The need for informed leadership

First, the two professions generally regarded as being of primacy at the time (medicine and nursing) required leadership from individuals who shared the defined body of knowledge and expertise associated with those professions and who were therefore generally held to know what their members were supposed to be doing and how they were supposed to be doing it. The exclusion of direct professional representation of psychologists, social workers and allied health professionals at board level may have reflected the traditional values of a healthcare model (but this of course will have adapted over the years as the status of these professions has gained ground on the others).

The need for line management

Second, whether they liked it or not, members of both professions required some sort of line management and this was seen as a way of circumnavigating the mystique arising from exclusive expertise. This role within clinical practice has grown considerably following a number of public inquiries, such as that into cardiothoracic services in Bristol (Secretary of State for Health 2001) among others.

Realistic expectations

Third, non-clinical managers needed to understand the realities of healthcare provision at the front line so that they did not drive performance in such a way as to render their expectations of clinicians unattainable. This extended to boards needing to assure themselves that their strategies were going to be consistent with what clinicians felt should be on offer to enable ownership and delivery at the front line.

Appropriate accountability

Finally, most doctors feel that, in pursuing their patients' welfare, they should be accountable only to another clinician from the same – or a similar – profession. Alternatively, accountability might rest with the most senior person in the managerial hierarchy (the chief executive), to whom the medical and nursing directors are themselves accountable.

Learning from business

The necessity to deploy humanistic concepts of this nature to the management of organisations is hardly the reserve of healthcare. Indeed, the biggest three advances in business over the past decade or two have been in information technology, internationalism and the development of skills that encourage the management of a workforce comprising people as opposed to ‘human resources’. The NHS has much to learn from the private sector in this respect and it must be a central role for clinicians in senior NHS management to ensure that these values become imbued in the ethos and culture of the executive team and wider board.

Why should this be important? Shouldn't care delivery be a relatively simple matter of taking on appropriately trained and experienced professionals and enabling them to get on with their jobs so that compliance with key performance indicators can be achieved and both clinical and corporate governance demonstrated?

Herein lies the importance of distinguishing between what one does and how one does it. The former may well be a relatively straightforward matter, but it is the latter that brings credibility to a patient's experience of healthcare, affects the reaction of a workforce to change and therefore dictates the likely success of the management of that change.

Style and tone are essential elements of successful interpersonal transactions – both on an individual basis and at a corporate level. They are important because they say something about one that other people can relate to, approve of and cooperate with or, failing that, at least grudgingly respect. And it is here that setting an example can be so powerful. If patient perceives a doctor's efforts as genuinely motivated by a wish to help and assist them, they are likely to concord and cooperate with the plan of action and a therapeutic alliance (crucial to a good outcome) can be established. Likewise, if senior management is perceived by the workforce as adopting humanistic principles, their attitude will be positively influenced and better relationships will be built between colleagues and managers.

Learning from feedback

This is reflected in a number of initiatives that ask patients and staff what their experience has been. For instance, 360 degree appraisal of medical staff invites patients' comments on their interpersonal and professional manner and both patient and staff surveys are typically part of the repertoire of key performance indicators for NHS trusts prescribed by central government. This reflects a very healthy understanding within the Department of Health that the experience of both patients and staff says a lot about how well an NHS trust is being run.

Added value from directors

If these represent in some way the core concerns of a board director, one may then invoke the concept of ‘added value’ from each individual director's post. This can be drawn from their specialist expertise (either in a clinical or a managerial sense) or from their personal skills (for example, charisma or emotional intelligence). This explains why board level positions are rarely described in detail – the object of the exercise is to create a team of people meeting certain fundamental requirements (as detailed above) whose interpersonal skills and personalities interact to add overall value through team synergy, but whose individual experience and expertise adds specific value in the form of specialist know-how and effective challenge.

Competency frameworks

Leadership is a highly sophisticated concept. The NHS Institute for Innovation and Improvement, for instance, has published a medical leadership qualities framework, endorsed by the Academy of Medical Royal Colleges (NHS Institute for Innovation and Improvement 2009). It describes competency sets at both postgraduate and post-registration level, where personal qualities such as self-belief, self-awareness, self-management, ambition and integrity increasingly drive direction-setting and service delivery as the leader grows in experience and seniority.

The Royal College of Psychiatrists' own Education and Training Centre (the CETC) has produced a leadership development programme that draws from the core curriculum and the expectation implicit in New Ways of Working (Department of Health 2005b) that consultant psychiatrists will undertake a clinical leadership role (of a multidisciplinary team) as a vital part of their added value to mental health services. The NHS Confederation is working with a group of medical managers in mental health to describe how mental health trusts can assess themselves in respect of the degree to which they provide a culture for the development and sustenance of leadership among senior clinicians. The British Association of Medical Managers (BAMM) has developed a competency framework for medical directors, detailing a professional development programme of hierarchical knowledge systems relating to communication, developing people, developing business, developing the self, the wider contexts and quality (www.bamm.co.uk). This has been created in consultation with BAMM's Medical Leaders Professional Council (which included, among others, medical leaders at a national and local level, Presidents of medical Royal Colleges, and leaders at the BMA, GMC and Department of Health) and is possibly the closest one can currently get to a formal description of the managerial competency set for a medical director.

Career progression issues

Beyond medical directorship

Career progression beyond medical directorship is opaque. The historical approach (doing it for a few years before retirement as the pinnacle of one's career and in so doing invigorating one's pension entitlement) will not work for talented younger medical managers who train earlier for a specific career aim.

Exit strategies need to be developed to ensure that the wealth of experience that some senior medical managers have built up is not wasted during the remainder of their careers.

At present, a majority return to full- or part-time clinical practice after 5 or 6 years in the role, becoming organisational ‘elders’ and providing advice and mentorship to others (including, it is hoped, their successors). A minority wish to extend their activities into regional or national roles, developing what are becoming known as ‘portfolio’ careers where a number of roles and posts are held contemporaneously. Obviously in circumstances such as these, the concept of secondments or ‘time-sharing’ of the psychiatrist becomes critical to the trust's ability to continue to operate clinical services well and efficiently despite losing some of the consultant's time.

An alternative exit strategy would be one of onward career progression – to becoming a deputy chief executive and then a chief executive, for instance. Although the thorny issue of being unable to continue working to a consultant contract while in this sort of office needs to be resolved, there is no reason why a stint of deputy leadership should not be part and parcel of what is expected of a medical director (or any other executive board member, for that matter) during their tenure. This is consistent with the current aspiration of the Department of Health that a majority of chief executive vacancies are competed for by at least one medical consultant.

Possible directions for the medical director role

Specific roles for medical directors can be predicted to evolve. Senior officer accountabilities are appearing for all sorts of areas where boards require assurance: controlled drugs management, information risk and revalidation, to name but three. Although administration of these areas can and will be delegated – creating potential for experiential training for aspiring medical managers – the board will always require an accountable officer to bring assurance regarding these issues to its table. The question will be whether boards will choose a nurse or a doctor, or continue to have both. It is therefore the foundation trust's understanding of, and belief in, the effectiveness of psychiatrists in attracting and achieving success that will form the basis for the continuation of the medical director function.

Consultant psychiatrists have a training and depth of expertise and experience that transcends that of most other professional groups. However multidisciplinary mental healthcare becomes, complex issues invariably percolate to the consultant in the team. Consultants need to rise to this expectation and challenge, acquiring new skills as part and parcel of the development of their sense of professionalism and the core competency set of their role.

The medical director is inevitably charged with describing and encouraging this process, whether or not this is made explicit, and boards depend, at least for the foreseeable future, on them doing so.