Doctors in the NHS
-do we all need leadership skills?
Nigel Bateman
March 2011
What is leadership?
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Definitions:
Lead (verb)
Guidance given by going in front
Cause to go with one
Direct the movements of…
Go first
Definitions
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Lead (noun)
Take the lead
Go in front
Guide
Definitions
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Leader
Member of Government
Front horse in a team
Orchestral lead
Line
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Leadership
Not mentioned!
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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 study
An 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
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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
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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 carerecovering 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
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Self awareness
Self management
Team leadership
Leadership in the wider world –
managing across and upwards
A good leader 1
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Listens
Tells the truth
Is honest in dealing with others
Inspires trust
Creates commitment
A good leader 2
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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.
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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
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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
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Education:
Curriculum development for UMDS and GKTSM.
Lead in creating the GPEP course for 28 students
with no new money.
For MRCPUKlead 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)