Improving the Performance of Health Services: the role of clinical leadership Chris Ham University of Birmingham 4 May 2007

The puzzle for policy makers and researchers í The retreat from managed care in the US í The abolition of the internal market in the UK í The return to planning in New Zealand í Why have big bang reforms not really worked?

There is no single reason í Governments change and therefore policies change í Reforms are terminated too quickly í Politicians are impatient (and work to short term timescales) í Policies are not always well designed

A major reason lies in the nature of health care organisations í Hospitals and primary care organisations are ‘professional bureaucracies’ í They are part of a ‘disconnected hierarchy’ í They are ‘organised anarchies’ í They cannot easily be commanded and controlled

Health care organisations have inverted power structures í Control rests more at the bottom than the top í Doctors and other clinicians focus on the patient í They identify with their team and department í Loyalty to the organisation is less important

Other organisations are also professional bureaucracies í Universities and schools í Firms of lawyers, architects, engineers and accountants í Management consultancies í They face the same challenge

But health care organisations have some defining features í Doctors are the most powerful of all professions í Health care has many professions or ‘tribes’ í Health care organisations are often large and complex systems í The doctor-patient relationship is the most intimate

Health care reform led from the top has to understand these features í Two examples from the UK í Re-engineering of the Leicester Royal Infirmary – led by the hospital chief executive í Giving patients booked hospital appointments – led by the Blair government í The drive from the top confronts the reality of clinical work

Re-engineering at Leicester Royal Infirmary in the 1990s í Applying private sector techniques to a public service í Introduced from the top of the organisation í Limited impact and some resistance from clinical staff í Re-engineering had to be adapted in the process of implementation

“Significant change in clinical domains cannot be achieved without the co-operation and support of clinicians... clinical support is associated with process redesign that resonates with clinical agendas related to patient care, services development and professional development... To a large degree interesting doctors in re- engineering involves persuasion that is often informal, one consultant at a time, and interactive over time... clinical commitment to change, ownership of change and support for change constantly need to be checked, reinforced and worked upon.”

Giving patients booked hospital appointments í There was wide variation between hospitals in outcomes í There was wide variation within hospitals in outcomes í Clinical ‘microsystems’ are where change happens (or does not) 24 hospitals participated in an experimental programme

Quality improved where change began with enthusiastic clinicians í Medical leaders were important in implementing change í Involvement by hospital chief executives was essential í Dedicated project management assisted improvement

Clinicians resented and resisted change imposed from above í ‘You tell Tony Blair that he can give me his diary and he can see how he likes to have someone fill it for him’ í Showing that patients will benefit from change is necessary but not sufficient í Doctors need to see that their work will improve too í For example, by reducing cancelled appointments and filling surgical lists í Change – even small change – is difficult

Mintzberg’s observation from 20 years ago í ‘government technostructures intent on bringing the professionals under their control’ í have limited impact – and may be counter productive í Other ways have to be found of bringing about change in professional work

The example of Kaiser Permanente í A self- managing medical guild í Doctors as shareholders í An exclusive relationship with the Kaiser Health Plan í Change and improvement occur from within

Doctors are in leadership roles throughout the organisation í Collegial and peer processes are used to achieve change í Improvement occurs ‘through commitment and not compliance’ í When change is agreed, it usually happens quickly í Doctors review the performance of their peers

Not all health care organisations are Kaiser Permanente í Hospitals and primary care organisations can be slow to change í The paradox of clinical innovators and conservatives í The need for an external stimulus or shock to produce improvement í A major role for national and local leaders – politicians and managers

A story from the UK of one chief executive í He transformed one large provincial hospital over 10 years í His focus was on the development of clinical leaders and managers í At all levels in the organisation í It moved from close to the bottom into the top 10% of performers

He then moved to a famous London teaching hospital í This hospital thought it was already above the top 10% í In reality it was well behind í An organised anarchy í Doctors had limited commitment to the organisation í Their focus was on research and private practice

Six years later it is improving rapidly í This hospital achieved the highest rating in the government’s ranking of hospitals í The change has occurred because of two main factors í A new chief executive í A programme to develop clinical leadership throughout the hospital

Research from Canada into hospital leadership í The importance of ‘collective’ leadership í The need for leaders to develop followers í ‘Followership’ in health care is even rarer than good leadership í Relations between leaders and followers are often fragile

What are the implications? í We must stop thinking about health care organisations as machine bureaucracies í We must remember they are inverted organisations í They are organisations in which the most powerful people identify with the microsystem

In professional bureaucracies, we need many leaders í Some will be managers, others will be clinicians í Improving quality must be led by clinical leaders í With the stimulus and support of managers and others í A clinician-manager partnership is the way forward

We need to invest in the development of clinical leaders í Training, development and support at all stages í Career structures to facilitate í Payment and rewards í We need to invest in the development of followers

Thank you í C Ham Improving the performance of health services: the role of clinical leadership, The Lancet March online publication í C Ham et al Redesigning work processes in health care: lessons from the National Health Service, The Milbank Quarterly, 81(3), 2003 í