On 7 March Dame Clare Marx, the current chair of the GMC delivered first President’s Leadership Lecture of the year on the subject of clinical leadership. In this edited transcript of her lecture, Dame Clare sets out what she sees as the increasing demands placed on the medical profession, and how leadership can make a tangible difference to patient care.
This article is reprinted from the Spring edition of College Voice, the membership magazine of the Royal College of Physicians and Surgeons of Glasgow. You can read the latest edition online here.
“My themes for this evening are the challenges of quantity and quality with which our profession is being met. I’ll give some evidence of the benefits of clinical leadership, then show you some examples of what I would call ‘clinical leadership in practice’. I’ll then explore my thoughts about what professional bodies and regulators can contribute to this space, before giving you some thoughts about how we, as individuals can develop.
So, what is the landscape which we are facing? I don't have to explain to anyone who reads the paper every day that the financial constraints of the service across the nation are very considerable. We are constantly hearing of cuts, of difficulties, of people trying to struggle with providing services when there simply isn't enough resource. These are often financial constraints, but also include pressures on our human resources.
We know that we're facing the challenge of an ageing population. We know that many of our population are not willing to take on the burden of doing the healthy thing for themselves. Families are spread across the world, and this loss of family cohesion means that the extended family, which traditionally may have looked after some of these ageing people, are not so available. There is also an increase in expectations from the people we serve, both in terms of the quality and the quantity of healthcare services to which they’re entitled. There is also growing belief of the people who work in healthcare that they can have what we would describe as 'normal lives', as opposed to the sort of life that means being in hospital almost every day of our lives.
We’ve seen an erosion of hierarchy. People are more questioning of us a profession.
INCREASING DEMAND FOR HEALTHCARE
And along with all this we’ve seen an extraordinary increase in demand for healthcare. For example, if you look at the attendances and admissions at the major A&E departments in England from 2003 to 2016, attendances have increased by around 20%, while admissions have increased by 70%.
It's extraordinary that we’re seeing this increase in the number of admissions through A&E despite the fact that we're providing an increased level of healthcare.
At the same time, there’s also an increasing demand for 'elective surgery', or planned surgery. From 2003 to 2016 in England we’ve seen a rise in planned surgical admissions from 0.8 million to about 1.4 million. This is over a period of around 12 years.
So this enormous change in what we're doing in the service. And in that time, the number of beds have reduced, the number of doctor and nurses has increased, the length of stay has come down, but we are doing more and more within the service.
So that's the quantity side of this equation, what about the quality?
If we compare levels of 30 day mortality following emergency laparoptomy between populations in the United States of America and the United Kingdom where we match procedures, demographics, and where the risk of surgeries have been matched, there is a clear difference between the risk of surgery in each country. You are more than twice as likely to die within 30 days of this procedure in the UK as if you were in the US.
There is something very different in these services. Now I know that you will all think that this is due to the fact that United States spends twice as much on healthcare as we do. Well, just listen up a little bit longer.
We can also compare the mortality rate for, England, Australia and the United States. If we look at the seven day and thirty day level mortality for admissions, the relative risk of dying shows there is a marked difference between results in England and Australia and the United States. The US does best, then Australia, then England. Does Australia spend a lot more than us?
Answer – yes. They spend quite a bit more than us.
But this difference in care is not simply about spending on health care. A paper published in the British Medical Journal in 2017 gives us some more insight. This paper showed that there was a 5% cumulative improvement in survival for every additional intensive care bed per hundred beds in the hospital, but also a 33% improvement in post-operative survival when a consultant is on site.
I think that this is a really interesting observation, and here's another one: there is a 22% improvement in the length of stay when a consultant is free of all other duties.
There is something we can do within the resource we already have which potentially could make a huge difference to our patients. And that is something that as a clinical community we have to take on board.
OUR PROFESSIONAL STANDARDS
And here is something else that I think we need to pay close attention to. And that is that there is huge individual professional variation in the standards of care we provide.
A study, published in the New England Journal of Medicine in 2013, showed risk adjusted complications against a peer reviewed skill rating for bariatric surgery. What they found is that the people observing these surgeons and rating their skills in all sorts of parameters were able to actually give them a score which related absolutely to the way that the patients did. So the bottom line is, and this has been a conversation that we've had in the medical fraternity for a long time, we know who the good surgeons are, and we know who the not so good surgeons are.
What are we in the community doing about the people who are not so good?
So there is a big demand for us to do something as a community, to change what we're doing and the way we're doing it, and to have some conversations with the people responsible.
And all of this is before we even get into the power of big data, artificial intelligence, or the genomic revolution. And if we are to make the best of these new things that are coming down the line, then I think we have to be prepared to really do something about the things which are already within our control.
It’s important because we hear it every day, "can't you do a bit more?” And the question is, should we just do more of the same, or can we actually do more with the resource we already On 7 March Dame Clare Marx, the current chair of the GMC delivered our have by changing? And that is why we need clinical leadership.
THE IMPORTANCE OF LEADERSHIP
So here’s my hypothesis. It’s from Michael West, a senior Fellow at the King's Fund, and he's currently doing some work for the GMC on welfare. "Leadership is the most important influence in culture - every interaction by every leader in healthcare shapes the culture of their organisations". Is it culture which is going to make the difference? Well I want to give you some evidence.
Firstly, some evidence that clinical leadership actually does something for patients.
Now, not many of us in medicine will find ourselves reading the International Journal of Human Resources Management, I suspect. But, if we did, we would find that Michael and his coauthors, back in 2002, pointed out that good team working in English hospitals is associated with lower mortality rates.
I doubt that it's any different in any country in the entire world. He also said that good executive leadership is associated with fewer complaints.
In another study, this time from America, entitled “Clinical leadership and hospital performance”, they looked at some evidence, and what they basically found was that, in general, clinical leadership in a hospital had a positive impact on the quality of healthcare, the hospital's social performance and in the financial and operation resources.
What about the impact of clinical leadership on employees within healthcare? I think this is particularly pertinent in our environment at the moment, because it's not just the UK who are noticing that doctors are feeling stressed, they're feeling undervalued and some of them are thinking that they don't want to continue in the profession. It is actually an international issue. I was over in the States last year and I heard that burnout in the clinicians over there is really getting up to epidemic proportions, and the same is the case in Australia and Europe.
So, what can we do with our employees that might make a difference?
A study from the Mayo Clinic published in 2015 showed the impact of organisational leadership on physician burnout and satisfaction. The study polled nearly four thousand physicians and they had nearly three thousands of them respond - better than most of the polls that we can get done in this country. What they found was that if they asked people to assess their leadership on a 12 point composite scale, the higher the leadership score, the less likelihood of burnout and the greater in the job satisfaction of respondents. That was statistically significant.
So there is a direct relationship between the quality of the leadership and the employees’ welfare, and that has to be really important for us to think about. What was interesting in this particular case was that it transpired that these clinical leaders were having "magic conversations" with their employees. You don't have to be a member of the 'Magic Circle' to actually have these 'magic conversations'. They are within the power of everybody in this room. They don't cost anything, and you could do it tomorrow.
CLINICIANS LEADING CHANGE
I want to now have a look at examples of clinicians leading change.
The first example is from Nottingham, where John Abercrombie, a colleague of mine on the College Council of the Royal College of Surgeons of England actually said "I want to try being a clinician at the front door”.
He organised his organisation so that the consultant was at the front door. John was a surgeon who deals with a pretty rare subsection of bowel surgery, and so for him to go from this sub-section of bowel surgery to just being at the front door is quite a big change, but he led his colleagues to do the same. They also took phone calls from GPs, so when you rang in to speak to a surgeon you spoke to a consultant.
After a year, what they found was that there was a 15% decrease in attendances for inappropriate referrals, there was a 57% increase in the number of same day discharges, reducing unnecessary admissions, the length of stay came down, and there was a reduction in the need for beds, a saving in bed days of 2635 days per year.
That was just by having a senior surgeon taking the first call from the GP and being the first person to see patients.
But there's something more than that, and we were talking about complaints. We all know how much energy and efforts complaints take. There was an 85% reduction in complaints to that service, and there was near universal satisfaction in terms of everyone who worked there. They were able to train people, they were able to be mentoring within the emergency department, and there were significant improvements in the patient experience metrics.
Now we are all in this to do something for our patients, so what's not to like about this sort of initiative?
I know that there are people who will say "well couldn't he be better employed doing his sub-specialty?", well, maybe he could, but this means that we have an alternative view of what a service might look like which might actually be of benefit to our patients.
Some of you will also have heard about the Getting It Right First Time (GIRFT) initiative, which is being led by Tim Briggs in England. It started off in orthopaedics and it was based around asking simple questions like - "why at the age of 70 do we not all put in a hip which costs £600 and has a 30 year, excellent clinical record as opposed to one which costs £5500 and has only been around for 5 years? What is the purpose of this?"
And they looked at all the metrics, and the GIRFT pilot then looked at things like length of stay and infection rates and litigation costs and re-admission rates, What they showed us is that there was huge variety within the service. And the variation in the service, a lot of it, was down to clinical choice. "I choose to do this operation", "I always use this stitch to sew up", "I always put in two drains", or whatever it is.
There is a lot of information available to us on best practice, and when that information was shown to surgeons, and it was shown that perhaps their infection rates were higher, or their re-admission rates were higher, then it challenged the individual clinicians to think hard about their practice, make enquiries about where best practice was, and actually make some changes which delivered patient benefit.
So we know that there is enormous scope, led by clinicians to make changes in the system.
WOMEN IN MEDICINE
Women currently account for over half of all graduates from medical schools in the UK.
But if you look at some of the recent work from the King's Fund in this area, what they show is that at present women are really still markedly underrepresented in the medical leadership work space. They are also underrepresented in academic roles, and of course in surgery in particular they are grossly underrepresented. But if we look at NHS Trusts in England, only 24% of Medical Directors are women. It's not a pipeline issue.
There are plenty of women in our profession now, there have been plenty of women around for a long time. What is it that we're not doing, either to encourage or grow these women, or to make the role possible for these women, because essentially, we have a service that was designed when it was mainly men? Maybe the challenge now is to run the service that now has 50% women in its medical workforce.
It's important, because as the King's Fund also pointed out, having women at the top of an organisation, particularly if you can get three or more, is likely to change the culture and improve organisational performance. So I think it's vitally important that we apply our minds to the challenge of how we nurture and grow more women to come into the clinical leadership space.
I think it is important to do it for both men and women, but there will be different offers for different sections of our community.
Now, in terms of promoting leadership, I think that there are things that we can do. I'd like to just say what we might be able to do as the General Medical Council, the regulator that regulates all doctors within the UK. We already set some outcomes for undergraduate medicine and we set standards for the post-graduate curricula.
Our aim is to set excellence as a standard, and develop the profession across the lifetime of their careers, starting with undergraduate education, though foundation, through specialty or general practice training, and then throughout their working lives. And the way that in part we can do that is by having some influence in the curricula that are set. I would recommend that for any of you that are involved in undergraduate education, to have a look at the document "Medical leadership and management", which was produced by the faculty of Medical Leadership and Management.
It's been endorsed by the Medical Schools Councils and by the GMC, by all the health services and the NHS Leadership Academy. It was launched back in October last year, and it gives guidance to medical schools preparing students for a lifelong career, in medical leadership. Unless we actually get people into the habit of not only recognising that they've been brought into medical school great leadership potential, but it is their duty, and it will be an enduring duty, to develop themselves as leaders for the benefit of their patients.
Unless we can actually get them to understand the competencies which are mapped out in this document, and are mapped against the outcomes for graduates, then we will have missed a really rich opportunity right at the beginning of their careers to enthuse that ethos of the importance of clinical leadership.
Too often we hear people later in their careers being so negative about leadership as part of their career, they say "Oh I've given up, I'm just going to go and see my patients and do a good job".
My hypothesis is that you can't do a good job unless you're prepared to involve yourself in the leadership of the service that you deliver.
The General Medical Council can, through its General Professional Capabilities (which include Leadership) challenge the profession to develop themselves and continue to do that throughout their career.
We have produced some documentation on this topic, "Leadership and management for doctors". Clinicians might want to look at the "My GMP" app from the GMC, because you will find this guidance there, and it is, like all the documents that we produce, both for the profession and the public, to look at. In this what we say is: "It is essential for good and safe patient care that doctors work effectively with colleagues from other health and social care disciplines both within and between organisations."
"Leading by example, you should promote and encourage a culture that allows all staff to contribute and give constructive feedback on individual and team performance."
The word "culture" comes up time and time again, but how often do we see from Colleges yet another survey talking about bullying and harassment. Who is doing that?
We are doing it.
If you go onto the wards, you hear people being shouted at down the phone by their colleagues.
If we were working in a service industry, and I know you're going to say we have many more stresses and strains, but those who do so are polite, and they are helpful.
YOUR PATIENTS NEED YOU
So in conclusion, here are some of my thoughts going forward. One of the best developments in the latter part of my career was when I saw a senior surgeon actually inviting in younger surgeons so that they could learn new techniques, and then the younger surgeons asking in the older surgeons because they would really just like to know a little bit more of something or other.
So, that business of peer-to-peer coaching could be such a wonderful part of your career if you do it properly, and there is also some work around on video based coaching, if it's not just done on a peer-to-peer level.
I think we shouldn't be proud about this, we should actually understand that we need to develop our clinical leaders in the same way, because we can't expect that they should just be born, they don't just come out of the womb like that. That is going to take time for education and coaching, and the fact is that many leadership competencies are actually things that we can develop.
And these are some of the really important leadership competencies which we can reflect on:
- Effective communication
- Emotional intelligence
- Adeptness at situational awareness
We can actually learn some of them, we can work at ones on which we're not good if we can actually get good feedback and develop it. It is something that some people find more difficult than others, and there are some bits of this that people have more of than others, but all of it is something that we can work at, but you have to be able to have some help.
We've got a serious job ahead of us. We are going to need to develop the clinical leaders with skills, training and support.
I know these things cost money and take time, but I would challenge you all just to have a little bit of a go tomorrow by going out there and asking some of those magic questions of your teams that we heard about, and just see how much of a difference that might make.
The profession is going to need to show leadership and make change possible for the benefit of our patients and citizens, despite the current squeeze on resources. We're being challenged by everything that's coming down the line from the future to make those changes.
We need to do this because clinical leadership really, really matters, and it is for everyone.
And if you're not medical, if you're a patient, then getting patient feedback is going to be important for those of us as well.
Your patients need you!
REFERENCES AND FURTHER READING:
“A comparison of mortality following emergency laparotomy between populations from the USA and UK” Benjamin H.L Tan, Jemma Mytton, Waleed Al-Khyatt, Christopher T. Aquina, Felicity Evison, Fergal J. Fleming, Ewen Griffiths, Ravinder S. Vohra Annals of Surgery 2017
“The link between the management of people and patient mortality in acute hospitals”. West M; Borrill C et al, International Journal of Human Resources management 13(8)1299-1310 2002
“Clinical leadership and hospital performance. Assessing the evidence base” Sarto and Veronesi, BNC Health Services Research 2016;16:169
“Impact of organisational leadership on Physician burnout and satisfaction” Shanafelt, Gorringe, Menaker, Mayo Clinic Proc 2015;90:432-40
“Medical Leadership and Management” Faculty of Medical Leadership and Management, 2019 “Leadership and Management for all doctors” General Medical Council, 2018
“Personal Best: Top athletes and singers have coaches. Should you?” Atul Gawande, Annals of Medicine October 3, 2011 Issue
Our second President’s Leadership Lecture of 2019 will take place in the College at 6.30pm on Tuesday 4th May, and will be entitled 'The changing face of medicine: 'Reflections of a 50 year journey’. It will be delivered by our eminent colleague Dame Parveen Kumar.
In her lecture Dame Parveen will discuss her work with the Royal Medical Benevolent Foundation and why caring for the profession should now be top of the agenda for all medical organisations. She’ll discuss how medicine has changed over the past five decades, and how the medical professions have had to adapt to changes in society and advancement in technology.
You can reserve your ticket for this event now by registering online here.