Clinical Directors Need More Time, Training and Support

A survey in Ireland had shown that Clinical Directors wanted more time, more training and more support, Dr. Julie McCarthy, National Clinical Lead, Clinical Directors Programme and Consultant Pathologist, Cork University Hospital, told the conference.

Dr Julie McCarthy
Dr Julie McCarthy

The survey carried out in 2015 – six years following the introduction of the CD model – had also shown that 88% of CDs were not budget holders, many were unclear about reporting relationships and there was still a significant gap between authority and accountability.
The survey had included the views of CDs, nurses, BMs and GMs.

Following initial “great expectations” there was frustration among Clinical Directors and Managers around what was expected of CDs and what was possible for them to deliver.
Speaking on “The Emerging Contribution of Clinical Leaders,” Dr. McCarthy quoted Machiavelli, who said ‘There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain of success, than to lead in the introduction of a new order of things.”

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There were difficult questions and difficult answers about the role of the CD.  What contribution could the clinical director model make to changing and improving the way health services are delivered, what was achievable and how could it be achieved.
Clinical leadership was holistic and applied to all sorts of people. “I embrace clinical leadership from all walks of the clinical professions.”

There were different leaders – institutional leaders, service leaders and frontline leaders, each of whom required a different skill set and all of whom required the organisation to support them.

The job description of clinical leadership/directorship in Ireland was thought to be a “work of fiction” and “overly ambitious,” introduced in order to curtail consultant private practice.

The theory behind the hierarchical model of leadership suggests that institutional leaders were clinical executives acting as stewards of the whole organisation. They should be highly credible to colleagues as clinicians and leaders and able to communicate their vision. They should have corporate level strategic thinking, political savvy and strong skills in negotiation and influence.

Service leaders were passionate advocates for their own service, responsible for clinical and financial matters. They were highly credible to colleagues, innovative and willing to take risks. They should have fluent service management skills in strategy and people development and budgeting.

Frontline leaders were great frontline clinicians who focussed on delivering and improving excellent patient care. They should be passionate about clinical work and could see opportunities for improvement. They should also have an understanding of systems and quality techniques.

“Clinical Directors should be institutional leaders, but it should also be remembered that real leaders are at the frontline and they are the clinical staff.

“We should have a distribution of leadership throughout the system. In 2009 when the Clinical Director model was introduced, we lost capacity because a lot of our previous service leads were stood down, so numerically we lost leadership capacity which we now have to rebuild.”

Dr. McCarthy said that the Clinical Director Job description provided for the following.

  • From the outset, in some hospitals, other non medical staff may also report to the Clinical Director. Over time, it is expected that each member of staff in the directorate will have a reporting relationship, through their line manager, to the Clinical Director.
  • Executive power, authority and accountability for planning and developing services for and managing available resources (direct or indirect) by the Clinical Directorate are delegated from the Employer.
  • The Clinical Director will be responsible for, and will have authority over, all medical services including resources for same (budget, staffing etc.).

The role of the Clinical Leader/Clinical Director was to achieve the best clinical outcomes and experience for patients within the available resources for the hospital or hospital group” (clinical director job description HSE 2012).

High performing organisations in other countries invested in medical leadership and had managerially trained medical leaders, such as the Mayo Clinic.

It was to deliver results, plan strategy, advocate for patients, empower colleagues and create new leaders, empower patients and be innovative.

Their job was a hybrid of managerial and leadership roles while maintaining their own clinical practice.

How hard could it be?  Dr. McCarthy quoted Chris Ham, CEO. The King’s Fund who said – “People say it is not rocket science – it’s not, it’s harder than rocket science.”

She said the job description of clinical leadership/directorship in Ireland was thought to be a “work of fiction” and “overly ambitious,” introduced in order to curtail consultant private practice and with the negative connotations of arising from IR talks. It was also introduced in isolation, without any wider reform of the system to accommodate effective integration or change to current practice.

“It is not an easy role and CDs need to be trained to be effective. We have a lot of CDs who feel like they are pushing a rock up a hill every day.”

The evidence from the literature going as far back as Johns Hopkins in 1973 recommended that in order for the CD role to succeed the following factors needed to be in place:

  • Executive managers willing to delegate authority for decision making.
  • Clinicians willing to assume responsibility for managing a business.
  • Nursing willing to support the change.
  • New management and financial systems in place.

She said success was possible if the clinical leaders were supported by the organisation and by the non-clinical managers in the organisation.

“Managers and clinicians see things differently because of the lines of accountability. Managers and executives are accountable for finances and KPIs – to central HSE and the Department of Health – and for delivering on initiatives that are often short term and political.

“Clinicians are accountable to their patients for giving them good quality, safe and timely care. They are also accountable to the Medical Council, and Clinical Directors are accountable to the IMC for failing to advocate for their patients.”

There is a concern among managers that medical leaders will implement change that costs more. Dr McCarthy illustrated a published article “A CEO checklist for high value health care” that demonstrated the ability to improve clinical care and reduce cost at the same time.

Dr. McCarthy said high performing organisations in other countries invested in medical leadership and had managerially trained medical leaders, such as the Mayo Clinic.
On the other hand there is current and historic evidence of bad outcomes for patients in institutions with poorly developed clinical leadership and Dr McCarthy referenced the Mid Staffordshire Francis report that highlighted deficiencies in clinical leadership.

Health care systems worldwide faced growing financial and performance challenges, particularly with the ageing population. The majority of a healthcare budget (80%) is spent by clinical staff providing clinical care. “Change is not implemented if it is mandated by politicians and managers. Change imposed on clinicians is unlikely to be as successful as change that they see will improve their own practice or their patient care.”