2009 only later added the other clinical professions as something of an afterthought, before being subsumed into a more generic framework. The NHS Leadership Academy for England has recently launched a whole suite of (increasingly multi-professional) programmes, but the emphasis is on postgraduate qualifications at certificate and masters levels, run in partnership between higher education institutions and international management consultancies. Described by the Leadership Academy as a ‘professionalised and standardised’ approach to leadership, possession of such qualifications is intended to become essential criteria for those applying for future leadership roles. The challenge of leader development versus leadership development A growing critique has emerged of in relation to leadership in healthcare, which pits ‘leader development’ versus ‘leadership development’ (Edmonstone, 2011c). The former focuses on the development of individual leaders through the enhancement of their personal attributes, qualities, behaviours, knowledge and skills—the creation of individual ‘human capital’. It is founded on a basic assumption that leadership exists within individuals, rather than in the relationships between them. Leadership is seen to be the property of the leader alone, divorced from the situational context in which it occurs. It assumes that leadership can be developed by increased self-insight and has a working metaphor of the leadership journey. There is also an inherent assumption that the personal development of many individual leaders will lead to improved social and organisational learning and, in addition to enhanced individual human capital, to the creation of ‘social capital’, although this may occur as much by accident as by design. In contrast, the alternative viewpoint claims that it is impossible to develop leadership without paying attention to the context in which it takes place. It places great emphasis on the importance of local history and culture as a prime influence on what is possible in leadership terms. Leadership is seen as a social influence process balancing order and change and conducted through the making and mending of relationships and is therefore a collective or shared activity, rather than an individual one. Enhancing social capital therefore means developing the quantity and quality of the connections and relationships in an organisation, network or system. Copyright © 2014 John Wiley & Sons, Ltd.
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Despite this emerging critique, which is not confined to healthcare (Hartley and Benington, 2011), almost all leadership activities in the NHS have been and are concerned with the development of individual healthcare leaders, rather than with that of healthcare leadership—a much more challenging and complex problem.
CONCLUSION Since the original 2009 paper was published, there has been a wealth of clinical leadership development initiatives, research and publications. From this, it is possible to arrive at the following conclusions: • There is a continuing lack of conceptual clarity as to what clinical leadership is and what it is for. For example, the previous and current papers used the term to cover what Mountford and Webb called service and frontline leaders, while it is clear that others use the term to also encompass institutional (or corporate) clinical leaders, such as medical and nursing and allied health professions directors. • Although leadership competency-based approaches are now the conventional wisdom, there has emerged a powerful critique with regard to the value of such an approach. It is also unclear whether such competencies are intended solely as a ‘lexicon’ for stimulating continuing dialogue and debate on leadership issues or whether they are intended as a one-size-fits-all prescription and thus a means of ‘soft’ control. • The voices of clinical leaders themselves resemble the dog in the Sherlock Holmes story that did not bark in the night-time. There is disappointingly little evidence of self-reflection or of a more critical and analytical consideration of clinical leadership emerging from these quarters. • What research has been undertaken on clinical leadership has largely focused on the evaluation of a range of clinical leadership development programmes, rather than on the nature of clinical leadership itself. This research has served to highlight the degree of continuing disengagement between clinicians and healthcare managers, together with the challenges of resourcing the development of leaders and leadership and the preference for work-based development approaches such as coaching, mentoring and action learning. • International comparisons serve to reinforce the development challenges mentioned earlier and also the importance of providing clinical leaders with real authority to make changes rather than the cosmetic tokenism highlighted in the earlier paper. Internationally, the UK healthcare systems have differed from the majority of countries by recruiting administrators, managers and financial experts to the most senior leadership positions. The current chief executive of NHS England once went on record as saying that he wanted a clinician on the short list for every local chief executive position that arose. One step beyond this would be to aim for the bulk of chief executives to derive from the clinical professions. Recent research (Ham et al., 2010, Veronesi et al., 2012) do show that strong representation at board level Copyright © 2014 John Wiley & Sons, Ltd.
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can make a significant difference to the challenges of clinical engagement (and disengagement). • Within the four nations of the UK, the divergence in healthcare policy and in approaches to clinical leadership and its development has increased and seems to be increasing further. This is especially evident in the preparation for clinical leadership roles where the NHS in England seems intended on ensuring that this is based upon higher education-based qualifications, whereas the approach adopted in Scotland seems much more practice-based. • Finally, all the approaches adopted have largely concentrated on leader development, rather than on leadership development. A focus on leadership development would concentrate on teams, networks and relationships and on work-related practice—what has been described as the ‘extraordinisation of the mundane’ (Alvesson and Sveningsson, 2003). It would also increasingly see leadership development as a multi-professional and multi-agency concern, rather than being confined to single professions and organisations. Certainly, as Albert Einstein is alleged to have remarked, ‘we cannot solve our problems with the same thinking we used when we created them’.
CONFLICT OF INTEREST The authors have no competing interests.
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