Clinical leadership was associated with better patient outcomes and should be valued and supported, Dr. Julie McCarthy, HSE National Clinical Lead, Clinical Director Programme, Quality Improvement Division told the HMI South Forum in University College, Cork, this month, Maureen Browne reports.
Dr. McCarthy said that while there were examples of excellent clinical leadership in Ireland, implementation of the clinical director model had been challenging, with evidence from surveys of a large number of Clinical Directors revealing that they wanted more time, more training and more support.
The survey of Clinical Directors included personal interviews in the Saolta and the University Hospital Limerick Groups and an electronic survey of clinical directors from other hospital groups. Responses showed that 88% of those surveyed were not budget holders, many were unclear about their reporting relationships and there was still a significant gap between authority and accountability.
Many were unclear about their reporting relationships and there was still a significant gap between authority and accountability.
Dr. McCarthy, who was speaking on “Clinical Leadership: How Hard Can It Be?” said the answer to this question was that it was not hard – it was impossible unless the current system evolved to one where clinical leadership was viewed more positively by both managers and clinical staff alike.
The National Clinical Director Programme
The Clinical Director Programme is one of the major quality improvement programmes within the Quality and Patient Safety Division of the HSE. The objectives of the programme are:
- Provide capacity building expertise and support to the clinicians taking up and delivering on the Clinical Director role in the Health services.
- Build leadership capacity (including a programme of support) for Clinical Directors to achieve maximum effectiveness in their role.
- Provide guidance on the structures for quality and safety (clinical governance) through the establishment of clinical directorates.
- To actively promote implementation of the model to realise its full potential in terms of enhanced patient care and clinical outcomes
The Clinical Director Programme, managed by Ms. Angela Hughes and led by Dr. McCarthy, lies within Quality Improvement Division of the HSE and the programme organises and hosts master classes and workshops at national level, undertakes site visits and surveys to capture clinical directorate issues.
Bespoke Clinical Directorate team training is being developed through a collaborative initiative with the Clinical Director Programme, National HR and the Institute of Leadership in RCSI. This will be piloted in the Saolta group, in response to feedback from the programme visit there, to further support clinical directors and their teams.
The Clinical Director Model
Dr. McCarthy said the UK model of clinical directors was introduced in the early 1990s following the 1983 Griffith report on NHS management, which advocated more active management of units by doctors including budgetary management.
Research showed that there was overwhelming and indisputable evidence of better outcomes for patients in institutions where clinical leadership was well developed.
The report suggested that doctors should be increasingly involved in management. However, once CEOs were made legally accountable for balancing the hospital finances, control was taken more centrally and there followed three decades of increasing managerialism in the UK’s NHS.
In 2007, (Lord) Ara Darzi was appointed as health minister and launched a policy document A High Quality Workforce: NHS Next Stage Review. Darzi’s vision was to put quality at the heart of health service provision and for clinicians to accept three key roles – practitioner, partner and leader.
This placed new emphasis on clinical leadership which other successful health providers have adopted. However in August 2010, Richard Giordano published a report for the King’s Fund UK which said ‘There is a strong suggestion that the support that clinicians need to work effectively with senior managers is lacking and this is especially true in the case of clinical directors who have received no support to develop their financial and planning skills to take evidence-based decisions, who seem to lack clear lines of communication with senior management, and who believe that they are marginalised in their decision-making structure.’
In Ireland, the clinical director model was introduced in 2008 in relative isolation without any wider reform of the existing system to accommodate effective integration or change to current practice. This resulted in significant challenges in implementing the model as it was envisaged and although there were areas in the country where significant progress had been made, this was not uniform nationally.
Dr. McCarthy said the success of the clinical director model relied on collaborative team working with trained managers and nurses and should be supported by training in areas of finance, health economics and some HR policies, amongst others. These ingredients, together with budget devolvement were fundamentally achievable.
Less easily achievable, but as important to the success of the model, were issues of line management of non clinical staff, encouraging senior managers to view clinicians in leadership and management roles as positive and changing the culture of other clinicians to one in which clinical leadership was supported and valued.
Evidence of the benefits of Clinical Leadership
Research showed that there was overwhelming and indisputable evidence of better outcomes for patients in institutions where clinical leadership was well developed. A 2002 study, which appeared in the International Journal of HR Management, showed that, with improved people management and team-working, patient mortality decreased.
An index of hospital quality scores in the USA published in 2011 showed there was a strong positive association between the ranked quality of a hospital in the areas of cancer, digestion and heart services and whether the CEO was a doctor.
Looking at the international situation, she said the concept of clinical leadership was not new. The Mayo Clinic, a 10 billion dollar not-for-profit organisation established in 1889, with 4,100 physicians, 61,000 staff, over multiple sites, was led by doctors, with no MBA. They worked in partnership with trained administrators and nurses. The combination of clinical leaders working with trained managers was critical for success.
There was current and historic evidence of bad outcomes for patients in institutions where clinical leadership was poorly developed, as highlighted by the 2013 Francis Report into the Mid Staffordshire NHS Foundation Trust.