Why?
Clinicians have a unique role within the health and care system: as long-term leaders, those working with patients daily, recognising risk, teaching a new generation of health and care professionals, and pursuing research excellence. Clinical leadership matters to what is on the agenda and to the way in which change is implemented.
The launch of statutory integrated care systems (ICS) has been deferred until summer 2022. This pause creates an opportunity to re-test the clinical enthusiasm for, and involvement with, what is being planned. A reality check is needed as to whether professionals busy with combatting a pandemic are properly sighted on the future NHS and their place in shaping it.
The pandemic has created some new functioning partnerships, visibility for public health clinicians, and ways of working that could lay the groundwork for what is ahead. However, these new ICS structures mark a significant transition, and we know from the past that amid such change, risk emerges, understanding gets lost, and strategic objectives may distract from the need to put patient care at the centre of all decision making. The culture of organisations reflects in large part the leadership behaviours that are valued and normalised, which in turn reflect who sets that tone. A tone that needs to be compassionate and to clearly hear the varied voices of communities and patients.
Five principles underpin the national guidance on clinical involvement at system level. Published in September 2021, the guidance sets a clear series of tests by which integrated care boards (ICBs) can assess their maturity, covering inclusive leadership, how to embed learning, creating time and support for leaders, and a pipeline for future leaders. It also sets a high ambition for the culture of systems; in particular, the NHS element of those systems. While established for ICSs, the principles are common and have lessons for place and new provider structures, such as alliances.
So, if the purpose is prized and the route is clearly marked, what makes this difficult?
Who?
These are difficult roles. Among one's colleagues, often dealing with the most delicate situations, leaders are needed, but drawn from a talent pool with many other options. Motivating people to want to play roles in clinical leadership remains difficult. The pandemic has shown how flatter structures, rapid decision making, and clever data can produce innovation, and may help to attract new leaders. However, developing people within those roles requires a structured and supportive model of leadership, both inside and across organisations, which helps to mitigate risks of burnout and turnover. Positively ensuring inclusive practices and deliberate diversity must be central to that.
Where?
For places to thrive, there needs to be a dialogue between clinicians from all backgrounds and settings. This challenges the bandwidth of trusts to support decisions unavoidably made at different levels. In many systems clinical leaders below board level will be asked to take an organisation-wide view in representing providers in place or neighbourhoods. There is a risk of talented clinicians being pulled to ICS level, leaving gaps at place – which is arguably where the greatest opportunities lie to improve population health and tackle health inequalities. Not all seniority and experience should be drawn to the 'top table'.
The demise of Clinical Commissioning Groups radically changes the leadership landscape for general practitioners. Dr Claire Fuller is leading an NHS England stocktake which aims to define how primary care can be most effective within integrated care systems. Key to that work is, again, clinical leadership. With the review focusing on neighbourhoods and prevention, it is clear how vital a role GPs, and other primary care professionals, have in a future population health focused model. That leftward shift depends on a focus on unmet need and continuity of care.
What?
ICSs will need to take governance overnight of safety and quality, alongside existing and extensive provider arrangements. Place has to find a role in that complex system. If team-working is often the key factor in safe practice, then they will be pivotal. There is a real risk of duplication. At-scale the big task is to help identify and tackle unwarranted variation, not to edit decisions best made locally.
Yet clinicians' time in leadership also cannot all be drawn into these traditional scrutiny roles. The re-design of work patterns to achieve recovery, the steps to improve population health, and understanding the public health needs, all requires clinical time. Having established the pool of talented, diverse clinical leaders, ICSs need to be thoughtful about how that time is best used. What counts is what works. Skills-based teams, both horizontally and vertically, are needed, rather than every profession stretched across every function.
Taking the time to get it right
There has to be an honest conversation about embedding clinical leadership at all levels of integrated systems, not solely at ICB level. The need to demonstrate readiness for the 'go-live' date for ICSs must not obscure the need to self-assess leadership maturity and the journey ahead. Three questions are worth considering as we go into 2022/23:
- Are all professions visible and involved looking across the whole landscape of a system's leadership or is there a dominance by one or two disciplines?
- How are early and mid-career clinical leaders really involved in the work of reform and can they shape the roles that they will grow into over time?
- Is time available to support our clinical leaders to build the relationships they need and develop their leadership skills alongside their professional expertise?
Breadth, depth and precious time will be the hallmarks of a thriving local system committed to giving clinical professionals a chance to lead the development of system working, and its structures and approaches within and beyond particular clinical specialisms. Approaching the start of system regulation at ICS level in 2023, now is the time to get this right in partnership with those professionals – building foundations first, at place.