Future doctors: the NHS needs your leadership
How you can transform the health service you work for in the future
The NHS must transform itself to meet the challenge of continuing to deliver a world class health service in response to an ageing and more complex patient population, and to achieve this within tighter financial limits. Doctors of the future are responsible for the evolution of the NHS to ensure that it survives long term. Junior doctors are already working with policy makers at NHS England to shape a radical reformation of health and social care services.
These new services will need engaged, informed doctors with a flair for organisation and teamwork. Future general practitioners could find themselves leading a multidisciplinary community provider team that employs geriatricians, nurses, and social workers. Hospital doctors may set up general practices alongside emergency care within hospitals. Clinical leadership, we are promised, will drive the changes in the NHS. But why is all this happening now?
Key challenges for the next five years
In October 2014, Simon Stevens, the newly appointed chief executive of NHS England, published the NHS Five Year Forward View, which sets out what he sees as the key challenges for the NHS over the next five years. Stevens’s team includes clinical fellows at NHS England—junior doctors who are taking time out of training to develop their experience of policy and strategy.
The team identified key challenges in three fields: disease prevention, quality of care, and funding and efficiency (see box 1). If these are not dealt with, the report says, the consequences will be a combination of massive spending on avoidable illness, unacceptable variations in care standards, and a limited service.
Box 1: Three key challenges identified by the NHS Five Year Forward View
- Health and wellbeing gap: If the nation fails to get serious about prevention then recent progress in healthy life expectancies will stall, health inequalities will widen, and our ability to fund beneficial new treatments will be crowded out by the need to spend billions of pounds on wholly avoidable illness
- Care and quality gap: Unless we reshape care delivery, harness technology, and drive down variations in quality and safety of care, patients’ changing needs will go unmet, people will be harmed who should have been cured, and unacceptable variations in outcome will persist
- Funding and efficiency gap: If we fail to match reasonable funding levels with wide ranging and sometimes controversial system efficiencies, the result will be some combination of worse services, fewer staff, deficits, and restrictions on new treatments
The report proposes that these challenges will be tackled through plans focused on three areas: working with patients and communities, developing new models of care, and practical implementation.
Leadership in the community
Working more closely with patients and communities is key to the prevention agenda, which will help the NHS to invest more smartly. For example, more money is now spent on bariatric surgery than on intensive lifestyle intervention programmes to prevent obesity, which can lead to complications such as type 2 diabetes. Although bariatric surgery is effective in terms of outcomes and cost, more patient support and education are needed to prevent obesity in the first place. In the future, the NHS will require doctors to lead on evidence based obesity prevention strategies, working with local authorities and schools as well as with health services.
Patients with long term conditions are seen as heavy health service users, but still spend on average less than 1% of their time with health professionals. Increasingly, health services are recognising that care needs to be more person-centred and focused on self management to support people properly during the other 99% of the time. National Voices, a coalition of health and social care charities, says “personalised care will only happen when statutory services recognise that patients’ own life goals are what count; that services need to support families, carers and communities; that promoting wellbeing and independence need to be the key outcomes of care; and that patients, their families and carers are often ‘experts by experience.’” This will require a three step change: improving information access for patients; supporting healthy choices and behaviours, including funding evidence based approaches such as group education; and finally giving patients more control of their care—what they receive, where they receive it, and from whom. Currently, just half of patients are comfortable with the control they have over their care. The recent #hellomynameis campaign reflects the desire and need to make services more centred on the individual and to put patients back in control. This is a simple plea, led by geriatrician and terminally ill cancer patient Dr Kate Granger, that asks all staff to introduce themselves by their first name at the beginning of every patient interaction. As a future doctor, you are likely to find working in the community and collaborating with charities, families, and carers an important part of your role.
Developing new care models
The new models of care being developed promise to break down traditional boundaries such as the outdated separation between hospital and community care, medical and social care, and mental and physical healthcare, by developing networks of care rather than by working within organisational limits.
A career in general practice could include leading the design of new primary care services, as well as having an active role in managing your local district hospital. Hospital consultants will be expected to support community services. This expectation is reflected by a recent training review, which said that doctors should be encouraged to take up generalist roles to meet the need for a diverse skill set and a broader scope of practice.
For doctors of the future, clinical expertise in isolation will not be enough. You will be expected to understand the challenges of the NHS in general, and of your local community in particular, and to work to address these, whether or not you choose to take a formal leadership role. As we’ve seen from the reports into failing hospitals (see box 2) doctors are increasingly expected to drive clinical improvement within their own services and in the wider community and to take responsibility for ensuring that quality of care and patient safety standards are met. The medical leadership and competency framework was developed by the NHS Institute for Innovation and Improvement and the Academy of Medical Royal Colleges. It sets out the competencies that doctors will need to become more actively involved in the transformation, planning, and delivery of health services. Clinical skills alone will not be enough and you will be required to possess the following qualities:
- The ability to seek out areas in need of change and targeted support
- An understanding of how to develop transformational change plans
- The ability to lead a team through a period of change
- The ability to create and nurture an environment where ideas can flourish.
What does this mean for medical students? Before your clinical years the first step can be as simple as recognising that you will be working as part of a complex system and thinking about how your environment affects the care that can be provided. Once you reach your clinical years, you can start to put this into practice.
Kevin Stewart, director of the clinical effectiveness and evaluation unit at the Royal College of Physicians, says: “You need to work on the system as well as in the system; it’s a professional responsibility. If we don’t exhibit leadership we are failing the patients and the profession.” He added: “Good leadership skills are as important as good clinical skills.” Look around during your clinical placements and ask yourself whether there’s a way to make life easier for the team and better for patients. This doesn’t have to be a clinical intervention. Does the ward round always rotate in the same direction each day, so the same patients are not seen until lunchtime when everyone is tired and hungry? Perhaps the last patient could benefit from being seen first the next day. Recognising a problem and raising it is an act of leadership that anyone can perform.
The act of leadership can reach beyond an individual patient to affect the whole system. For example, imagine you are a foundation year 1 doctor and you cannulate a patient, but you take two cannulas so you have a spare one. The unused cannula gets damaged and ends up in the sharps bin. If this happens once a day and each cannula costs £1 (€1.47; $1.39), that’s £5 a week or £260 a year. There are about 7500 foundation year 1 doctors in the NHS. That discarded cannula, repeated throughout the system, costs £1 950 000 a year. You could end up saving the NHS many millions of pounds. If you are looking for some help in turning an idea into reality, or just for some inspiration, visit www.changeday.nhs.uk. NHS Change day is an annual event that showcases projects and programmes from all over the country, all starting with one step towards making a difference.
Mark O’Donnell, care of the elderly consultant at Blackpool, Fylde, and Wyre Hospital NHS Trust, says everyone needs to start thinking this way. “The NHS has significant financial challenges, and the only way to address this is through innovation. And innovation comes from leadership,” he says. “You don’t need to be in a formal leadership role to show leadership. Don’t be afraid of offering suggestions. You can start paying attention to your environment now. Look for the simple solutions, practise raising issues with a senior; think about the part you play in the larger system and how you can improve that system. To serve each patient as well as possible, you need to optimise the running of your workplace, your team, and where possible your organisation.”
Box 2: Reading to prepare for a leadership role
Here are some suggestions for further reading to understand the changes now affecting the NHS:
- Francis report (Mid Staffordshire NHS Foundation Trust Public Inquiry) www.midstaffspublicinquiry.com/report
- Keogh report (review into the quality of care and treatment provided by 14 hospital trusts in England) www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdf
- Berwick review into patient safety www.gov.uk/government/publications/berwick-review-into-patient-safety
- Five Year Forward View www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
- Shape of Training review (review of postgraduate training to ensure that doctors are trained to the highest standards) www.shapeoftraining.co.uk/static/documents/content/Shape_of_training_FINAL_Report.pdf_53977887.pdf
- Health and Social Care Act 2012 www.gov.uk/government/publications/health-and-social-care-act-2012-fact-sheets
1St George’s Medical School, London, UK
Correspondence to: email@example.com
Acknowledgments: I would like to thank Geraldine Lynch for her advice during the researching and writing of this article. I would also like to thank Jake Matthews and Dan Fountain for their help in sourcing the quotes from Kevin Stewart and Mark O’Donnell at the Faculty of Medical Leadership and Management 2015 conference.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
- Stevens S. Five year forward view. NHS England, 2014. www.england.nhs.uk/tag/five-year-forward-view/.
- #hellomynameis: http://hellomynameis.org.uk/home.
- Greenaway D. Shape of training: securing the future of excellent patient care 2013. www.shapeoftraining.co.uk/static/documents/content/Shape_of_training_FINAL_Report.pdf_53977887.pdf.
- NHS Institute for Innovation and Improvement and Academy of Medical Royal Colleges. Medical leadership competency framework. 2010. www.leadershipacademy.nhs.uk/wp-content/uploads/2012/11/NHSLeadership-Leadership-Framework-Medical-Leadership-Competency-Framework-3rd-ed.pdf.
Cite this as: Student BMJ 2015;23:h1524