Strong medical leaders: the key to high-quality care in these austere times?

I've just returned from the annual conference of medical leaders in Australasia, where I gave a keynote address on delivering high performance in austere times. The invitation to speak arose from recent work I've done with colleagues on medical leadership in the NHS, and the Fund's thinking on how to improve NHS productivity in a decade of austerity.

My message to the conference was simple. Health care systems around the world will not survive in austere times – let alone deliver high performance – without exceptional medical leadership. This is because the most important opportunities to improve productivity are to be found in unwarranted variations in clinical practice, such as prescribing, the use of diagnostic tests, and lengths of stay in hospital.

Tackling these variations cannot be done by politicians or managers. Rather, it requires every clinical team to take responsibility for reviewing its use of resources with the aim of improving the quality of care and reducing costs. I was reminded of this essential truth on a visit to Intermountain Healthcare in Utah in May, where sustained effort has been put into supporting doctors and other clinicians to do precisely this, with stunning results. One example is the reduction in deaths from sepsis from 18 per cent in 2004/05 to 10 per cent in 2008/09. The drop came three years after committing to the goal of treating more patients with a recommended 'bundle' of strategies, resulting in identification and treatment at a much earlier stage than at most hospitals .A key message is that resources are wasted when the quality of care is compromised. At Intermountain Healthcare, they tackle this by engaging clinicians in developing guidelines on best practice and reviewing performance against these guidelines. Medical leaders at all levels use performance data to challenge their peers in order to drive continuous improvements in quality and outcomes.

Visiting Intermountain Healthcare and other high-performing systems, such as Kaiser Permanente and Virginia Mason Hospital and Medical Center, underlined the central role of medical leaders in bringing about improvements in care. In all of these organisations I met many doctors who have gone into leadership roles and willingly and enthusiastically taken responsibility for the quality and cost of care. These doctors were impressively bilingual; equally comfortable talking about quality and outcomes as they were discussing productivity and efficiency.

The lesson for the NHS is to redouble efforts to involve doctors in leading work to improve performance and to do so as a matter of urgency. The Fund is playing its part in these efforts by offering a new suite of development programmes and by undertaking research into high-performing NHS foundation trusts in England. We have also invited Brent James, who has led developments at Intermountain Healthcare over many years, to speak at our annual conference in November.

A message I brought back from Australia is the need to raise the profile and status of medical leaders in the NHS. The Royal Australasian College of Medical Administrators plays a key role in doing this on the other side of the world and the recently established Faculty of Medical Leadership and Management has the opportunity to do the same here. Both myself and Vijaya Nath will be speaking at the Faculty's upcoming conference and talking to medical leaders about some of our leadership programmes, which we have recently redesigned to support the development of current and future medical leaders. The King's Fund will be contributing to the FMLM's upcoming conference and supporting future aspirations for professionalising high-quality medical leadership and management. Without a critical mass of credible and respected medical leaders equally fluent in the language of managers and clinicians, the NHS will struggle at best and fail at worst to make the changes needed to survive the decade of austerity.

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Comments

#40849 David Oliver
Consultant Physician/President Elect
Royal Berks/British Geriatrics Society

Dear Chris

As a jobbing doctor who has also taken on various local and national leadership roles i couldnt agree more. I do think its a shame that we look overseas and dont always celebrate some of the clinically led quality improvement on our own doorstep though. I have just given a series of lectures in Canada and our Canadian colleagues were genuinely impressed by many of the quality initiatives around the care of older people i described there.

The care of older patients with hip fracture, services for people with dementia (including antipsychotic prescription), and stroke services provide just three examples of national quality improvement programmes based on standards developed and owned by clinicians, national audit and system incentives and national quality improvement. The RCP future hospitals commission (whilst too soon to judge its impact) is another example of clinicians seizing the imperative, challenging their own practice and driving change and there are numerous other examples such as the "Silver Book" setting out standards for emergency care of older people.

At local level there are also many outstanding examples from the NHS of clinically led quality improvement - for instance the two recent health foundation studies from sheffield and south warwickshire on improving patient flows and unblocking acute hospitals.

So we can deliver clinically led change in the NHS and people are delivering it. The frustration to me is that we are so slow to adopt and implement the lessons from high performing sites and servics and end up with people in their own patch reinventing the wheel. Secondly that instead of paying for costly private sector consultancy we could be doing much more to have existing NHS staff with experience of driving change sharing the lessons with other sites and helping them to transform their services. You might argue we are better at innovation than adoption and spread.

On a note of caution, however, despite the criticisms of process-driven "targets and terror" i didnt notice doctors (myself included) a decade ago making any concerted national effort to reduce A&E waits or hospital acquired infection or bring waiting lists down and we were quite complacent about those issues.

What most other countries could not achieve we in the NHS must treasure though. The fact that we have national clinical audits with every site participating, national quality standards and guidelines, national system incentives, national contracts etc mean that when we do pick a priority for change such as hip fracture, stroke or dementia we have the apparatus to drive clinically-led change across the whole NHS. Rolls Royce US services such as VA or Kaiser or Mayo Clinic do not have to provide universal services for whole populations free at the point of the delivery for the equivalent per capita spend of 8.9% of GDP so of course they can liberate excellence and innovation, but whole population outcomes in the US are worse than they are in the UK for twice the spend. Ultimately our system is designed to provide a half decent offer at lowish cost to the whole population rather than to liberate and facilitate excellence.

But i do agree that we need to do far more to develop clinicians with leadership potential. The system is currently haphazard and many clinical leaders get sucked into the nuts and bolts of balance sheets and operational management to the extent that they arent free to innovate for excellence

David Oliver

#40851 Mark McCartney
GP
Golden Beach Medical Centre

It is a pity you did not take the opportunity to talk to some front line clinicians in Australia to understand how different the system is. There is lots of leadership from GPs who lead in the management of their individual patients. GPs have early access to diagnostics and payment for treatments which in the UK are the preserve of secondary care - this no doubt keeps many away from hospital emergency departments, which are facing the same demand pressures that are occurring in the UK. Our medical leaders need to trust the front line clinicians to deliver appropriate care - and this will lead to better care in the community and less money being spent on hospitals which have sucked up all the additional NHS budget in the last 10 years

#40919 Sally Lewis
GP and Primary Care Clinical Director
Aneurin Bevan Health Board

Dear Chris,
I also completely agree with this. In primary care, there is a great need to reduce variation in practice in many areas using peer review to raise standards and share good practice. My hope is that the contractual model for general practice will also evolve to support this approach as well as providing a career structure for those who would wish to develop their medical leadership/management and quality improvement skills.
This would also go some way to addressing problem of 'adoption and spread' of innovation as described by the previous commentator and which I recognise.

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