Patient-level leadership and management

There will always be some patients who prefer to see a psychiatrist. Reference ReedReed (1991) describes the role of the consultant as the patient's personal doctor ‘at the highest medical level in whom [the patient] can place his trust and confide the most intimate of his aspirations fears and secrets in the assurance of confidentiality […] The advantages of this personal doctor service, where responsibility is accepted by and anchored in a named individual rather than “a service” or “a team” are clear and are certainly appreciated by our patients’.

Indeed, the government, supported by the Academy of Medical Royal Colleges, has more recently developed the Name over the Bed initiative (Academy of Medical Royal Colleges 2014). The initiative ensures that patients have a named responsible consultant/clinician who takes overall responsibility for all aspects of their care. Patients should know who their responsible consultant/clinician is. This was developed as a result of one of the Francis Report's (Reference FrancisFrancis 2013), key recommendations that if a named clinician were accountable throughout a patient's treatment in hospital, then patient safety and the overall quality of care could be improved. Psychiatrists are able to take on this role and be accountable for the care of their patients.

Another result of the Francis Report is the greater focus on a doctor's responsibility to raise concerns. When psychiatrists have concerns about patient safety, they have a professional responsibility, as outlined by the GMC (2012b), to raise these concerns. There is also the professional duty of candour (GMC 2015), which sets out how doctors must be open and honest when things go wrong or if a patient has suffered harm or distress. Given that, at times, raising concerns or being open about things going wrong may conflict with professional and personal loyalties, it can take great courage and leadership to do so.

A paper by Reference Craddock, Kerr and ThaparCraddock et al (2010) describes how, at an individual patient level, psychiatrists are able to provide good care, particularly in complex cases. As a result of their training, they have a unique understanding of the biopsychosocial model of illness and the interplay between physical and mental health. This gives them expert skills in diagnosis and management. Psychiatrists are able to use their management skills in coordinating and overseeing situations where treatment for patients involves multiple modalities (e.g. overseeing medication, psychological therapy and occupational therapy). When patients require input from other medical specialties, psychiatrists, owing to their knowledge of healthcare systems, are well positioned to facilitate and organise this. Psychiatrists can also organise input from agencies such as social services and the voluntary sector, if patients require this. When considering treatment, psychiatrists are able to show leadership and make informed judgements about when to depart from management protocols and guidelines. This is important because the complex nature of mental ill-health means that patients’ needs are not always best served by rigid adherence to guidelines (Reference Craddock, Kerr and ThaparCraddock 2010).

Leading teams

Working in a team is a central feature of psychiatric practice, and without clear leadership and effective communication teams, do not work well and often fail to achieve what they set out to do.

It is recognised that there are differing opinions on whether or not consultant psychiatrists should lead multidisciplinary teams (MDTs). In discussing the role of consultant psychiatrists, the Royal College of Psychiatrists (2010: p. 13) states that ‘a consultant psychiatrist can, and indeed is uniquely positioned to, lead a team in such a way that practice and outcomes for patients are good and are continuously improving’. Psychiatrists are skilled in building rapport, negotiating, understanding group dynamics and managing conflict, all of which are useful for working within teams (Reference Chapman, Johnson and KilnerJohnson 2013).

A group of professional bodies, among them the Academy of Medical Royal Colleges and the British Medical Association, have issued a consensus statement on the role of the doctor, which states: ‘Doctors alone amongst healthcare professionals must be capable of regularly taking ultimate responsibility for difficult decisions in situations of clinical complexity and uncertainty, drawing on their scientific knowledge and well developed clinical judgement’ (Medical Schools Council 2008). Within teams, there is often shared decision-making and distributed responsibility, but there will be times when one person in the team needs to take a difficult decision, and this is likely to be related to situations of complexity or uncertainty.

Leading organisations

Mental health services continue to undergo significant changes as they move from institution-based services to locally based ones, and change demands leadership.

Reference BohmerBohmer (2012) describes why doctors should be involved in medical leadership. At the highest level, it is the clinicians who will keep the politicians who reform healthcare delivery systems focused on patient well-being. Arguably, it is only those clinicians working within healthcare systems who are able to understand their complex nature. Therefore, they are best placed to understand what is doable and affordable, thus optimising organisational performance and improving outcomes.

Reference GoodallGoodall (2011) looked at data from the top 100 US hospitals in 2009, as identified by the index of hospital quality (a widely used media-generated ranking of quality). She looked at three specialties: cancer, digestive disorders and heart disease/heart surgery. Her study showed that there was a strong positive association between the ranked quality of a hospital and whether the chief executive officer (CEO) was a physician (P <0.001).

There are only a few CEOs working in UK healthcare organisations who are psychiatrists. Matthew Patrick, CEO of South London and Maudsley NHS Trust gave his views on why leadership in psychiatry is important:

Doctors in leadership roles are expected to help ease opposition among their peers. A leader's status depends on their perceived competence, and one can argue that those who have worked as doctors are more credible. Reference Falcone and SatianiFalcone & Satiani (2008) describe how doctors in leadership positions act as role models for medical staff, and their presence may help hospitals to attract other talented medical personnel. Medical leaders are likely to share the same values as clinical staff and, therefore, they may create better working conditions for them. Thus, one can argue that you need doctors to lead doctors. Box 3 summarises the reasons why doctors are good medical leaders within organisations.

Medical engagement is associated with better outcomes in healthcare. Engagement is ‘a persistent, positive affective motivational state of fulfilment in employees that is characterised by vigour, dedication and absorption’ (Reference Schaufeli and BakkerShaufeli 2004). Engagement is a two-way process: organisations work to engage employees, with employees having a degree of choice in their response (Reference MacLeod and ClarkeMacLeod 2009). Reference West and DawsonWest & Dawson (2012) highlight a study by Prins et al (Reference Prins, Hoekstra-Weebers and Gazendam-DonofrioPrins 2010) of more than 2000 Dutch doctors, which found that those who were more engaged were significantly less likely to make mistakes. They also report on a study by Reference Laschinger and LeiterLaschinger & Leiter (2006) of more than 8000 hospital nurses, which found that higher engagement was linked to safer patient care.

Leadership and management styles

There are numerous models and theories of leadership style, dating back many years. Reference Lewin, Lippitt and WhiteLewin et al (1939) identified authoritarian, democratic and laissez-faire styles of leadership and demonstrated that leadership style has a significant effect on group productivity and group interactions. Reference GolemanGoleman (2000) described a set of six leadership styles, namely: affiliative, coaching, coercive/commanding, democratic, pace-setting and authoritative. These styles are based on aspects of emotional intelligence (Box 4).

A key element of both leadership and management is communication. About 40 years ago, a study of managers and their roles in the British Overseas Airways Corporation reported that communication skills were critical (Reference RackhamRackham 1977). Three groups were identified: ‘not performing’, ‘successful’ and ‘super-successful’. The study examined the differences between ‘successful’ and ‘super-successful’ and found that these groups demonstrated different types of communication. Managers used two different styles, ‘push’ and ‘pull’. The ‘super-successful’ managers were able to switch between those styles depending on the situation, whereas ‘successful’ managers tended to use only one style. More recently, such adaptability has been described as situational leadership, whereby leaders are able to assess a situation and change their style depending on the readiness, current skills and developmental level of team members (Reference Hersey, Blanchard and JohnsonHersey 2008).

Reference Chapman, Johnson and KilnerChapman et al (2014) demonstrated that the medical leaders in their study had a variety of patterns of use of leadership styles. The most frequently used styles were found to be affiliative, democratic and authoritative. Use of leadership styles was influenced by a range of factors, including: external factors affecting the organisation; personal style preferences and wisdom; the activity being undertaken; and team, individual or organisational experience or expectation of leadership style in that setting.

The King's Fund (2012) describes how the dominant NHS leadership style has historically been pace-setting. This is characterised by leading from the front, laying down targets and having minimal collaboration with peers. Evidence from various sources, including the Francis Report (Reference FrancisFrancis 2013) suggests that this top-down approach actually results in poor-quality care. The report acknowledges that a new approach is required for NHS leaders. One approach that might be suitable is the ‘engaging leadership model’ (Reference Alimo-Metcalfe and Alban-MetcalfeAlimo-Metcalfe 2008), which emphasises teamwork, collaboration and connectedness. With this model, ideas are listened to, mistakes are used as learning opportunities and managers are engaged with staff members.

What makes psychiatrists great leaders?

Psychiatrists, as a result of their training, have developed many of the necessary skills to be good medical leaders. Psychiatric training encompasses many of the key components of self-awareness and self-regulation. Psychiatrists spend years thinking about their own feelings to better understand interpersonal interactions. Some undergo their own personal psychotherapy. They develop strategies to become aware of their own feelings and are able to quell impulsive reactions to patients so that they remain calm in the face of difficulties (Reference Chapman, Johnson and KilnerJohnson 2013). Reference Stanton, Sethi and DaleStanton et al (2011) assessed emotional intelligence in psychiatrists and surgeons. The study found that psychiatrists scored higher than surgeons in emotional self-awareness and empathy. The authors commented: ‘One would expect psychiatrists to be more empathic and emotionally reflective, thinkers and feelers’.

Psychiatrists, by the very nature of their work, are seeking to develop people, and one marker of outstanding leadership is the development of other leaders. Reference FergusonFerguson (2011: p. 103) argues that when you have influence over another individual, you are in fact leading them. She goes on to state that outstanding managers, on the other hand, drive individuals to perform at the highest level they are capable of, and that this is more about control, as opposed to the freedom that leadership affords.

MCQs

Select the single best option for each question stem

1. 1 As regards the difference between leadership and management:

   1. a leadership is about planning, organising, budgeting, troubleshooting and delivering results through the efforts of others; management concerns vision and strategy

   2. b leadership concerns vision and strategy; management focuses on people, the future and on areas where there is often limited certainty and no agreement

   3. c leadership concerns vision and strategy; management is about planning, organising, budgeting, troubleshooting and delivering results through the efforts of others

   4. d outstanding leaders develop leaders of the future; management focuses on people, the future and on areas where there is often limited certainty and no agreement

   5. e leadership focuses on efficiency and the present; management operates best where there is certainty and agreement.

2. 2 Pick the false statement. Engaging doctors in medical leadership and management is essential to:

   1. a drive prevention, early diagnosis and intervention

   2. b integrate responses to physical and mental healthcare

   3. c engage patients and support self-management

   4. d reduce the number of non-medical managers in the NHS

   5. e monitor outcomes.

3. 3 The following initiatives have been introduced in the UK to encourage doctors to develop leadership and management skills. Which of these statements is false?

   1. a The Faculty of Medical Leadership and Management has been developed to support doctors in developing their leadership and management skills

   2. b The Faculty of Medical Leadership and Management has developed standards in leadership and management for medical professionals

   3. c Leadership and management is being introduced into most curricula for doctors in training, however it is not suitable for undergraduate medical school curricula

   4. d Schemes have been set up in some organisations where doctors can shadow senior managers and leaders

   5. e There is a GMC Leadership and Management document which sets out a doctor's duties.

4. 4 The Name over the Bed initiative:

   1. a ensures that patients have a named responsible consultant/clinician who takes overall responsibility for all aspects of their care

   2. b was developed by the Care Quality Commission

   3. c ensures that patients own details are written above their hospital bed to improve patient safety

   4. d was developed as a result of the Dalton Review

   5. e was developed as a result of the Five Year Forward View.

5. 5 What qualities do doctors possess that can make them good medical leaders?

   1. a Doctors know the complex healthcare system

   2. b They act as role models

   3. c They share the same values as clinical staff

   4. d Medical leadership at an organisational level is associated with better patient outcomes

   5. e All of the above.

MCQ answers

1

c

2

d

3

c

4

a

5

e