Examen microscópico

The picture that emerges from our research is of variations in the structures and processes of medical leadership in the NHS trusts we studied.

Notwithstanding these variations, there are some common themes and many similarities in the challenges trusts face in making their chosen arrangements work effectively. We now go on to analyse how the findings can be interpreted making use of existing literature on the subject and the policy context in which our fieldwork was undertaken.

As we noted in chapter 1, successive governments have not been

prescriptive about models of medical leadership in the NHS, even though politicians of all parties have emphasised the importance of doctors and other clinicians being involved in leadership roles. In this context, it is not surprising that a variety of structures have been adopted, nor indeed that these structures should be changed from time to time. The arrangements that exist reflect the decisions of local NHS leaders on what is needed in their organisations, leading to the various permutations we have described. Our case studies reveal that whatever the structure adopted, roles and relationships vary between directorates, divisions and service lines. There are also variations in the perceived effectiveness of medical leadership at this critical middle level of the organisation. There are variations too in the

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engagement of doctors at this level and in the performance of the services concerned.

The literature we reviewed in chapter 2 would see these variations as a natural consequence of health care organisations being professional bureaucracies. To use the language of Paul Batalden and colleagues (e.g. 71;72;73), health care organisations comprise a collection of clinical microsystems which form the basic building blocks of care delivery. To borrow a nautical metaphor, these organisations are much more like an armada than an aircraft carrier, underlining the critical importance of

distributed leadership in clinical microsystems as well as strategic leadership at the level of the organisation itself.

If this is the case, then much hinges on the quality of microsystem leaders and the roles and relationships at this level. Again as we emphasised in chapter 2, leadership in professional bureaucracies needs to be collective as well as distributed, a property of teams and not individuals. The importance of collective leadership is recognised and reflected in the findings of our research, particularly in the evidence we have gathered about the key role of the duality of medical leader and general manager supplemented by other sources of expertise when required. It appears that this duality has superseded the triumvirate as the effective focus of leadership in trusts even though the triumvirate still exists on paper.

In our fieldwork, we heard time and again that the impact of medical leaders depended critically on their personal credibility and their ability to lead peers who were often highly skilled and autonomous professionals. It was for this reason that trust leaders focused on developing doctors as leaders and introducing greater formality and professionalism into the process. To return to Friedson’s typology (30), the ‘administrative elite’ of doctors in leadership roles has resulted in increasing differentiation between these doctors and the ‘rank and file’ whose main focus is their clinical work, leading to the engagement gap we noted above.

A common theme in our findings is that the journey that began with the Griffiths Report of 1983 (9) and its argument that doctors should play a bigger part in the management of services and budgets has continued but is by no means at an end. The challenges faced by Trusts and their medical leaders, as summarised above, remain significant, including how leaders can engage followers and how more doctors can be supported to become leaders. Also, based on the evidence we have gathered, there is no reason to suggest that new organisational archetypes have supplanted the

professional bureaucracy as the dominant form in the NHS, notwithstanding the emphasis on managerialism and market based reforms.

To be sure, service line management structures have been adopted in some NHS trusts and they bear many of the hallmarks of the managed

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literature. These structures are often used in combination with clinical directorates and divisions. Our own exposure to organisations that have pioneered service line management, beyond the case studies reported here, offers some basis for arguing that they may in time evolve into new

organisational archetypes, and as we discuss below this is a fertile area for further research. But the fieldwork we carried out and the results of our questionnaire survey indicate that this time is some way off for the organisations we studied.

Returning to the typology outlined by McKee and colleagues (32) in their study of clinical directorates in Scotland in the 1990s, the research reported here points to a move away from ‘traditionalist’ and ‘managerialist’

structures to ‘power sharing’ arrangements in the current English NHS. We base this claim on the fact that most of the case study sites described themselves as medically or clinically led or having aligned structures in which doctors shared power with managers, rather than being managerially led. The sites also provided some evidence of their structures and processes leading to innovation and service change of a different order to that

described by McKee et al in their account of how ‘traditionalist’ directorates functioned.

Yet although roles and relationships have moved on, there is no reason to question fundamentally the argument of Greener and colleagues (53) about the persistence of established relationships and dynamics between doctors, nurses and managers. To be sure, progress has been made on the journey of involving doctors in leadership roles that started with the Griffiths Report in 1983 but the organisations we studied are not yet at the point that

Griffiths advocated in his prescription for the NHS. We would also endorse the analysis of Greener and colleagues and that of others that medical leaders in hybrid roles (the administrative elite in Friedson’s (30) language) continue to occupy a relatively precarious middle ground. Hybrid roles do not have the same status as that attaching to medical leaders who are committed to clinical, research and educational activities, and it is therefore not surprising that our research found that competition for these roles is often limited.

To make this point is to underline the challenges of changing an NHS culture in which doctors who go into leadership roles in NHS trusts are

sometimes perceived by their colleagues to have gone over to the dark side (74). Our findings also echo other work that has drawn attention to the lack of clear career structures for doctors taking on these roles, the financial disincentives that may exist, and historically at least the absence of

appropriate training, development and support (41). Changing cultures is of course much more difficult than putting in place new structures and

processes and yet it is fundamental if the aspirations of politicians to strengthen medical leadership are to be translated into practice.

© Queen’s Printer and Controller of HMSO 2013. This work was produced by Dickinson et al. under the terms of a commissioning contract issued by the Secretary of State for Health.

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