Negotiating obstacles to clinical leadership
Now we will explore possible obstacles to the development of clinical leadership and strategies that might be adopted to overcome them.
Despite the growing enthusiasm for clinical leadership and investments in training and development significant challenges remain. In the English NHS one recent review concluded: “…it is clear that medical leaders face many challenges and occupy a relatively precarious middle ground between senior managers and their medical colleagues. There are many barriers to involving doctors effectively in leadership roles, and in most organisations a step change is needed to overcome these barriers…” (Dickinson et al., 2013).
These difficulties apply even when doctors (or other clinical professionals) take on – what are frequently labelled as ‘hybrid’ management and leadership roles. Studies of these ‘hybrids’ often emphasise the difficulties of the job and the variable commitment of those who become part time leaders or managers. Early research on clinical directors for the UK, for example noted that “In addition to being able to ‘hunt with the service providers’, the clinical director must also ‘run with the unit managers’” (Packwood et al., 1992). Others describe how hybrids are constantly struggling to combine clinical credibility with management expertise. Doctors in these roles frequently report hostility from colleagues (being perceived as a ‘management nark’ or ‘turning to the dark side’) or feeling uncomfortable about supervising their peers.
Partly for these reasons, it has been noted that many clinicians who become managers or leaders do so for pragmatic reasons and are sometimes less than fully committed. Forbes et al. (2004: 167) identify two groups: ‘reluctants’ and what they term ‘investors’ or doctors who have ‘actively pursued a management opportunity as an alternative to clinical medicine’. McGivern et al. (2015) also distinguish between ‘incidental hybrids’, oriented towards defending the status quo and ‘willing hybrids’, who have more developed, stronger professional-management identities.
In addition to this are questions about how far efforts to re-educate or re-train professionals to become leaders will have the desired effect. In part this is due to the unique organisational context of health care. Hospitals have traditionally been organised as ‘split hierarchies’ with doctors (and other clinical professions) ‘remaining somewhat apart’ from administrative roles and responsibilities (Hunter, 1992). Many junior doctors may be also be deterred from pursuing leadership/management roles because these roles are poorly rewarded, with no obvious career path if one steps outside clinical practice. According to Ham (2003: 1979) when “management has to compete for time and attention with clinical work, research” and “opportunities to enhance personal income…” it is “easy to see how the default position of independent clinical practice succeeds”. Lastly it is possible that (non-clinical) general managers themselves may resist or stifle attempts by doctors or nurses to take on leadership roles which they may regard as a threat to their own authority and status. This may be linked to a ‘unitary’ and ‘command and control’ mind-set of general managers which ‘denies the legitimacy for clinical leadership and emphasises instead a single source and locus of control (general management)’ (Edmonstone, 2008; 296).
Dickinson, H., Ham, C., Snelling, I. & Spurgeon, P. (2013) Are We There Yet? Models of Medical Leadership and their effectiveness: An Exploratory Study. Southampton: NETSCC, HS&DR.
Edmonstone, J. (2008) Clinical Leadership: The Elephant in the Room. International Journal of Health Planning and Management, 24 (4): 290-305.
Forbes, T.; Hallier, J. & Kelly, L. (2004) Doctors as managers: investors and reluctants in a dual role. Health Services Management Research, 17 (3): 167-176.
Ham C. (2003) Improving performance of health services: the role of clinical leadership. The Lancet, 361: 1978-1980.
Hunter, D.J. (1992) Doctors as managers: poachers turned gamekeepers? Social Science and Medicine, 35 (4): 557-166.
McGivern, G. Currie, G. Ferlie, E. Fitzgerald, L. & Waring, J. (2015) Hybrid manager-professionals’ identity work: the maintenance and hybridization of medical professionalism in managerial contexts. Public Administration, 93 (2): 412-432.
Packwood, T., Keen, J. & Buxton, M. (1992) Process and structure: resource management and the development of sub-unit organisational structure. Health Services Management Research, 5, (1): 66-76.
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