Facilitator: Pam Garside

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• Facilitator Pam Garside
• Newhealth and Fellow,
• Judge Business School University of Cambridge

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• Arrival with Tea Coffee
• Welcome Introduction
• Pam Garside, Newhealth and Fellow,
• Judge Business School University of Cambridge
• Leadership Learning The Darzi Fellowship
• Dr Fiona Moss, Postgraduate Dean, London
  Deanery
• Presentations from Darzi Fellows
• Dr Neil Browning, MRCGP, Richmond Twickenham
  PCT
• Dr Maya Nagaratnam, Mayday University Hospital
  NHS Trust
• Dr David Bridle, East London NHS Foundation Trust
• The Importance of Clinical Leadership in
• Delivering NHS Londons Strategy Strategic
  Direction
• Ruth Carnall, NHS London Chief Executive

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What it means to be a Clinical Leader
Professor Lord Darzi, Parliamentary Under
Secretary of State at the Department of
Health The Context of Clinical Leadership
Dr Andy Mitchell, Director of NHS London and
the London Clinical and Business Support
Agency QA session facilitated by Pam
Garside Conference closes at 1800 followed by a
networking drinks reception
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Leadership and Learning Darzi Fellowships

• Fiona Moss
• Postgraduate Dean London

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• We are very good at training clinicians to look
  after individual patients but fail completely to
  train them to understand and to look after the
  system of care.

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Leadership and organisational skills why?

• Essential for quality improvement
• Any improvement in the quality of care requires
  an organisational change
• Essential for patient safety
• Essential for any change management

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Leadership and organisational skills why now?

• Medicine used to be simple, ineffective and
  relatively safe. Now it is complex, effective and
  potentially dangerous
• Cyril Chantler, The role and education of
  doctors in the delivery of health care Lancet
  1999

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Organisational skills from various curriculums

• Communication skills
• Team working
• Delegation
• Leadership
• Supervision
• Conflict resolution
• Quality/safety improvement processes
• Clinical governance

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• Every system is perfectly designed to produce
  precisely the results that it gives
• Paul Bataldan and Donald Berwick, Institute of
  Health Care Improvement, Boston c1997

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Organisational responsibility doctors and other
professionals
Other professionals
Medical Director
Organisational responsibility
Clinical Director
Doctors
Management course
25yrs
65yrs
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Are we missing a trick or two or three?

• Huge amount of organisational work in Trusts
• Huge amount of organisational experience
  potentially available to trainees - daily
• Opportunities for training waiting to be realised
• Organisational and leadership training should be
  based in Trusts
• But Trusts need the capacity and resources and
  perhaps permission to undertake this training

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Darzi Fellowships MDs in London asked

• What if.. an SpR worked with you full time
  for 1 year on a change management project in your
  Trust?

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Darzi Fellowships what?

• SpR working to MD/clinical director full time for
  1 yr
• Change management project across system of or
  pathway of care between organisations
• Quality improvement/safety improvement/clinical
  governance projects within an organisation
• Explore Trusts ability to train in
  organisational skills for SpRs and others

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Darzi Fellowships support?

• Bespoke leadership development course
• CIHM, Leeds. Diane Plampling and Martin Fischer
• Modular
• Learning sets, communities of learning
• Opportunities for fellows and MDs to learn
  together
• Synapse web based community www.synapse.nhs.uk
  

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Darzi Fellows who?

• 41 Fellows
• 8 Primary care and 8 Mental Health Trusts
• Negotiation skills
• Prepared to change and adventurous
• Manage uncertainty
• Contributors
• Organised

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System changes needed so that

• All clinical professionals acquire organisational
  and leadership skills during clinical training
• Organisational learning is centred on clinical
  care
• Organisational skills are valued
• Organisational skills are assessed
• Trainees expected to take on appropriate
  organisational responsibilities

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Quality improvement and patient safety is
everyones business
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Training and education is everyones business
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• Training for quality improvement and safety
  includes training clinicians not only to be very
  good at looking after individual patients but
  also ensuring that they acquire the
  organisational skills to enable them look after
  the system of care on behalf of their patients.

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• Dr Neil Browning, MRCGP
• Richmond and Twickenham PCT
• Sponsor Dr Marilyn Plant PEC Chair

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My Darzi Fellowship

• The vision and leadership for change
• The challenge of change in Richmond
• Improved quality of patient care and experience
• The engagement and enablement of clinicians
• To build future NHS capability and quality

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• Dr. Maya Nagaratnam, MBBS FRCA
• Mayday University Hospital NHS Trust
• Sponsor Mr Gavin Marsh, Medical Director
• Darzi redesign service area medical workforce
  planning, supporting South West London Trauma
  Network

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• Dr David Bridle
• East London NHS Foundation Trust
• Darzi Fellow to Dr Tim Lambert,
• Medical Director

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• Psychiatric Clinical Practice
• Empathy Holistic Understanding
• Psychotherapy ? Perspective Changing
• Personal experiences (beyond clinical practice)
• Developing holistic nuanced perspective
• Darzi Fellowship
• Contribute locally enhanced perspective
• Robustly equip with skills for future

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• Ruth Carnall
• NHS London Chief Executive

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• Professor Lord Darzi
• Parliamentary Under Secretary of State
• at the Department of Health

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• Andy Mitchell
• Director of NHS London and the
• London Clinical and Business Support
• Agency (LCBSA)

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The Context of Clinical Leadership
Dr Andrew Mitchell Medical Director NHS London
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• Good leaders take people where they want to
  go....
• ...great leaders take them where they ought
  to be

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Clinical Leadership
Transformational change and continuous
improvement within a context of organisational
and environmental awareness....
The Organisation
Culture
Political systems
Environment
Social Structure
Environment
Technology
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Clinical Leadership Improves Performance
Hospitals with greatest clinician involvement in
management score 50 higher on key measures of
organisational performance McKinsey Quarterly
2008
In attempted service improvement , organisations
with strong clinical leadership are more
successful NHS SDO 2006 Managing Change and
Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a
collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS
Institute 2007
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Barriers to Leadership Development

• The System
• The Profession

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Barriers The System
No defined career path for leadership Appraisal
often poor quality Poor infrastructure of
leadership development Financial disincentives
Lack of organisational affiliation Leadership
training not valued Lack of encouragement
Relationship to clinical roles not identified
Retirement
Levelling off
Mid-career Crisis
Expansion of interests
Gaining Tenure
Gaining Membership
Basic Training, Socialisation
Entry into World of Work
Education Training
Growth, Fantasy, Exploration
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Barriers The Profession

• Leadership not always seen as a core to identity
• No correlation with professional success or
  positive outcomes
• Evidence base for management viewed as weak

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Enablers to leadership development

• Understanding the science of leadership
• Correlating with quality of outcome
• Recognising the strength of distributive
  leadership across the clinical spectrum
• Positive role modelling
• Building a supportive infrastructure
• Providing clear incentives

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Leadership Models The Science of Leadership?
Non-essentialist
Situational
Constitutive
Individual
Contingent
Trait
Non-essentialist
Essentialist
Context
K Grint The Arts of Leadership
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Distributed leadership
Articulation of a clinical vision Corporate level
strategic thinking Negotiation and influencing
skills
Organisational leadership
Responsible for service delivery Detailed
knowledge of evidence base
Service Leadership
Front-line leadership
Credible leadership focused on quality and
service improvement
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An organisations prime strategy is to protect
the cultural organisational identity created by
its core assumptions and values Gagliardi
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Images of Organisation
The organisation as..
...a machine..
..a culture..
..a political system..
..a psychic prison..
..a brain..
Gareth Morgan
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The Organisation as a Machine

• Legacy of Fordist thinking.
• In clinical life evidenced by
• Strategies
• Frameworks
• Service specifications
• Trust policies
• Guidelines
• Protocols
• Organograms
• Competencies

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The Organisation as a Culture
The Cultural Web Schein
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The NHS Cultural Web
Ward rounds Shroud waving Infantilising patients
Johnson 1995
Rituals
Myths
Symbols
Retinues Names/logos Big institutions
Villains Heroes Change agents are fools
Organisational paradigm
Power
Waiting lists Consultant episodes Financial
reporting
Communication
Doctors Professional bodies Prima donnas OB
networks
Private practice Merit awards Professional
recognition
Incentives
Hierarchical Mechanistic Pecking order Tribal
Structure
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The Organisation as a Psychic Prison
The Organisation as a Psychic Prison
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The organisation as a political state

• Politics is interplay between
• Interests
• Conflict
• Power
• Power relations between actors determines
  outcomes. Conflict and clash of interests results
  in dysfunctionality.
• Power is means by which conflict resolved.
• Sources of power
• Formal authority
• Control of resources
• Control of decision making processes
• Control of the informal agenda
• Interpersonal alliances and networks
• Authentic leadership

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The Organisation as a Brain
The Learning Organisation

• Organisational function depends on information
  processing
• Organisations are therefore communication and
  decision making systems
• Organisations can learn through
• Single loop mechanisms
• Double loop mechanisms

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Clinical Leaders of the Future

• Self awareness
• Strengths and weaknesses
• Political and negotiating skills to influence
  colleagues
• Commitment
• Environmental awareness
• Able to scan and assimilate the hard data
• Organisational awareness
• Ability to read the organisation in all its
  forms

A value system that is based on quality of
patient care
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A Strategy for Cultural Change

• Deformative Creating a different construct of
  reality that moves people
• Reconciliative Overcoming tensions and
  negotiating an agreed social order
• Acculturative Demonstrate the new rules of the
  game
• Enactive Demonstrate active improvement
• Formative Incorporate into the cultural
  thinking
• Bate 1994

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The NHS Cultural Web
Rituals
Symbols
Myths
Responsive to patient need
Flying the quality flag
This place provides a great service and I would
bring my family here
Organisational paradigm
Power

Communication
In the hands of patients as much as professionals
Structure
I contact whoever I want and they get back to me
straight away
Incentives
Patient representation at its heart
Driven by quality and innovation
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• Question Answer Session
• Facilitator Pam Garside

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• Networking Drinks Reception
• Refreshments Area

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