Doctors in the NHS -do we all need leadership skills?

Doctors in the NHS-do we all need leadership skills? Nigel Bateman March 2011

What is leadership? • Definitions: Lead (verb) Guidance given by going in front Cause to go with one Direct the movements of… Go first

Definitions • Lead (noun) Take the lead Go in front Guide

Definitions • Leader Member of Government Front horse in a team Orchestral lead Line • Leadership Not mentioned! • Source: Concise Oxford Dictionary

Leaders in the NHS Does the NHS lack leaders? Are there doctors leading the profession? If not - can we select and train them? Please discuss these questions from your own experience – Team presentations

What qualities does a leader have? Understands the situation Recognises what needs to be done (to improve the situation) Motivates a team to take the action needed Reports the results of the action taken Reflects on his/her performance

Understand the situation Clinical/managerial knowledge (background to decision making) Draw on previous experience Know what resources are available Weigh the options for action

Recognise what needs to be done Understand problem Consider options available Choose action(s) which should produce best outcome Decide the timing of the intervention

Motivate the team Ensure all team members understand the nature of the problem Outline to them the possible solutions Decide the correct solution(s) Ensure each team member knows their role Direct the time of the intervention After intervention: Collect feedback from team as to results of the action taken

Report the outcome Analyse the result of the intervention taken Report analysis to appropriate authority with suggestions for change Accept responsibility for your role

Doctors in the NHS Do we behave like this- • in our medical practice? • in our management of resources? • in our management of teams? Please discuss these questions. Team presentations

What next! Tea and discussion.

Case studyAn unexpected death. Time: 1999 Place: A teaching hospital with tertiary responsibilities in a Region of England. A unit caring for patients with respiratory failure requiring ventilatory support at home – a 12 bed high dependency unit

Your role • You are a qualified professional • You are the Clinical Director of the Chronic Respiratory Care Unit • You do not work in the Unit now although you have in the past

Staffing • 1 consultant (Dr A) : Clinical lead • 1 ST 5 doctor • 1 CMT 2 doctor Cover for each doctor by colleagues of similar experience available. • 1 Sister-ward manager • 14 qualified nurses • 4 medical technicians

The patient Age 66 years Male - only child Qualified accountant, now retired Married for 5 years (previous carer) No children Normally lives in own home with wife and resident carer

Medical history 1 Age 12 - poliomyelitis causing paralysis of the left leg and significant weakness of both hands. Managed activities of daily living with some difficulty Age 45 – started to have breathing difficulties at night (kyphoscoliosis and weak diaphragms) home breathing aid helped

Medical history 2 Age 55 - pneumonia requiring admission to ITU and tracheostomy. On discharge needed IPPV at night – home carer and support package arranged. Age 62 – pneumonia again. On discharge required continuous IPPV. Hand weakness made self suctioning difficult – wife and carer trained.

This admission 6 weeks ago Pneumonia right lower lobe - ? Aspiration Treated with antibiotics and full supportive care- recovering and should be fit for discharge next week. But: Patient says he is fed up with life as it is : “If my hands were strong enough I would disconnect the ventilator myself”. Wife worried that patient will commit suicide. Carer and GP aware of these concerns.

Response to background concerns Psychiatric consultation: Low mood due to circumstances but not clinically depressed. Competent to take decisions about future care. After discussions with patient, wife and carer an enhanced care package was arranged prior to discharge. GP contacted and agrees to continue care at home.

Your problem Dr A, the consultant in charge, asks to see you and reports: Patient admitted 6 weeks ago with pneumonia. No more clinical improvement was expected and an enhanced care package had been arranged. After long discussions with patient, wife and carer and with the GP a discharge date had been set for next week. Wife not happy with this outcome. Patient found with ventilator disconnected by wife when she arrived to visit her husband. The alarm had not functioned as it was disconnected. The patient was dead. Death not expected clinically and not explained by immediate enquiries made by Dr A. Would like you to be aware that wife will make a formal complaint about the care provided in the unit.

What next? As the Clinical Director responsible what should you do straight away? What leadership skills are required?

Your enquiry This confirms that there is doubt about how the ventilator had been disconnected. Possibilities considered: Accidental disconnection occurred not noticed by ward staff. Patient disconnected himself. Wife disconnected patient. Staff member disconnected patient. No satisfactory explanation for the alarm dysfunction found No definite conclusion possible.

Your action at this stage The unit: Should it be closed while further enquiries take place? If not what should be done to ensure the safety of the other patients? Staff: Should any staff member be suspended while enquiries take place? Team presentations.

What happened. Immediate action taken: Medical team strengthened and leadership changed. Nursing procedures reviewed and protocols modified. All equipment checked to ensure alarms are working.

Result of complaints procedure Hospital management enquiry: Reason for ventilator disconnection not established. Alarm working when reconnected – no reason for disconnection found. Referred to Criminal Prosecution Service as “willful killing” could not be excluded: Not enough evidence to bring a case against any individual or the institution.

Individual outcomes Institutional support for you in your role in management inadequate: you resign. Dr A never speaks to you again as he feels you did not support him when he needed it. He retires 2 years later a bitter man. The ward manager resigns and leaves the Trust to take a job running community services in another region. Wife still believes her husband was “killed” by inadequate ward care. Institution unscathed by incident.

? A lack of leadership Could any of these outcomes have been altered by better leadership skills at any level? Team discussions.

Essential leadership skills • Self awareness • Self management • Team leadership • Leadership in the wider world – managing across and upwards

A good leader 1 • Listens • Tells the truth • Is honest in dealing with others • Inspires trust • Creates commitment

A good leader 2 • Challenges assumptions • Is innovative • Takes risks when necessary • Has inner strength • Does what is right and inspires others to follow • Are we like this?

References Halligan A. The need for an NHS Staff College. J R Soc Med 2010:103; 387-391

My credentials. • Teacher of medical students 1966-today • Educational supervisor for medical trainees 1980-2007 • Department head 1984-1992 • Clinical Director 1988-1995 • Trust Executive Member 1990-1995 (Guys and St Thomas’ Hospital Trust formed 1992) • Assistant Dean Medical School 1993-2005 (Guys, Kings and St Thomas’s School of Medicine formed 1998) • Chairman MRCPUK Part 2 Board 1998-2004 • Chairman Scenario Editorial Committee MRCPUK PACES 2004-2010 • Senior Examiner MRCPUK PACES RCP London 2004-2008 “managed” 750 examiners for PACES. Committed teacher and trainer of medical practice.

My achievements 1 • Patient care: • 1981 Introduced fibreoptic bronchoscopy in our outpatient department. • 1981 Introduced multidisciplinary clinic for all patients with lung cancer in the hospital. • 1988 Lead the development of services for patients with HIV in the Trust. • 1998 One of a team of 12 who drove the amalgamation of Guys and St Thomas’ hospitals to form the GSTT.

My achievements 2 • Education: • Curriculum development for UMDS and GKTSM. • Lead in creating the GPEP course for 28 students with no new money. • For MRCPUK- lead for change in Part 2: separation of written from clinical and creation of PACES lead for standardised scenarios for history taking and communication skills designed the SQG system for writing questions for the written papers (with a lot of help from USMLE)

Doctors in the NHS -do we all need leadership skills?