Professionalism and Excellence in Scottish Medicine - A Progress Report

Chapter 3

Developments in Management and Leadership

3.1 Scottish Patient Safety Fellows

The Scottish Patient Safety Fellowship Programme: www.scottishpatientsafetyprogramme.scot.nhs.uk/programme/fellowship-programme was introduced to develop and strengthen clinical leadership and improvement capability in NHSScotland in order to support the implementation of the Scottish Patient Safety Programme (SPSP). The Fellowship Programme is led by HIS, in partnership with NES and NHSScotland territorial boards.

The specific aims and objectives of the Fellowship are:

• to develop and strengthen clinical leadership capability to support the SPSP
• to contribute to the development of a long term quality improvement and patient safety culture
• to establish a learning support network for transformational leadership
• to strengthen existing collaborations within NHSScotland

The Fellowship Programme seeks to develop clinicians working on the front line in NHS Boards to become patient safety and quality improvement experts within their own Boards, equipping them with the skills to lead local change programmes in order to ensure that the patient safety is well integrated within NHS Boards.

Fellows typically develop leadership roles within their original NHS Board, or nationally (with the Scottish Government or special health boards such as Healthcare Improvement Scotland). The Fellowship Programme is currently recruiting to its sixth cohort of Fellows and has a network of over 400 Clinical Fellows based across Scotland and internationally.

3.2 Clinical Leadership Development for Doctors

NHSScotland needs to ensure increasing engagement and participation of doctors in management and leadership roles. Although the challenges will vary according to context, there are common themes which are underpinned by:

• The recognition that service improvements can on occasions be blocked or frustrated by powerful clinical groups (sometimes associated with unprofessional behaviour) - unless clinicians feel directly involved in the designing and planning of these changes
• Current and future financial pressures will require innovation and radical change which in turn needs to be driven by committed, engaged clinicians.

For contemporary doctors in training the MLCF (produced by the NHS Institute for Innovation and Improvement and the Academy of Medical Royal Colleges in 2008 and updated in 2010) has driven postgraduate curricular change. The domains of the Framework (see Figure 1) are listed at Annex B. The Framework is designed for clinical and non clinical staff and has been incorporated into the education and training of all doctors in the UK through inclusion in professional standards and outcome statements. At undergraduate level, this is through its inclusion in Tomorrow's Doctors. At postgraduate level the Framework has been integrated into the Foundation Programme curriculum and the 2010 Specialty Training curricula, which are all approved across the UK by the General Medical Council.

Scotland has its own strategic approach to leadership development, of which the MLCF is a part. However, there is recognition that additional efforts are needed, which is why the Scottish approach (led by NES through its National Leadership Unit - NLU) is to ensure that doctors at every level who need leadership development have a route to achieving this. Further detail of the programmes provided by NLU can be found at Annex C.

Figure 1: The Leadership Framework^[1]

3.3 Leadership Development for Scottish Medical Trainees

In Scotland, NES has developed a flexible range of resources in this area, recognising that trainees will enter the leadership and management component of their training from a range of different backgrounds. However, there is a clear recognition that every trainee needs some competence, that some will seek extended skills, and that a few will want to integrate a leadership and management track within their clinical training, in whatever specialty. NES is a provider of core resources through the LaMP approach, currently set up to offer foundation and leadership and management development to all Scottish trainees in higher training - around 500 individuals per annum. Further development of leadership and management training will inevitably require access to external provision from a range of organisations.

The National Management Trainees Scheme (MTS) has a group learning framework designed to bring together emerging leaders from clinical and non-clinical professions to learn together (as well as from each other - see also 'Paired Learning' below). The MTS model for national management trainees and trainee doctors has been in place since 2005 and in 2012 was extended to include other non-medical clinical staff. Figure 2 below illustrates NES' planned conceptual approach to leadership and management development for medical trainees.

Figure 2: Planned menu of leadership development options for Scottish Medical Trainees

Key to abbreviations:

MTS = Management Trainee Scheme / National Management Trainees' Group Learning Framework
CLF = Clinical Leadership Fellowship scheme
LfL = Launchpad for Leadership
LaMP = Medical Leadership and Management Programme

The establishment of the FMLM of the UK Academy of Medical Royal Colleges is an important development. By late 2012, nearly 40% of Scottish trainees had joined the Faculty. In England and Wales this initiative has led to the establishment of a number of Clinical Leadership Fellowships offering medical trainees the opportunity to spend a year working with senior colleagues in a range of national organisations, including the Department of Health. In the first year 11 trainees were appointed and this has now risen to 16 for 2012/13, ranging in seniority from FY2 to ST6. A wide range of host organisations have agreed to mentor the appointees including the GMC, NHS Commissioning Boards, the National Institute for Healthcare and Clinical Excellence (NICE) and the Academy of Medical Royal Colleges.

3.4 Scottish Clinical Leadership Fellows

A decision has been taken that Scotland will mirror this development and funding has been recently secured for 2 Fellowships who have been appointed in late 2013, with a view to increasing the cohort in future years, following evaluation. The Fellowships are aimed at doctors in training and aim to introduce the appointees to policy and strategic work at national level in Scotland, linked to the 5 domains of the MLCF, referred to above. NES are responsible for the selection and recruitment of these Fellows, who will be hosted by a variety of organisations including Scottish Government, Health Boards, and the GMC.

In a parallel development, the Board for Academic Medicine is seeking support for an enhanced Scottish Senior Clinical Fellowship scheme. This builds on the current successful programme that was well evaluated in terms of impact and value for NHSScotland and the wider Scottish economy.

This scheme would ensure that Scotland is able to recruit and retain the very best early-career clinical academics who will play a crucial role in improving the health, healthcare and wealth of our nation. If approved, it will build progressively over a 5 year period to support 20 Fellows in total with a rigorous appointment process and evaluation, as was the case with the first Scottish Senior Clinical Fellowship scheme.

3.5 NHS Education for Scotland and Royal College of General Practitioners Scotland project: 'Developing Leadership in Primary Care'

This joint project was initiated in 2012 with support from SGHD Primary Care Directorate. It originated from recognition by both organisations that the success of the 20:20 Vision and the forthcoming integration of health and social care will require an enhanced professional leadership role for primary care contractors, specifically general practitioners and pharmacists. The NHS of the future requires systems thinking. This will involve ensuring that professionals, who are geographically disaggregated or disadvantaged, are able to provide leadership for flagship NHS policies from within primary care. There are currently disparities of access for contracted professions which require to be addressed if their leadership contribution to government policy is to be fully realised.

Using an evidence-based approach, the project has identified 3 strands of activity needed for the development of primary care leadership capacity and capability:

• Creating the right conditions for leadership development, including changing current incentives and drivers for GPs and other professions.
• Development of direct and formal approaches for leadership development at different levels. Currently Action Learning Sets involving cross sector teams working on real problems facing them and the communities in which they work is being trialled. A network of capability, involving NES, RCGP, NLU and possibly private providers is envisaged.
• Using informal and indirect approaches to embed primary care issues within existing leadership development programmes. Liaison is taking place with the NLU about primary care engagement with the currently available national leadership programmes. Discussions are also taking place with NES on how better to embed leadership in the GP appraisal and revalidation processes.

The project has commissioned a Practice Based Small Group Learning (PBSGL) module 'Introduction to Leadership', which is now being piloted. It will be available this autumn to 1,600 GPs (30% of the Scottish GP workforce) as well as pharmacists and practice nurses.

This project will run for a further year, during which further progress on direct and formal approaches will be made and a second phase project developed. Further details are available in Annex D.

3.6 Delivering the Future

NES has established a high level leadership development programme which aims to identify senior clinical leaders from across the clinical professions and prepare them for future roles at Board, regional and national level. The programme commenced in November 2005 and NES are now recruiting for the ninth cohort which will commence in November 2013.

While the specific roles that participants currently hold will vary across Boards, participants are normally already in strategic clinical leadership roles but are a couple of years from undertaking Board, regional and national roles.

Each cohort consists of 24 participants selected by a local (Board level) recruitment process. Over the 9 cohorts around 40 - 50% are doctors. Longitudinal evaluation of the programme indicates that over 87% move on to promoted or expanded roles.

3.7 NES proposals for development in (and leadership of) Quality Improvement (QI)

A further NES proposal aims to align leadership development and training with the Quality Strategy and 20:20 Vision for NHSScotland. It embeds a strategic, tiered approach to education and training in QI methodology for trainees, as depicted in Figure 3.

Figure 3: Tiered approach to education and training in Quality Improvement (QI) methodology for training

The vast majority of doctors in Scotland will be well aware of the many Scottish Patient Safety Programme initiatives but may sometimes feel that they are the target of such initiatives, rather than stakeholders, or even leaders, and drivers of improvements in patient care. This proposal aims to overcome such barriers, starting at level 1 with Foundation, Core and ST 3 trainees and culminating in Level 3 (Launchpad for Leadership - LFL), with QI training integrated with leadership development and training. The target audience is higher specialty trainees in the last 18-24 months of training, building on learning in LaMP, to prepare them in their future roles as consultants and GP leaders. Further detail of NES training in QI is found at Annex E. A key feature of level 3, the LFL programme, is to 'buddy' trainees with management trainees (see below).

3.8 Paired Learning

A recurring concern in the Annual Reports submitted by the CMO Specialty Advisers, and also in discussions in SMASAC, relates to the consultant/middle management interface, where all too often there seems to be a lack of shared common understanding of the other party's agenda and motivation. This lack of common understanding has sometimes been described as a 'chasm', and has the clear potential to generate lack of trust between senior clinicians and management. Given the list of challenges facing NHSScotland, including the need for better service planning, this is an area that needs serious consideration of measures that might be put in place to improve mutual understanding between consultants and their middle management colleagues. Paired learning might be one such means of achieving this.

A seminal report published in February 2012 by NHS London describes the 'Paired Learning' leadership development established at Imperial College Healthcare NHS Trust in 2010:

www.imperial.nhs.uk/prdcons/groups/public/@corporate/@communications/documents/doc/id_033648.pdf

In this initiative, Specialist Registrar doctors and band 7-8 managers were paired up in order to learn from each other's expertise, and gain a different perspective into each other's roles. The following is an extract from the Executive Summary of that report:

'The study found the Paired Learning Programme to significantly increase preparedness for leadership roles for both Specialist Registrar doctors and managers across a wide range of domains. The qualitative analysis demonstrated that the co-development of managers and doctors had a powerful impact on the personal learning, attitudes and behaviour of participants. In addition there were a number of demonstrable wider organisational benefits, resulting in improvements in patient care through the collaborative work done within the programme.'

This kind of low cost, work based peer learning is also being taken forward in NHSScotland through the Leading Quality Network hosted by the NLU within NES. The Network supports clinicians and managers to learn together and to increase their collective capacity and capability in applying QI methodologies and leadership, to increase the pace of transformation towards the 20:20 Vision. Scottish Government approved a 3 year funding programme (2012-15) to develop and implement the work programme for the Network.

3.9 Conclusion

It is clear that in the 4-5 years since the publication of the Professionalism and Excellence Report there have been a number of very positive developments, particularly in relation to the postgraduate curricula, and opportunities for management and leadership training for clinicians. NHS Boards and NES need to ensure that trainees in particular are aware of these throughout their career.

SMASAC has maintained the profile of Professionalism and Excellence in a number of ways, including asking Specialty Advisers to provide information in their annual reports on involvement in relevant activities at local, regional or national level, and using its annual meeting with Specialty Advisers as a forum for discussion of this area.

However, there remains much to be done to address the concerns of trainee doctors and Directors of Medical Education, and to bridge the perceived consultant/middle management 'chasm' referred to above. In addition, the statement in the 2009 SMASAC Report that:

'The role of management in service development and the reciprocal relationship between managers and doctors is seen as very important. Management expertise is increasingly seen as a valuable skill set with the need for better mutual understanding, development skills for doctors and for managers to help clinicians drive forward service development….'

This needs to be made a reality in day to day working. The next chapter outlines potential ways of achieving this.