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Lead on: What next for clinical leaders?

Lead on: What next for clinical leaders?
4 September 2013

Clinicians are in charge but what are the potential pitfalls? A research project from The Open University, funded by the National Institute for Health Research, looked into the issue 
Clinical leadership is central to the rationale for establishing and for maintaining Clinical Commissioning Groups (CCGs). But the challenge of engaging clinicians from both the primary and secondary care sectors seems to be immense. 

Clinicians are in charge but what are the potential pitfalls? A research project from The Open University, funded by the National Institute for Health Research, looked into the issue 
Clinical leadership is central to the rationale for establishing and for maintaining Clinical Commissioning Groups (CCGs). But the challenge of engaging clinicians from both the primary and secondary care sectors seems to be immense. 
One aspect of this challenge is to engage GPs actively in the process of commissioning and service redesign. A second aspect is the need to engage with secondary care clinicians in something far more meaningful than token representation. 
Significant improvements will require new ways of doing things. It is argued that clinicians, rising to the challenge of leadership, provide the solution. They can seemingly offer specialist knowledge, credibility and reputational power. 
Clinical leadership of and around CCGs will require medics and other clinicians to lift their horizons and their aspirations from the immediate patient experience to wider system design issues. To date, this has not been the preferred mode or orientation for most clinicians. 
A whole series of questions now confront would-be clinical leaders in and around CCGs and those wishing to enhance the opportunity for clinicians to play a larger part in service design.
The key issues
There are four main questions:
First, what is the range of clinical engagement and clinical leadership modes being used in CCGs? In other words, what varieties of approaches are being used to help secure engagement of clinicians in active leadership roles? Which of these are more effective?
Second, what is the extent and nature of the scope for clinical leadership and engagement in service redesign that is possible and facilitated by commissioning bodies – particularly the CCGs and the HWBs?
Third, what are the forces and factors that serve to either enable or block the achievement of benefits in different contexts, and how appropriate are different kinds of clinical engagement and leadership for achieving effective service design?
Fourth, which behaviours and which support structures best enable clinicians to play a positive role in leading service improvements? 
Indicative evidence
Initial studies of the pathfinder CCGs while they were in shadow form indicated some considerable uncertainty about the direction and extent of accountability. This notably included whether accountability was upwards to NHS England or downwards and outwards to their members and their partner organisations. 
There was uncertainty also about the relationships between different segments of CCGs – most notably between the operational elements and the assurance elements and about the links to the wider body of GPs. This point extends also to the uncertain role and authority of the locality groups. There was particular difficulty in engaging new GP leaders and nurse and hospital consultant leaders as required by new regulations. There was even some actual resistance to these requirements and expectations. 
The prime objective of the CCGs – in conjunction with NHS England – is to ‘improve outcomes’. In the current context this is seen to require active clinical engagement and leadership of service design. As the (outgoing) chief executive of the NHS has noted, much will depend upon how clinicians ‘breathe life’ into the new institutional arrangements in practice. Our own recent research offers insight into this mode of practical behaviour. We set out to find what clinical leadership – as a process – looks like in practice. In particular, we wanted to know how clinicians have been involved in significant examples of service redesign. We focused on two relatively under-studied areas: sexual health services and dementia services. Both had been subject to relative neglect and they carried the potential for very substantial improvement of a transformational kind. To secure such improvements would require cross-boundary collaboration – working across and even at least partially dissolving former boundaries between primary and secondary care and further with social care. 
Four cases of cross-boundary service redesign attempts for dementia and sexual health in London and Greater Manchester were studied. Each case contained multiple organisations including GPs and primary care trusts, acute hospital trusts, mental health trusts, local authorities and independent sector providers.
We interviewed a total of 74 informants including hospital consultants, junior doctors, nurses, GPs, other clinicians, managers and commissioners. Feedback events were held with informants and others in the NHS where clinicians and managers were able to respond to our findings and to offer additional insights. The work preceded the official launch of CCGs but the lessons about what encourages some clinicians to take a leadership role and the behaviours that enable this are relevant whatever the precise institutional arrangements.
The findings reveal: 
 – The forms which redesign took.
 – A series of obstacles to the exercise of clinical leadership in the NHS.
 – Enablers of clinical leadership and new ways of thinking about the competencies involved.
Forms of redesign
In both sexual health and dementia services the general thrust of the redesign was to integrate services. For example, genito-urinary medicine and contraception services were modernised by streamlining services into a one-stop shop where multiple needs could be met in a single consultation with a clinician who could deal with diverse needs. Service users were consulted and, as a result, clinic opening times were extended and clinic facilities greatly improved. 
In dementia care, a somewhat similar shift was achieved by integrating previously diverse specialist clinics into community-based ‘memory clinics’ so that GPs had a clearer idea of where to send patients in need of diagnosis. 
Some senior clinicians – hospital consultants in the main – complained that it was difficult for them to exercise leadership in service redesign because they were excluded from the routines of decision making undertaken by the managerial hierarchies of their Trusts. Some reported being discouraged from straying beyond their normal clinic sphere and a few said they were not even consulted about changes which impacted upon their service areas or which were adjacent to their areas. 
A further set of barriers to the smooth exercise of clinical leadership was the degree of complexity and fragmentation of the complete system of care, which had to be comprehended and surmounted. 
In dementia services, one of the characteristics of current practices is that diagnosis and care are scattered across multiple institutions, agencies and professions. No one ‘owns’ the condition. Before redesign, there was a divide between psychiatric services and geriatric services. GPs might send a patient to either service. In sexual health services, there were similar challenges in understanding and bridging the largely separate worlds of GUM and reproductive health services. The task facing any would-be clinical leader or group of leaders is therefore heightened by the need to engage with cross-boundary issues – including agencies and bodies external to the health service such as local authorities and independent sector organisations. 
A complicating factor for both settings was that other kinds of organisational changes were relatively commonplace. Separate trusts frequently rationalised services, closed and opened units, moved staff from one unit to another but without any notable improvement in service for users. This meant that distinguishing between the ‘noise’ of merely moving around the furniture, from the stirrings of more significant far-reaching changes could be difficult. 
Notably, in all the cases GPs played a relatively small role in the service redesigns that were achieved. Clinical leadership came from other quarters – mainly hospital consultants but also some nurses. This will need addressing urgently under the new arrangements.
Enablers and what clinicians need to be good at 
Service redesign was in each case sanctioned and triggered by national initiatives and policy papers. Mobilisation of local effort was much easier when it was seen to represent fulfilment of national level strategy. The National Dementia Strategy and the National Sexual Health Strategy were crucial in shaping local cross boundary service redesigns. The implication is that exhortations for more local clinical leadership need to be balanced by continuation of the clinical effort at national level in developing strategies for particular clinical areas.
Local clinical leadership stems in part from the intrinsic interest of many clinicians – doctors, nurses and allied health professionals – in understanding the wider system of care experienced by their patients. The motivation to improve interfaces and bring together the forms of care people need often finds expression in informal initiatives to link with other parts of the health service and with social care. This is an important resource for more formal and structured service redesign projects. Network organisations linking clinicians and managers across a locality or region have a vital role in fostering this kind of clinical vision and help develop a sense of belonging and commitment. There is a case for extending their scope, bringing in social care and third sector organisations. 
Drawing upon the above instances, GPs and CCGs need to take note of how some successful service redesigns have been achieved in practice. Below we seek to clarify the key lessons. 
Cross boundary innovation required clinicians to develop a more extensive network. It also required being open to reshaping clinical and non-clinical practices and different components of the service, such as clinic organisation, booking systems, IT systems and tariffs. Service design is inherently difficult – it involves challenging established habits distributed across a wide range of occupational areas, as well as across organisational boundaries. 
Engineering these kinds of service changes required tactful persuasion and negotiation across multiple boundaries. Clinicians needed to negotiate with each other as they sought to ‘defend’ their clinics and their staff while also seeking ways to design new service provision more suited to patient needs. They needed to enter into negotiations also with commissioners and their Trust management teams. Commissioners likewise required considerable skill in understanding the range of factors at play and they too needed to handle the negotiations with care. 
Each of these relationships required the senior clinicians to accept responsibility for leadership. We found that the more successful clinical leaders were able to be open to constructive redesigns while also bringing along their colleagues. Clinicians who were too entrenched found they were outmanoeuvred by commissioners and other stakeholders; conversely, those who were too gung-ho risked losing the trust and support of their professional colleagues. Informal, lateral, leadership could mobilise and bring along clinical colleagues, and conversely, formal project planning on its own could be relatively ineffective. The most effective service redesigns were achieved when both of these processes worked in tandem.
We identified four main types of clinical leadership at individual level (shown in Figure 1) positioned along the dual dimensions of scale of ambition and micro-political capability. 
Those clinicians who scored low on scale of ambition and political capability remained relatively passive; the localised leaders utilised interpersonal and planning skills to achieve incremental service improvements; leaders lacking followers brought passion to bear and rushed ahead but became exposed out on a limb; while high-impact leaders brought to bear both an appropriate scale of ambition and a set of micro-political capabilities. 
Challenges emanating from the national level which have been well forged with high quality clinical input can provide a vital top-down mechanism for shaking up established thinking at local and regional level and providing clinicians who have been thinking about how to improve the structure of the services with an opportunity to make their case and take it forward. Local clinical leadership is not an alternative to top-down national strategies; rather the two can productively feed off one another. 
 1. For example, PRUComm (2012) Exploring the early workings of emerging Clinical Commissioning Groups: Final report; London.

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