The conundrum of clinical leadership: after your patients, who is it that you serve?

I am a consultant Orthopaedic surgeon, and for more than eight years served as Clinical Director of Orthopaedics and Plastics at Barts Health NHS Trust.

In taking up the post I had next to no formal teaching or training in leadership and was expected to take on the operational and strategic leadership of the group. In doing so I uncovered fundamental differences about expectations of the purpose of the role. Some viewed it foremost as one of public service, ensuring the provision of evidence-based care to one of the most socio-economic deprived communities in the UK (alongside being one of the biggest Major Trauma centres in the UK). Others understood the key responsibility to be that of leading a £75 million business, with an obligation to deliver value to the taxpayers that funded it.

This difference in emphasis was the first clear sign to me that although everyone working in health care sets out with the prime aim of providing care to patients – a single clear unified objective – what that actually meant in practice was much less clear. I took it upon myself to educate myself, completing a master’s in health care leadership from an American Ivy League school, attending courses at INSEAD business school, Harvard Business School, and the London Deanery. This certainly gave me an education, not just in the theory and evidence around the role of clinicians in leading (as well as delivering) health care, but also the size of the leadership knowledge gap for those starting out as consultants – world experts in their specialty, with almost no formal knowledge of how to lead themselves or the teams of very intelligent and motivated professionals they work alongside.

Taking the experience I had gained, I became the trust’s lead for consultant leadership development. In this role I set up a unique partnership with The King’s Fund to deliver a co-designed and agile leadership development programme for consultants at the trust. Within the suite of programmes, the one for senior clinicians had three modules. The first looked at leading yourself – a journey of self-understanding about how we perform as leaders, how we are viewed by our superiors and our followers and the distinction between our behaviours when calm and when under duress. The second focused on leading a team – optimising performance and efficiency within our teams, understanding how we view and respond to each other, and exploring the multicultural teams we work with, aiming to maximize inclusivity to maximize team performance. The final module looked at leading within a system – how to draw on the stakeholders and support available to you to deliver change, how to attract staff and funding, to grow your strategic reputation alongside your clinical one. The King’s Fund brought their knowledge of the wider health and care system and in-depth experience of leadership development; I held the granular understanding of the Barts Health context and challenges, plus first-hand experience of the tensions juggled by clinicians in these roles. More than 500 consultants have now attended one of the programmes, and we have received great feedback on how valuable people found the experience.

The theme which arose most frequently held echoes of my first experiences of clinical leadership and the tension over who decides what good leadership is. On the ground some prioritised fighting their corner to secure staff and funding for their teams, taking innovative best practice from international conferences, collaborations and evidence to deliver the best available care. Others prioritised the need to serve the systems requirements, focusing on the implementation of prescribed changes, delivering value that was financially accountable, managing the parameters agreed in annual contracting and making savings without compromising safety. The two aren’t the same and the clinical leader was stuck in the middle of this dilemma.

What often plays out is a very polarised approach of a clinician leader opting to ‘serve’ their colleagues, doing everything they can to secure limited resource but struggling to deliver on the system needs; or a leader opting to ‘serve’ the system requirements, holding colleagues to task, accountable for delivering their metrics of success. For the former, the end of tenure is more likely to be a return to the fold as ‘one of the gang’ while for the latter it maybe more likely they move up the clinician ladder with the potential to eventually be a medical director, chief medical officer or even a chief executive. Of course these are gross generalisations and do not attempt to define any individual leader, but they do demonstrate the conflicting demands on the clinician as leader, where at the extremes it is hard to deliver all things to all people.

The programme created a safe space to surface these sorts of quandaries, which typically do not get raised as part of a leadership development programme. No programme should offer a universal answer but should instead challenge leaders to understand their purpose, their strengths and then see how they can be utilised to deliver something robust and sustainable, so that despite the conflicts our patients get served to the best possible standards.

I am extremely grateful to Sally Hulks from the King’s Fund and Lois Whittaker from the Barts Health NHS Trust Education Academy who gave me the opportunity to set up and deliver these programmes which marry up the vast knowledge and theory behind effective healthcare leadership with the on the floor real challenges of clinicians trying to lead in a lean and changing landscape. I truly believe jointly led programmes are crucial in developing the very best leaders and would encourage any clinical leader to find ways to take time to reflect on their role in delivering change within a complex and challenged system.