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4 | BMA News 18 November, 2017

How to evolveeffective leaders of hospitals is aquestion that has yet to beanswered. However,other high-poweredprofessions mayprovide the cluesneeded to find away forward. PeterBlackburn reports

Evidence counts foreverything in so many partsof the health service.

Treatments without strongevidence bases are not oftenoffered, surgery carrying more risksthan benefits is unlikely to becarried out and preventive caretends to be underpinned by public-health data and trends.

Until recently – and healthsecretary Jeremy Hunt’s penchantfor ‘seven-day services’ – evenoverarching policy was generallybased on firm data, and aconsensus among studies.

But while doctors, patients andhealth experts have, over recentyears, largely been clear thatclinical leadership is a positive forthe NHS – and vital to any effortsto transform and sustain services –evidence has often been scant.

So is it right to suggest doctorsand healthcare professionals inleadership roles is a good thing? Asthe NHS looks to continue itsbottom-up reorganisation on thequiet, with accountable careorganisations and new models ofcare growing and taking charge,now is a vital time to ask thequestion and have the answers.

For Amanda Goodall (picturedright), an expert in leadershipbased at the Cass Business School,the answer is clearly yes.

‘Being a capable generalmanager alone is not sufficient,’ Ms

Goodall, who has led globalresearch into expert leaders for anumber of years, told the UKLeaders in Healthcare conferencein Liverpool earlier this month.

Ms Goodall’s studies havefeatured academic institutions,basketball teams, Formula Oneorganisations and have, morerecently, begun to look athealthcare. The issue, she said, is‘how much core business

knowledge should leaders have?’In one study, which took place

in 2009, Ms Goodall looked at 58US university economicsdepartments during the course of15 years and measured theirperformance.

‘My key findings were the best universities were more likely to be led by top scholars and they increased the

performance of their universities,’she told the conference.

‘The higher a president’s life-time citations, the more likely itwas that their university improvedin their performance. We founddepartments go on to improvewhen they are led by heads whoseown research is well-cited.’

A question of sportAnd does the argument ring truefor the sporting world too?

A test of 15,000 basketballgames – including control factorslike team payrolls – found that starplayers make better coaches, MsGoodall said.

And a study of F1 examinedperformance of every team for sixdecades up to 2011. It found, MsGoodall said, that ‘the mostsuccessful team leaders are morelikely to have started their careersas drivers’.

‘Ten years’ driving experiencewas equal to a 1 per cent higherprobability that the leader’s teamgained a podium position,’ she added.

And the example of sport isn’twithout merit when looking atleadership, despite some scoffs inthe audience, Ms Goodall said.

‘Some people in managementlook down on sport as a setting butif you’re looking at leadership it’svery useful: you have clear criteria,you can see where managers

come in and performance variablesare very simple. You either win oryou don’t.’

But what does this all mean forhospitals and other healthcareorganisations?

It would be unfair to suggestthat people without a frontline carebackground could not make goodleaders. After all the examples areeverywhere. Take Peter Homa, forexample, a distinguished formeracute teaching trust chiefexecutive and now head of theNHS Leadership Academy – a manwho rose from being a hospitalporter through years ofmanagement-training schemes.

But are clinical experts morelikely to make good leaders? Anddo we need to encourage more of that?

Again, for Ms Goodall, who hasbegun to make waves in the field ofexpert leadership in healthcare, theanswer is a simple yes.

‘Hospitals were traditionally led by doctors but that hasdramatically changed in the UKand USA – although it hasn’tchanged as much in Europe,’ she said.

‘Many journal articles havedebated the merits of physicianleadership but until recently therehas not been much evidenceshowing the relationship betweenphysician leadership and hospitalperformance.’

In the driving seat

GOLDEN AGE: The mostsuccessful teams are run bymanagers who started out asdrivers, a parallel that has beendrawn with medicine

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‘The ladder tips over depositing the owner on to

his patio’

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18 November, 2017 BMA News | 5

Until now. A recent study, led byMs Goodall, looked at the top 100hospitals in the USA for cancer andheart surgery and separatedhospital chief executives intophysicians or non-clinicalprofessionals.

‘I was surprised at the impact,’Ms Goodall says. ‘Quality scores areapproximately 25 per cent higherin physician-run hospitals.’

The study was followed up byanother: Does PhysicianLeadership Affect Hospital Quality,Operational Efficiency, andFinancial Performance? Led byAmerican academic Michael Tasi,the study – which looked across 12medical specialties at 115 hospitals– found that hospital systemswhich were physician-led hadhigher-quality ratings across all ofthe areas. They also found therevenue, or profit, of the hospitalsshowed no major difference. Intotal 34 of the hospitals studiedwere physician led.

Leading the packWhile it is early days for research inthe area Ms Goodall says theaccumulated evidence acrossprofessions is in clear support ofclinical leadership being a positive.

She said: ‘Being a doctor is not aproxy for having managementexperience or leadership skills butI’m suggesting it’s the startingpoint. It’s better to train a doctor inmanagement than it is to train amanager in your world.’

She added: ‘We think they[clinical leaders] have an input intoorganisational strategy – if youknow it well you can more easilyunderstand a strategy for the future.

‘We believe if you have someonewho is a fantastic medic oracademic running an organisation– we think it sends a signal to otherhires. They can impart the dream;they can explain it in a way otherscan’t. Overwhelmingly the effect is positive.’

But it is not just about clinicalleaders as chief executives. As onemember of the audience at theconference pointed out, why woulddoctors become CEOs rather thanmedical directors – taking a rolethat often carries much more flak,may be made to carry the can forfailures others make and might notbe as well remunerated.

Surely for a health service tofunction effectively, doctors of alllevels must be leaders?

Amit Nigam (pictured above), aqualitative researcher from theCass Business School, thought so.

‘Most people when they thinkabout leadership they think aboutpeople in positions of formalauthority,’ he said.

‘But one thing that comes up ifyou do any research in hospitals orhealthcare settings is just the factthat doctors, all doctors on thefront line, play de facto roles as

leaders in their organisations. Theymay not lead the wholeorganisation but they haveinfluence and authority – and howwell these people play theirleadership roles can shape the wayan organisation performs and howit can improve over time.’

At a time of great change that is vital now, more than ever, Mr Nigam says.

‘The NHS is not going to be ableto transform or thrive given thechallenges it faces unless it finds a way of engaging allphysicians to their potentialleadership capacity within.

‘Research shows doctors andtheir roles as leaders are importantbecause doctors can champion orblock changes in their organisationeffectively. The evidence fromhospitals on service improvementis very consistent that doctors at alllevels really are important.’

However, all this postulating isvery easy for academics. But forstretched doctors with shrinkingresource, time and morale it is alleasier said than done.

Can doctors across hospitalsand healthcare organisationsbecome leaders – and will thathave value?

Sarah Hammond, a consultantanaesthetist based at St George’sHospital, London, and member ofthe Faculty of Medical Leadershipand Management, said they can –with a little help from trusts – andthey should.

She said: ‘I come from anorganisation that is in quality andfinancial special measures and Isometimes feel this isn’t always theculture of my organisation – but weare in a process of turning around.Why does it matter? There is greatevidence for correlation betweenstaff engagement andorganisational performance. Andit’s within employers’ gift to change this.’

Dr Hammond cited a govern-ment white paper, the FrancisReport, 2013, and study by

Applied Research as evidencing the need for doctors as clinicalleaders.

‘The white paper found hospitalswith good staff engagement hadbetter mortality rates. Unless weengage our employees we won’t be able to deliver the far-reachingchanges we need. Doctorengagement can improve yourstandards and targets and make you a higher quality and saferorganisation.

‘Doctors generally want to stayin an organisation for a long time,they are invested in it, they haveorganisational memory andunderstanding: why things haveworked and why they might not have.

‘Any clinician involvement inchange management and serviceimprovement delivery are likely tobe more successful because theyare deemed to be someonemotivated by quality and safetyrather than being more lean orfinances. People are more likely to listen.’

A winding roadFor Dr Hammond the answers areobvious – but getting there is thedifficult part. And it meansengagement, engagement andmore engagement.

She said: ‘Leadership is the keyto engagement – medics have gotto feel connected to the purposeand that’s by making it easy forthem to feel included. There’s stillquite a lot of disconnect betweenthe board and the ward. Thedifference between what ishappening and what the people atthe top are being told is growing.

‘The people engaging with usneed to be resilient – we need tohear uncomfortable things aboutthings not going well – there’soften a huge amount ofdefensiveness in response tocriticism. I’ve seen people shut upfor reporting bad news and that

resilience needs to be better.‘And email is not engagement.

Just because we’ve sent you anemail to tell you something doesn’tmean you’ve been engaged in the process.’

If one thing is clear in the chaosand confusion of the modern NHSit’s that change is coming. Thehealth service is divided and unfitfor purpose.

If that change is going to besuccessful it is becomingincreasingly clear that the evidencesuggests it must be clinically led.

With the recent storms in thewindswept northern wetlandshas come a flurry of ladderinjuries.

Although the stock andtrade of comedic silent movies,in reality ladder injuries arerarely funny. The scenario iswell known: the satellite dish orTV aerial is displaced on its axisor blows off altogether on astormy night.

Just as in the long-runningTV drama Casualty, depictinglife in emergency medicine,where the programme’s firsttwo minutes set the scene for apredictable outcome, so too inreal life even before the stormhas subsided, and because thehousehold’s favourite scriptedreality TV episode is replacedby a message which tells theviewer that there is no satellitesignal, the future victim hasgone to his shed to rummagefor an extension ladder; youand I know how this will end.

Climbing ladders is adangerous habit, which goessome way to explain whywindow cleaners havejettisoned theirs in favour oftelescopic brushes dribblingwater, and operated from thesafety of the ground. It is selfevident that climbing a ladderpropped on the side of a housein a storm, without eithersecuring clips or a spouseleaning their considerableweight on the bottom rung,spells accident.

Falling off a ladder willusually result from over-stretching to the side, sothat the ladder tips overdepositing the owner on tohis patio, lawn or gardenhedge from 20ft up.

Occasionally, where theangle of lean is too acutethe ladder will simply slidedown the wall throwing itspassenger off, or with aladder propped too steeply,the victim falls backwards.

One can predict theresulting head and spinalinjury along with long-boneand pelvic fractures. Thosewho decide to jump off half-way down will also be in themarket for crush fracturesto their heel bones andankles.

So far this autumn wehave seen half a dozenladder falls, with onesuffering significant and life-changing injury; none willbe scaling ladders for some

OPINIONFRONTLINE — tales from the emergency department

‘Hospitals with good staffengagement had better

mortality rates’

considerable time, if ever. My own personal ladder was

borrowed by my brother 18months ago, and with mycombination of fear of heights andknowledge of the effect of acuteloss of height, to be honest, Ihaven’t been pushing him for its return.

So when a slate was blown offmy roof in Storm Brian I didn’thave the widely adopted option tobe foolish, and, already knowingthe dangers of DIY, I insteadarranged for a professional withhis white van to come and sort outthe repair.

This involved an anxious wait ofseveral weeks, followed on the bigday by much sucking of airbetween teeth and finally anoverweight youth in need of atrouser belt climbing the ladderwhile his boss stood at the bottom with phone in handpresumably with 999 on speed dial.

Or was he using hissmartphone’s calculator insteadto fix his fee?

Charles Lamb is a consultant inemergency medicine. He writes

under a pseudonym

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