This section has been written by Stuart Holmes, medical student at Manchester University:

Next Stage Review: High Quality Care For All

In 2008, the government asked a surgeon, Lord Ara Darzi, to undertake a review of the NHS for its 60^th Birthday.  His final report, entitled High Quality Care For All, set out a vision for a health service with quality at its heart.

To enact this he called for the development of leadership and management skills for clinicians.  He argued that clinicians are at the frontline so are best placed to improve the service.

Liberating the NHS

The 2010 Health White Paper, Liberating the NHS, affirmed the development of leadership and management skills for doctors.

The health reforms in the White Paper give primary care clinicians responsibility for purchasing (i.e. commissioning) care from provider organisations like hospitals.  This new architecture for the NHS will require certain doctors to take unprecedented financial and managerial responsibility for their actions.

How has this been implemented?

The NHS Institute and the Academy of Medical Royal Colleges developed the Medical Leadership & Competency Framework for doctors to use to guide their development of these skills (see section below).  This has been embedded into both medical school and postgraduate specialty curricula. 

There are now lots of opportunities for doctors to develop these skills in their postgraduate training, either through out of programme fellowships or alongside their training programmes.  Less is provided for medical students but many medical schools do now offer opportunities like SSCs in leadership and management (see the ‘How can I develop leadership skills?’ section below).

The framework was first published in 2008 by the Royal Academy of Medical Colleges and the National Institute for Innovation and Improvement.  The 3^rd edition (2010) can be downloaded from the resources section at the bottom of this page.  The remit of the framework covers all medical students and doctors and a separate guide was also produced entitled ‘Guidance for Undergraduate Medical Education’ to ensure that leadership competencies are embedded into the undergraduate curricula.

Both within the main framework and the undergraduate one, five domains of leadership skills are considered. Each domain has four subsections and each subsection defines four competencies to be attained.

The domains are:

Some ways that you can relate to the five domains as a medical student  These ideas have been summarised from Helen O’Sullivan’s chapter called ‘Medical Leadership’ in the book edited by Simon Watmough, 2011 (see resources below):

1. Demonstrating personal qualities – Self-awareness is an important part of developing as a leader. (That is something that is in common with having a clear career goal, so the interactive exercises on this website should help you with this!) In addition, if you are given the chance to have a 360 degree feedback appraisal, you should take it, as this can help you set some goals in your personal development plan. It can also give you some insight into strengths and weaknesses. Look at the list of sub-domains -you will certainly be given the chance to practice some of these personal qualities whilst at medical school.
2. Working with others – throughout medical school you will have many chances to practice your team working skills, including opportunities to work in multi-disciplinary teams with other healthcare professionals. One of the ways to improve these skills is to get peer feedback from your fellow medical students. As you gain more experience in your later years you can practice more leadership and teaching skills with those that are more junior to you.
3. Managing services – In your clinical years you can try to talk to patients and their families to get an idea of their experiences and how services, e.g. primary and secondary healthcare, function together. Take advantage of any opportunity to shadow a health care manager.
4. Improving services – you can take part in audits or SSCs. Try to develop you analytical thinking and curiosity about how services could be improved.
5. Setting direction - This is the most difficult aspect to demonstrate as a medical student. Here you should look for opportunities to evaluate impact, make decisions and apply knowledge and evidence.

As a medical student you can develop leadership skills that you will find useful in the future when you take on more senior roles.  Here are some ideas below which have been provided by Stuart Holmes, medical student at Manchester Medical School and Sophie Kreppel, medical student at Peninsula Medical School.

The list is not a definitive one; can you relate these ideas to the 5 domains above?

• SSCs  -  Many medical schools have responded to the increasing interest in leadership and management for doctors by providing SSCs for students to develop these skills. 

If no such opportunity exists in your institution, why not help design one?

Case Study written by Stuart Holmes, medical student at Manchester Medical School:

'A group of enthusiastic students examined their curriculum for the competencies in the Medical Leadership Competency Framework.  They presented their findings to the curriculum development lead at the medical school and he suggested that they help address some of the highlighted deficiencies by designing an SSC.                

They worked with clinical tutors at the medical school to design and pilot an SSC that taught participants about leadership and management through teaching students in the year below about audit.  Whilst the SSC is beneficial on its own, these students gained most from the process of engaging with the medical school and being involved in the creation of a curricular component.'

• IHI Open School – IHI is an international network to promote healthcare improvement. It runs an Open School to supports local networks of trainee health professionals to develop leadership skills for quality improvement.  Various medical schools in the UK already have active chapters (find out more online) and you can easily establish one with a few like-minded peers if not.

Joining the Open School as a student gives you free access to online courses to learn skills for Quality Improvement, Leadership and Patient Safety.  The Open School England also organises regular conferences to bring together like-minded people to share improvement stories and learn from improvement experts.

• Joining a Society eg. medsin, sexpression, marrow etc, , or even starting your own society.
• Becoming a committee member – e.g. On the BMA student committee. Students can do as little or as much as they want on the committees with some going to international conferences.
• Becoming a NHS Evidence Student Champion. This is a scheme provided by NICE and allows students to undertake peer teaching activities and evaluate their impact.
• By looking out for other local initiatives. Sophie Kreppel, a medical student at Peninsula Medical School says ‘At Peninsula we have opportunities for students to become members of a student parliament. The parliament is a focus group, and there are 2 members from each year who represent the year, and bring up any concerns. They are required to talk to the rest of the year and try to come up with ways in which things can be improved.’

Followership is the act of following a leader. Helen O’Sullivan demonstrates in the book edited by Simon Watmough, 2011 (see resources below) how followership is important in medicine:

‘ A collaborative approach, where there is more shared decision making and working across interdisciplinary boundaries requires doctors to understand how to work as part of a team and to accept the leadership of others. As a junior doctor you may work with a senior specialist nurses who have been working in that specialty for 30 years or more. Also, you may need to follow the advice and guidance of occupational therapists when deciding if one of your patients can be discharged from hospital. All leaders are followers because not only do they have to follow their own leader but they need to understand and take a lead from their own teams.’

As you develop in your career, you should very gradually find you are moving more from a followership role to a leadership role. A good leader should actively seek the opinions of those in their team. If a leader is making a decision based on poor information, then someone with good followership skills should be able to tactfully and diplomatically challenge the leader. This can be very difficult to do, but it could make the difference between a good and a bad patient outcome.

Further reading:

• Medical Leadership Competency Framework, Enhancing Engagement in Medical Leadership Third Edition, July 2010: http://www.institute.nhs.uk/images/documents/Medical%20Leadership%20Competency%20Framework%203rd%20ed.pdf
• Guidance for Undergraduate Medical Education:

http://www.institute.nhs.uk/images/documents/Guidance%20for%20Undergraduate%20Medical%20Education%20-%20Integrating%20the%20MLCF.pdf

• Article in Surgeons News 
• BMJ article: Medical leadership: why it’s important, what is required, and how we develop it: http://pmj.bmj.com/content/87/1023/27.full.pdf
• The future of leadership and management in the NHS: No more heroes: http://www.kingsfund.org.uk/publications/nhs_leadership.html
• E-learning for healthcare learning resources: http://www.e-lfh.org.uk/projects/lead/index.html
• The Faculty of Medical Leadership & Management - http://www.fmlm.ac.uk/. Peter Lees’s blog (Founding Director of the new Faculty of Medical Leadership and Management)   - http://www.fmlm.ac.uk/blogs/peter-lees
• The Network – online community connecting medical students, doctors and other healthcare professionals
• The Health Foundation - has a strong interest in leadership development for improving quality 
•  Book: Simon Watmough (2011). Succeeding in Your Medical Degree (Becoming Tomorrow's Doctors), Learning Matters. (Contains a chapter on Medical Leadership).