Not being Dr Kelso - why the good doctors should be in charge
Eric Edison & Sam Oxley
Guest Writers
There is a perceived cultural divide between those on the front-line doing their best to treat patients, and those in the back office undermining their clinical autonomy by making resource-based decisions that limit their practice. This is an outdated and even irresponsible point of view. The Mid-Staffordshire disaster, where attempts to cut costs led to failures in care, neglect and humiliation of patients, was an almost inevitable consequence of this dichotomy.
Lessons must be learnt and the future of the NHS lies in co-operation between doctors and managers, with doctors in charge and leading the way. To do this they will need to acquire leadership and management skills and experience as well as medical knowledge. In fact, these are now assessed at application to core and speciality training posts. But what is medical leadership, why is it important and how can students stay ahead of the game?
Medical leadership is not just about the personal qualities of a select few in charge. It is about the medical profession driving forward improvements to healthcare services, rather than have these forced upon them. All doctors, whether junior or consultant, with their superior experience on the front line, should be able to identify situations where things could be done differently, and have the initiative and the skills to improve them.
This is less about individuals and their character traits, and more a disseminated professional attitude, much like the duty to make the care of your patients your first concern. No doctor should ‘leave it for others to sort out’, when they see an area affecting their patients that could be improved upon.
Management on the other hand, involves simplifying and organising processes to maximise the potential of an organisation. It is well accepted that doctors are expected to manage their time and the team around them. It is also becoming increasingly important that they manage resources.
Consider yourself in a couple of years as a junior doctor in A&E facing a patient with a head injury on a Saturday night. Can they be discharged? Do they need to be kept overnight? Do they need an urgent CT or surgical consultation? The decision will be based upon evidence of clinical benefit and outcomes but also on cost-analysis and resource-based considerations. For example, is it possible to get a CT scan now? Are there beds free? The point is this management of resources is not beyond the realm of medicine;; it is central to what we do as doctors, and vital to patients.
There are often situations where management decisions are impeding clinical practice – often the result of management and clinicians not communicating effectively. These issues are reported in the news time and again. The most famous case was the Mid Staffordshire Inquiry where hundred of patients may have died because of management that was focussed on cost-cutting and hitting government targets. It is easy to blame the efficiency drive itself for these failures but in a struggling economy with rapidly rising healthcare costs we need to provide good services more effectively in order for the NHS to survive. The key problem was that managers and clinicians were not communicating effectively. Front line workers need to have a say in how the services they run are provided. It should not be left to others with no medical background to determine clinical practice. Of course there is a role for dedicated managers, but medical engagement is necessary. There should be no ‘us-and-them’ mentality, only a common desire to maximise and improve our services for patients.
Indeed, the recognition that more must be done by the medical profession is having a significant impact on the training and assessment of doctors and medical students. The Medical Leadership Competency was devised to be a national tool for training and self-assessment, in which all doctors should demonstrate proficiency. To be certified an effective and safe doctor in the UK, it will be necessary to attain competencies in management and leadership as well as clinical skills. As well as generic skills all doctors need, there are skills specific to different specialities. For example, surgeons need to understand the pathways of patients through pre-op, theatre and post-op recovery and how these can be optimised. Hospital medics need to take responsibility for the safety and quality of care in the wards where they work. GPs need more specific management skills in the day-to-day running of practices and proposed reforms suggest they could be in charge of local budgets, controversial though this is.
Given the importance placed on leadership and management skills, it is surprising how few medical students are aware of the concept at all. Some are even hostile to the idea, holding anarchic preconceptions of ‘going over to the dark side’ by thinking about management. Not only should students be considering how to bolster their portfolios in this domain, but students can take on leadership roles even during their training. Medical students are in a unique position to capitalise on their ‘outsider’ role, and spot what others may miss. These can lead to opportunities for quality improvement projects which aim to improve patient care as well as offering opportunities for those much-coveted publications.
For example, students at UCL are assigned projects to follow a patient with a chronic illness over the course of their first clinical year. One such student noticed that there were certain recurrent problems encountered by patients on their journey. A project is now underway to improve certain aspects of the patient pathway. Students notice these things every day and should be brave enough to be an advocate for patients.
Support for this project is being provided by a society recently set up at UCL. Several medical schools now have their own ‘Medical Leadership and Management’, or similarly named society. Young Civitas for Medics is an independent group supported by the think-tank Civitas that provide debates and talks around clinical governance.
These groups are working together to send the message to students that Medical Leadership is a fundamental aspect of our training and careers and is important for patient care. As well as portfolio accreditation, there are opportunities to get involved and get published for projects that will have a real impact on patients. The Medical Leadership Network is a new initiative launched this year which will bring together students with senior doctors, managers, researchers, and others. The aim is to pair those who have projects with those willing to give their time to participate in one, and to provide help and support for those with ideas to realise their plan. It will also help those looking to organise SSCs, or work experience with professional firms.
The medical profession in the UK is at a turning point, where more is required to constantly improve services to patients. Patients demand it, and the medical profession has a duty to deliver. Doctors must accept the leadership responsibility which goes with clinical freedom, or risk their autonomy and status as providers of quality healthcare. As medical students, we can start thinking about this now, in order to not be left playing constant catch-up with patient’s expectations. Doctors should lead improvements for the healthcare of their patients, and not let themselves be led by others.
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