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Dr Mahiben Maruthappu, a Senior Fellow to the Chief Executive of NHS England, ably assisted by Sir Bruce Keogh, NHS England’s National Medical Director, examine the future of health system leadership.
“The eyes of the world are turning to Great Britain. We now have the moral leadership of the world, and before many years are over we shall have people coming here…learning from us in the twentieth century as they learned from us in the seventeenth century.” – Aneurin Bevan, July 5, 1948
As the UK’s National Health Service enters its 67th year and a new parliamentary term, eyes are drawn towards its future.
The health service has made important strides in the past 15 years – public satisfaction in the NHS has almost doubled, cancer survival is at its highest ever, and the service was ranked the highest performing health system by the Commonwealth Fund.
Simultaneously, the NHS faces the rising pressures of a growing, ageing population with more long-term conditions and increasingly expensive treatments and technologies.
Achieving further improvements and sustaining high-quality care will require a cohesive effort by NHS staff, unprecedented leadership, and clear coordination of the 1.3 million NHS workforce.
These challenges are not unique to the NHS. After the recent global economic crisis, health systems faced substantial financial pressures, as well as increasing demand for health services.
There are now common goals between nations of achieving the triple aim of improving population health, patient outcomes and cost control, combined with triple integration of mental and physical, primary and specialist, and health and social care services.
These challenges and ambitions forge unity of purpose, but if change is to be achieved a new cadre of leaders is needed.
Traditionally, NHS leaders have developed along a sequential path. Front-line experience has been followed by adoption of larger scale roles. Skills are accumulated and leaders migrate from the periphery to the centre – appreciation of clinical variation, financial matters, and hospital productivity is deepened, and capabilities improved.
Such leaders have been clinicians, allied health professionals, or managers who progressively translate their experience from ward to board.
However, better integrated and more cost-effective health systems require a new type of leadership.
Current NHS architecture depends on alignment and consensus rather than use of crude levers. As we move forward, leaders are needed with experience not only from ward to board, but also from across system boundaries into social care, local government, the voluntary sector, and industry. Local knowledge needs to be balanced with the ability to empower and enable from national standpoints.
The NHS requires leaders with the capacity to engage and collaborate with a broader range of stakeholders across systems of care.
Leaders able to maintain peripheral and central roles in parallel, delivering at both the front-line and national level,building skills in both contexts concurrently.
Leaders grounded in common values with a broad outlook that is patient centred, population focused, and cost aware.
Leaders with experience of innovation, improvement, and implementation at pace, empowered rather than hindered by the system.
If these leaders are to be developed, new opportunities are required.
In academia, tracks such as the Walport Academic-Clinical Pathway have been established that facilitate a bench-to-bedside approach with parallel clinical and research training.
In the context of leadership, greater opportunities to gain experience across the system are needed in national, managerial, local health organisation, social care, or industry roles. Such opportunities could be enabled through more flexible training possibilities.
In a way similar to academic–clinical pathways, front-line and system training would need to take place in parallel rather than in sequence, through protected time for such roles, ranging from, for example, 1 to 3 days per week.
Individuals from mid-career level onwards could be eligible, and receive appropriate recognition for delivering in these capacities. By gaining experience in both front-line and cross-system positions, professionals with both patient and managerial experience could be developed with a broader appreciation of the health service architecture.
The design, costs, and feasibility of such a programme would need to be developed and evaluated.
There is a need for greater plurality in NHS leadership, to ensure it is better aligned with the provision of integrated care, underpinned by improved quality and financial stewardship. The models in the Five Year Forward View present an excellent opportunity for training such leaders.
Development of a new cadre of leaders will require recognition and unified support at local and national levels. Design and implementation of such programmes could well determine the success of health systems in the UK and elsewhere.
- This article first appeared in the Lancet.