- 26 November 2008, Committee Room No.10, House of Commons

• Professor David Fish, Medical Director, UCLH NHS Foundation Trust
• Professor Martin Marshall, CBE, Director of Quality, Health Foundation
• Professor Jenny Simpson, CEO, British Association of Medical Managers
• Mr Bernard Ribeiro, CBE, Former President, The Royal College of Surgeons of England

With commentary by Eileen Sills, CBE, Director of Nursing, Guy's and St. Thomas's NHS Foundation Trust

This is the fifth in Civitas's series of debates, chaired by Professor Aidan Halligan, that look at some of the key themes, drivers and milestones in the Next Stage Review of the NHS conducted by Lord Darzi.

'Quality', wrote Lord Darzi in his recent Next Stage Review of the NHS, 'is improved by empowered patients and empowered professionals. There must be a stronger role for clinical leadership and management throughout the NHS'.

As the report acknowledged, compared to leading healthcare organisations such as Kaiser Permanente in the US, the NHS has very few clinicians in leadership roles - a fact fast being seen as a rate-limiting step to achieving quality of care. A raft of measures to encourage its development has been proposed, but will they be effective? Is this a new dawn, or merely a false beginning?

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• Full summary text (.pdf)
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'We must support all clinicians at all levels to understand the environment they operate in and the opportunities that exist for change.' - Eileen Sills

Personality and vision

'Leadership', said Professor Aidan Halligan in his introduction to the debate, 'is about personality and vision'.

As Professor Jenny Simpson put it 'leadership is not about heroics or Powerpoint slides; it's about behaviour, communication and relationships... It's about balancing incompatible dualities; being strong, but not arrogant; being resilient, but also sensitive; being compassionate, but able to make decisions on where to spend money; and [above all] putting service before personal ambition'.

'Leaders', said Professor Martin Marshall, 'must have a vision, a selfless commitment and humility'. That vision, for all the panellists, was putting the patient at centre stage. As Professor David Fish put it 'for me, the resilience [key to leadership] comes from imagining a patient is in the room....from providing a compass point for what patients and their families want'.

Mr Bernard Ribeiro focused on the absolute importance of telling the truth, of 'holding true to your ideals and being an advocate for patients, even if it may prove unpopular...such as with publishing clinical outcome data in surgery'. For him, leadership is the seven 'Cs': courage, confidence, creativity, caring, charisma, character and the vital 7th, communication (or learning to listen).

The common thread for all the panellists was the importance of emotional intelligence. As Professor Simpson said 'you can only change people's behaviour by making people want to do something...to articulate a vision that presses an emotional button'.

Clinicians at the fore

'Ultimately', summarised Eileen Sills, 'those that make the biggest difference to the service for patients are clinicians'. To move health care strategy forward, particularly in terms of patient experience and navigating pathways of care, 'we must', she continued, 'support clinicians at all levels to understand the environment they operate in and the opportunities that exist for change'.

Professor Simpson went further. 'The anatomy of the health system is as important as that of the human being in delivering high quality care', she said. 'Without having clinicians in managerial positions...things will never work as well as they should; clinicians will always struggle to fulfil their duties'.

Professor Fish drew particular attention to the role of the 'next generation' in this. 'Young leaders are the future', said Professor Fish, 'they are energetic, carry less baggage and are used to things happening'; Mr Ribeiro and Professor Simpson highlighted the examples of the Scrubs Society at Nottingham University and Bammbino for what was possible.

More widely, there was agreement that the vision for leadership applies not just to doctors, but nurses and all health professionals. 'Anyone can put the vision of the patient', said Professor Fish, 'no-one holds the holy grail....all clinicians, exposed to the rawness of human emotion, are well placed to align for change'. Mr Ribeiro offered a caveat. 'In surgery', he said, 'it would be difficult to perceive a leader who is not surgically trained', but contended 'the wider future is multi-disciplinary learning based around the treatment and management of certain diseases. Here, many will have the skills to lead.'

The key, surmised Professor Marshall is that 'the focus of clinical leaders [should be] on quality...quality in biomedical areas, [but also] in terms of access, interpersonal skills, continuity of care and equity'.

The challenges

Professor Marshall opened his account with reference to Mahatma Ghandi's tour of the mill towns in northern England in the 1930s. Ghandi was asked "what do you think of British civilisation?" His reply: "I think it would be a good thing". The same, Professor Marshall contended, could be said about leadership in the NHS. As Professor Simpson put it 'in the past clinical leadership represented trying to make something happen in a system that didn't want it to'.

The key for clinical leadership is not just identifying potential leaders, giving them role models and developing emotional intelligence - difficult challenges highlighted by all the panellists - but, as Eileen Sills summarised, 'that organisations are ready and able to allow clinicians to lead'.

There now seems to be sea-change towards this. 'It's our responsibility to do something about it', said Eileen Sills, to rise to the challenge: to identify and develop leaders, particularly in the younger generation; to grow leaders across the ever-growing primary-secondary care divide; and, as Professor Fish put it, 'to align systems... and transform cultures... so that the patient always at the top of our concerns'.

Mr Ribeiro concluded by quoting from Baroness Onora O'Neill's Reith Lectures in 2002: "If we want a culture of public service", she said, "professional and public servants must in the end be free to serve the public rather than their paymasters."

Please find a full summary text of the debate, with comments made in discussion from Stefan Cantore, Dr Keith Brent, Professor Tony Butterworth, Sir Denis Pereira Gray, Dr Paul Robinson, Daghni Rajasingham, Denise Chaffer, Professor Arulkumaran Sabaratnam, Dr James Mountford, Dr Alistair Flowerdew and Dr Ram Moorthy here.

Any thoughts on the debate? Post them here.

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