Chapter 1: Medical Leadership
Professionalism and Excellence in Scottish Medicine
It is 5 years since publication of the SMASAC report on Promoting Professionalism and Excellence in Scottish Medicine.
That report, which celebrated success and achievement in the first 60 years of the NHS, highlighted several key themes to further enhance the role and contribution of the medical profession across NHSScotland, and urged a call to action in a number of areas:
- Promoting better medical leadership at all levels of the service
- More effective team working
- Increasingly evidence based services underpinned by a strong research base
- Doctors as role models for doctors in training and other health professionals
- Doctors as advocates for health services and the health needs of the population.
Following an initial implementation phase led by SMASAC and the Academy of Medical Royal Colleges and Faculties in partnership with a number of other groups
in Scotland, a stock take of progress and definition of a range of further key actions to increase momentum of delivery and demonstrate further progress through a range of initiatives was published in January 2014: Professionalism and Excellence in Scottish Medicine - A Progress Report - 2014.
The Report has resulted in the development of a wide professional alliance from across Scottish Medicine jointly led by the CMO and the Academy of Medical Royal Colleges and Faculties in Scotland. This has evolved into a high level Implementation Group representing all aspects of the profession in Scotland. The Professionalism and Excellence agenda is being promoted through a number of routes, all with a strong emphasis on supporting medical leadership development. This includes introduction of Scottish Clinical Leadership Fellows, co-ordination of a range of formal leadership development opportunities and promotion of widespread use of 'Paired Learning' to promote mutual understanding and foster a culture between medical leaders and Health Service Management that is driven by service quality improvement.
The value of individual professionalism in ensuring and enhancing patient safety and quality of care is explicitly recognised in 'A promise to learn, a commitment to act' https://www.gov.uk/government/publications/berwick-review-into-patient-safety, Don Berwick's response to the recent Francis report on the Public Enquiry into Mid-Staffordshire NHS Trust http://www.midstaffspublicinquiry.com. The King's Fund has also recognised the need for a shift in the culture of leadership within medicine. Their recent publication, Developing collective leadership for healthcare http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/developing-collective-leadership-kingsfund-may14.pdf, advocates a change in the culture within medicine towards an 'everyone is a leader' approach. They recognise, citing examples from Salford NHS Trust, that there is a strong association between good, high-quality leadership and improved patient safety and outcomes.
The current system of leadership and management within NHS Scotland is often seen as "top-down". There is now clear evidence that a more powerful approach to leadership and staff engagement is a "bottom-up" approach, where staff on the front line of service delivery take ownership for developing a culture of safety, quality and effectiveness.
It is now recognised that leadership development should not wait until a doctor is in a consultant post, but that this learning should be embedded throughout medical training, starting with undergraduates.
All doctors, irrespective of role and specialty will, often without formal recognition, display leadership behaviours during their day to day work. Service organisation, education of junior colleagues and allied health professionals, management of available time and resources, responding to safety concerns or complaints and simply being a positive role model or mentor, all require leadership skills. The future of Scottish medicine relies on the enhancement of leadership behaviours on the front line in order to deliver a safe, effective and person-centred health care system.
The Progress Report identifies a number of stretching, targeted recommendations and, in relationship to medical leadership, highlights a number of national leadership development opportunities supporting all levels of the profession. These include:
- The Scottish Patient Safety Fellowship Programme - a partnership between Healthcare Improvement Scotland (HIS), NES and territorial boards was introduced to develop and strengthen clinical leadership and improvement capability in NHS Scotland in order to support the implementation of the Scottish Patient Safety Programme (SPSP). Fellows (presently numbering more than 400) typically develop leadership roles in territorial or special NHS Boards or with the Scottish Government.
- Clinical leadership development for doctors - the Medical Leadership Competency Framework has underpinned postgraduate curricular change and also is included in the GMC's Tomorrow's Doctors http://www.gmc-uk.org/Tomorrow_s_Doctors_0414.pdf_48905759.pdf for undergraduates.
- Leadership development for Scottish Medical Trainees - NES has developed a flexible range of resources in this area, including the Leadership and Management Programme (LaMP) which offers leadership and management development to all Scottish Medical Trainees in higher training, as part of a conceptual framework which also includes the Management Trainees Scheme, the Clinical Leadership Fellowship Scheme, and Launchpad for Leadership.
- Scottish Clinical Leadership Fellows - aimed at doctors in training, 8 senior medical trainees are now in post and participating in this programme across a broad range of host organisations, with a view to developing and producing a supply of doctors in the future with enhanced leadership capabilities.
- Developing Leadership in Primary Care - a joint collaborative project initiated in 2012 by the Royal College of General Practitioners (RCGP Scotland) and NES, with the support of SGHSCD Primary Care Directorate. This project aims to enhance the professional role of primary care contractors, specifically general practitioners and pharmacists using an evidence based approach.
- Delivering the Future - NES established an ongoing high level leadership programme in 2005 which aims to identify senior clinical leaders from across the professions. Longitudinal evaluation indicates that over 87% move on to promoted or expanded roles.
- Development and Leadership of Quality Improvement (QI) - This NES initiative adopts a tiered approach to education and training in QI methodology for training. The target audience is specialty trainees in the last 18-24 months of training building on prior learning in the LaMP.
- Paired Learning - A recurring theme in SMASAC Annual Reports, submitted by CMO Specialty Advisers, relates to the often dysfunctional nature of the consultant/middle management interface throughout NHS Scotland and lack of a shared common understanding. Improved mutual understanding and more effective working between consultants and middle management colleagues is essential if NHS Scotland is to succeed in delivering policies such as the 20:20 vision and health and social care integration. Experience of a Paired Learning Programme at Imperial College NHS Trust (2012) www.imperial.nhs.uk/prdcons/groups/public/@corporate/@communications/documents/doc/id_033648.pdf found that co-development of doctors and managers had a powerful and positive impact on participants, resulting in improvements in patient care. The Leading Quality Network hosted by the National Leadership Unit within NES is taking forward this important work in Scotland.
Ensuring senior clinical leadership and engagement at all levels of management is an internationally recognised key to success and high performance in healthcare organisations across the world. Senior medical leadership in vital patient safety, medical training and clinical service improvement requires a culture of clinical engagement including recognition from within the profession of individual responsibility to contribute. Active and dynamic medical leadership also requires explicit and consistent recognition and support through contractual arrangements, job planning and appraisal.
The challenging high level aspirations underpinning the Scottish Professionalism and Excellence in Medicine initiative require committed medical leadership. The initiative has the endorsement and support of a wide range of individuals and organisations in and allied to NHS Scotland, all of whom have made a commitment to actively pursue and deliver this important agenda. Achieving success will exemplify the widespread, cross-agency professional collaboration that has characterised much of our progress in the Scottish Health Service. Active medical leadership and engagement at all levels is at the heart of this success.
Email: Mark Johnstone
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