Lessons from the London Darzi fellowship

The prestigious Darzi Fellowship has now passed its 10^th birthday. During that time many Darzi Fellows have experienced a unique combination of learning, development, innovation and leadership. There is an ever growing alumni of Darzi Fellows, these Fellows are a new generation of healthcare professionals, who have a clinical role or background coupled with the skills of systems leadership, and innovation.

The Darzi Fellowship is a case study in best practice for clinical leadership development. The evaluation of the London Darzi Fellowship programme carried out by Stoll et al., (2010) describes the value of the fundamental relationship between workplace and programme learning, described in the following diagram:

The report by Stoll and colleagues attributes the success of the programme (which at this stage was for doctors only) to:

• Committed and learning oriented MD
• Supportive Trust culture
• Working on ‘ambitious but appropriate’ live projects
• High quality mentoring
• Learning programme that targets transformational change
• Combining workplace and external learning
• Network of support – from formal to informal social learning

As the Fellowship developed into a clinical leadership programme, and the context in which the Fellowship operated change, the design of the fellowship was iterated, and the impact remained. Conn et al., (2015) in their survey of Darzi Fellows found 94% of their 90% survey return rate reported the programme as worthwhile. 85% felt more empowered to improve health care systems, particularly through developing collaborative clinical networks.

Overall a Longtitudinal study of the Darzi fellowship (Mervyn & Malby 2017) demonstrates its effectiveness in securing clinical leadership who can contribute too and lead the Triple Aim – ensuring high quality healthcare, securing overall community health and managing costs. The study showed that:

• Fellows are emerging as leaders, acting as catalysts for sustainable change in the healthcare environment
• The Darzi programme continues to be successful with learning and behavioural change sustained after the Fellowship year

Malby et al (2018) found that in a review of the Darzi Fellowship “Several concurrent processes must happen for clinical LD programmes to be genuinely impactful. Leadership students must collaborate as a group or team. Innovation, the basis of systems change, is the result of a team effort. These clinical teams should be diverse, especially multidisciplinary with a level of healthy conflict, and the students must be reflective and resilient. “

The Darzi Fellowship Programme at LSBU is designed based on the principles proposed by Edmonstone (above) along with those of Swanwick and McKimm (2014) who summarize a set of principles for design of leadership development namely that they should be:

• Practical: through the incorporation of the development of key skills such as coaching, change management, and negotiation
• Work oriented: by including project work as a key component supported by action learning sets
• Supportive of individual development: through 360° feedback, coaching, and mentoring
• Link theory to practice: through the provision of selected leadership and management literature, relevant to the educational context
• Build networks: through action learning, coaching, and social networking.

The Current Fellowship

The Darzi Fellowship supports early career clinical leaders, who take a year out from clinical training/ practice to develop their skills and capabilities in leading complex change. Fellows work on an intractable complex problem (the Fellowship Challenge) within an NHS organisation, where previous attempts to make an improvement haven’t made the difference expected; or an emerging complex problem where it’s not clear what to do. Host organisations provide an innovation space for the Fellows to test out new approaches to complex (wicked) local issues, in order to make a real difference to the quality of local health services.

The Fellowship work includes:

• Inquiry
• Developing a culture of change
• Discrete projects across a system
• Building collaborative relationships
• Connecting theory to practice, and a better use of data in the system
• Systems leadership

The PGCertLeadership in Health (Darzi)  takes Fellows through a journey of foundations of change, learning all the approaches needed to undertake a complex change, from scoping through to implementation and evaluation. Development of understanding of methodologies for change, personal strategies and skills for leadership including working with peers and with diversity are embedded in the programme workshops. These are applied and reviewed in Action Learning Sets and through the coaching and co-consulting sessions with Faculty where Fellows seek advice and support for the design and implementation of their change work.

A major strand throughout the programme is developing the ability to work effectively and productively with peers from diverse backgrounds (including service users). Throughout the programme the Fellows are exposed not only to the theory of clinical leadership but also to experienced clinical leaders, who share their personal approach. This also provides a network for the Fellows for current and future mentoring.

A  critical part of the Fellowship is learning about how to coproduce change with citizens as peers – here are colleagues from the LSBU Peoples Academy who join the programme.

The programme is congruent with the principles for effective leadership development identified in the last blog and re-listed here below:

Effective Leadership Development Principles and Practices

Overall the evidence suggests that any Clinical Leadership Programme needs to include the following:

1. Adult learning methods in understanding distributed leadership, systems and how they work, power, approaches to quality, change management, collaborative decision-making. This means an inclusive, collaborative approach to learning events (workshops) with little didactic learning.
2. Skills development in working with diversity and conflict, negotiation, personal resilience, change practices for wicked and tame problems, inquiry, critical analysis, reflection, learning to live with uncertainty, and working with people and communities as assets.
3. Organisational application – a real piece of leadership change work where the clinical leader can practice their new knowledge and skills, and learn through doing and reflection, and peer review with colleagues in an action-learning approach.
4. Clear mentorship of the clinical leader in their own organisation as they learn to apply their new learning in practice, providing air cover for the clinical leader to experiment with new skills and practices.
5. Leading as peers – using the clinical leadership learning group as the case material for understanding how to work as clinical peers in a distributed leadership model.
6. Personal Leadership application – knowledge development supported in its application by coaching.
7. System mentorship to support ongoing careers and sustainability of the programme learning.
8. Opportunities to build networks for personal development and support beyond the programme, and in support of the organizational change effort they are leading.

The Darzi Fellowship will shortly open for applications at LSBU for September 2019. Please contact me if you would like to host a Fellow.

References

Conn, R., Bali, A. & Akers, E. (2015) Taking time out of training to shed light on “the dark side’ BMJ 351:h5231

Malby, R., Mervyn, K., Boyle, T (2018) Darzi Clinical Leadership Fellows: an activity theory perspective. Journal of Health Organization and Management. Vol. 32 Issue: 6, pp.793-808

Mervyn K, and Malby, B (2018) Longitudinal Study of the Impact of the London Darzi Fellowship Programmes. Years 1 – 8. London South Bank University.

Stoll L, Foster-TurnerJ, Glenn M. (2010). Mind Shift. An evaluation of the London Darzi Fellowships in Clinical Leadership. London Deanery and IOE London

Swanwick T, McKimm J. (2014) Faculty development for leadership and management. In: Steinert Y, editor. Faculty Development for the Health Professions. New York, NY: Springer.

 

Does Clinical Leadership Make a Difference and how do you Develop Clinical Leaders?

I’m being asked about what makes effective leadership development, so here is a summary of what works! The next blog is a case study of the London Darzi Fellowship as an example.

The Impact of Clinical Leadership

Basically where there is good clinical leadership organisational performance is good – people get a better deal.

The importance of clinical leadership for healthcare change has been well described (Swanwick and McKimm, 2011, Edmonstone, 2009, Wilson et al., 2013, Malby et al., 2013). The direction of travel is clear, and to an extent this has been an ideological movement (healthcare quality will be improved and costs reduced if clinicians are at the heart of decision-making). However there is emerging evidence of the beneficial impact of clinical leadership. Kirpatrick et al (2007) conducted a National Inquiry into the relationship between management and medicine. This identified that “Clinical-management engagement is often associated with a) improved productivity (through the redesign of clinical work) – Degeling et al (2003); b) enhanced capacity for change and innovation (Fitzgerald and Ferlie 2006). A number of studies have found that poor performance and clinical failure were linked in part to a ‘disconnect’ between medicine and management (Healthcare Commission 2006, Mannion et al 2005). Many have also identified a positive link between effective clinical leadership and improved patient care. There is then some evidence to suggest that improving the capacity of doctors and managers to co-produce services will add value in the system.” (p 5)

A subsequent review conducted by the Faculty of Medical Leadership and Management, The King’s Fund and the Center for Creative Leadership (West et al 2015) showed the importance of leadership in the health service. The review concluded that ‘There is clear evidence of the link between leadership and a range of important outcomes within health services, including patient satisfaction, patient mortality, organisational financial performance, staff well-being, engagement, turnover and absenteeism, and overall quality of care’

Veronisi et al (2013) found a significant and positive association between a higher percentage of clinicians on boards and the quality ratings of service providers, especially where doctors are concerned ‘This positive influence is also confirmed in relation to lower morbidity rates and tests to exclude the possibility of reverse causality (doctors joining boards of already successful organisations). ‘

Overall it is now clear that high organisational performance results when good clinical engagement occurs, and higher quality care results from strong clinical leadership (Dellve et al., 2018; Reinstern et al 2008, NICS 2003).

Clinical Leadership Development

Having recognised the need for and benefits of clinical leadership, the next issue has been the readiness of the clinical professions to take on these roles. Whilst the attitude to leadership has changed, and whilst clinicians are taking up roles that embrace leadership, their development for these roles is less robust.

Leadership development and management development has long been embedded in nursing career development, and is increasingly common in medical careers (with intercalated degrees that include management). However many hospitals have little or no management or leadership development for their consultants, or directorate leads, and that is mirrored in primary care where opportunities for GPs to develop these skills has been sparse. The readiness of medicine mirrors the early ambivalence, and sometimes vociferous opposition of the profession to integrating management into its practice. As attitudes changes the development of the profession in terms of management and leadership skills has fallen behind. This is partly because the profession has taken time to realise that management and leadership isn’t straightforward ‘common sense’. Many stories of the early days of CCGs are told where GPs believed that running their own small business was adequate preparation for committing public resources through commissioning.

No matter what the causalities the reality remains that:

‘…consultants rarely receive leadership training and might experience problems with the transition into management roles, particularly in relation to conflicts with their other responsibilities to patients, colleagues and life outside work.’ Lewis 2013

‘Successful reshaping of local health systems depends heavily on the leadership of clinicians, working with partners in social care. But clinicians are rarely trained in the major change management skills they need for the task. Moreover, they get little career support for challenging perceived boundaries between clinical and management roles. Consequently the systems leadership roles where clinicians can make such a big difference may not appear to them as attractive or feasible career opportunities.’ NHS 2016

In fact according to Edmonstone (2009) “no systematic and structured national leadership development provision for doctors existed prior to 2001-2002” (p 210).

The Darzi Fellowship programme (resulting from the 2008 Darzi review) originally for doctors and now for all the clinical professions, in its 10^th year is the longest standing programme for developing clinical leaders in London. It demonstrates the value of investing in clinical leadership development (Malby and Mervyn 2017).

Leadership in high performing health systems is distributed (Denis et al 2011) and therefore in focusing on clinical leadership development for the future, the model of development should not just be for senior leaders but for the full range of clinical leaders, working at multiple levels and in multidisciplinary teams contributing to securing quality healthcare for all. This is supported by West et al (2015) report on leadership in the NHS which states that successful organisations are “leader-ful” not just “well led”.

In addressing clinical leadership effectiveness organisations need to provide clinical leadership in an integrated multidisciplinary model across all levels of organisational decision-making.

Effective Clinical Leadership Development Programmes

Of course effective clinical leadership development has many of the characteristics of any effective leadership development programme. The difference is the context in which clinical professionals join a leadership programme (the dominant role of expertise in the profession; the lack of prior leadership and management development in training).

At its heart any clinical leadership development programme needs to be based on the best intelligence about adult learning. This is the bedrock.

Adult Learning

Adult learners require far more than just information; they require a myriad of teaching technologies. These adult learning principles to the design of our programme (Knowles 1984):

• Adults need to know why they are learning something
• Adults learn through doing
• Adults are problem-solvers
• Adults learn best when the subject is of immediate use

Effective adult learning programs use double loop learning methodology based on for example Kolb’s experiential learning framework (Kolb 1984), and support continued learning and development through learning communities such as action learning sets so that participants ‘learn how to learn’, and have a deeper sets of alternative ideas and behaviours from which to choose to act (Schon 1987).

Effective Leadership Development

West et al. (2015, p 3) found that across levels of leadership development programmes – individual, task-based, team, organisational, national “…there is little robust evidence for the effectiveness of specific leadership development programmes”. However there are reappearing themes such as self-awareness and personal reflection, communication, teamwork, leadership styles, a support network, duration of one year and experiential learning, in studies of the learning impact of Leadership Development (LD) programmes. (Strawn et al., 2017; Tsyganenko, 2014, Pradarelli et al., 2016,).

In a review of Leadership development programmes Edmonstone (2013 p 537) proposed the following common design principles for effective leadership development programmes:

• “Starting with ‘what is’
• Focusing on the end-point
• Real time, real work, real people
• Explicitness about underlying values
• Addressing system-wide issues
• Embedding development with core business
• Embracing diversity
• Addressing sustainability

Effective Leadership Development Principles and Practices

Overall the evidence suggests that any Clinical Leadership Programme needs to include the following:

1. Adult learning methods in understanding distributed leadership, systems and how they work, power, approaches to quality, change management, collaborative decision-making. This means an inclusive, collaborative approach to learning events (workshops) with little didactic learning.
2. Skills development in working with diversity and conflict, negotiation, personal resilience, change practices for wicked and tame problems, inquiry, critical analysis, reflection, learning to live with uncertainty, and working with people and communities as assets.
3. Organisational application – a real piece of leadership change work where the clinical leader can practice their new knowledge and skills, and learn through doing and reflection, and peer review with colleagues in an action-learning approach.
4. Clear mentorship of the clinical leader in their own organisation as they learn to apply their new learning in practice, providing air cover for the clinical leader to experiment with new skills and practices.
5. Leading as peers – using the clinical leadership learning group as the case material for understanding how to work as clinical peers in a distributed leadership model.
6. Personal Leadership application – knowledge development supported in its application by coaching.
7. System mentorship to support ongoing careers and sustainability of the programme learning.
8. Opportunities to build networks for personal development and support beyond the programme, and in support of the organizational change effort they are leading.

References

Baker GR, Denis J-L. (2011) Medical leadership in health care systems: from professional authority to organizational leadership. Public Money and Management. 31:355–362.

Berwick DM, Nolan TW, Whittington J. (2008). The Triple Aim: Care, health, and cost. Health Affairs. 2008 May/June;27(3):759-769

Conn, R., Bali, A. & Akers, E. (2015) Taking time out of training to shed light on “the dark side Available at: http://careers.bmj.com/careers/advice/Taking_time_out_of_training_to_shed_light_on_%E2%80%9Cthe_dark_side%E2%80%9D# (Accessed:10/01/18)

Darzi, A. (2008). NHS Next Stage Review Leading Local Change. London: Department of Health

Darzi, A., Quilter-Pinner, H., Kibasi, T. (2018) Better health and care for all: A 10-point plan for the 2020s. The final report of the Lord Darzi Review of Health and Care. Institute for Public Policy Research. June

Degeling, P., Maxwell, S., Kennedy,J., Coyle, B. (2003)  Medicine, management, and modernisation: a “danse macabre”? British Medical Journal, 2326(7390): p. 649-652.

Dellve, L., Strömgren, M., Williamsson, A., Holden, R.J. and Eriksson, A., (2018), ‘Health care clinicians’ engagement in organizational redesign of care processes: The importance of work and organizational conditions’, Applied Ergonomics, 68, pp.249-257.

Denis, J.-L., & van Gestel, N. (2016). Medical doctors in healthcare leadership: theoretical and practical challenges. BMC Health Services Research, 16(Suppl 2), 158. http://doi.org/10.1186/s12913-016-1392-8

Edmonstone, J. (2009) Evaluating clinical leadership: a case study. Leadership in Health Services, Vol.22 Issue: 3, pp.210-224,

Edmonstone, J (2013) What is Wrong with NHS Leadership Development British Journal of Healthcare Management Vol 19 No 11 p531-538

Evans, E.J (2004). Thatcher and Thatcherism (the making of the contemporary world). 2^nd Edition. Routledge

Fitzgerald, L., Lilley, C., and Ferlie, E., Addicott, R., McGivern, G., Buchana,D. (2006) Managing Change and Role Enactment in the Professionalised Organisation. National Co-ordinating Centre for NHS Service Delivery and Organisation R & D. London.

Healthcare Commission (2006) Annual Health Check. London.

Kings Fund (2011) The Future of Leadership and Management in the NHS. No more heroes. Report from The King’s Fund Commission on Leadership and Management in the NHS p ix

Kirkpatrick, I., Malby, R., Dent, M., Neogy, I., Mascie-Taylor, H., Pollard, L., (2007), National Inquiry into Management and Medicine: Final Report, Centre for Innovation in Health Management, University of Leeds, January

Lewis, M. (2013) Reflections on a changing role in clinical management. International Journal of Clinical Leadership 17 (4): 227-234

Malby, R., Mervyn, K. and Pirisi, L. (2013), ’How professionals can lead networks in the NHS’, International Journal of Leadership in Public Services, 9(1/2) pp. 4-4.

Malby, R., Mervyn, K., Boyle, T (2018) Darzi Clinical Leadership Fellows: an activity theory perspective. Journal of Health organization and Management. https://doi.org/10.1108/JHOM-05-2018-0133

Mannion, R., H.T.O. Davies, and M.N. Marshall, (2005) Cultural characteristics of “high” and “low” performing hospitals. Journal of Health Organization and Management, 19(6): p. 431.

Mervyn K, and Malby, B (2018) Longitudinal Study of the Impact of the London Darzi Fellowship Programmes. Years 1 – 8. London South Bank University.

McNulty T, Ferlie E. (2002) Reengineering Health Care: The Complexities of Organizational Transformation. Oxford: Oxford University Press

L.J. Millward., Bryan, K. (2005),Clinical leadership in health care: a position statement, Leadership in Health Services, Vol. 18 Iss 2 pp. 13 – 25

NHS (2016) Developing People – Improving Care A national framework for action on improvement and leadership development in NHS-funded services. National Imporvement and Leadership Development Board.

National Institute of Clinical Studies (NICS) (2003) Factors Supporting High Performance in Healthcare Organisations. Melbourne, Australia: NICS

Noordegraaf M. (2011) Risky business: how professionals and professional fields (must) deal with organizational issues. Organizational Studies.  32:1349–1371. doi: 10.1177/0170840611416748

Pradarelli, J.C., Jaffe, G.A., Lemak. C.H., Mulholland, M.W. (2016), A leadership development program for surgeons: First-year participant evaluation, Surgery, 160(2) pp. 256-263

Rienstern J, Bisognano M, Pugh M. (2008) Seven Leadership Leverage Points for Organizational-Level Improvement in Health Care. 2nd ed. Cambridge, MS: Institute for Healthcare Improvement;

Schön, D. (1983). The Reflective Practitioner: How professionals think in action. London: Temple Smith

Spurgeon P, Clark J, Ham C. (2011) Medical Leadership: From the Dark side to centre stage. Oxford: Radcliffe Press

Strawn, K., McKim. A.J. & Velez, J.J. (2017), Linking Experiences and Outcomes within a Postsecondary Leadership Development Program. Journal of Leadership Education, 16(1) pp. 34-46

Storey, J. and Holti, R. (2013) Possibilities and pitfalls for clinical leadership in improving service quality, innovation and productivity. National institute for health research service delivery and Organisation Programme

Swanick, T., McKimm, J. (2011) What is Clinical Leadership…and why is it important. The Clinical Teacher. Blackwell Publishing. Vol 8 P22-26.

Swanwick T, McKimm J. Faculty development for leadership and management. In: Steinert Y, editor. Faculty Development for the Health Professions. New York, NY: Springer; 2014.

Tsyganenko, M.V. (2014), The Effect of a Leadership Development Program on Behavioral and Financial Outcomes: Kazakhstani Experience, Procedia Social and Behavioral Sciences, 124 pp. 486-495

Veronesi, G., Kirkpatrick, I. and Vallascas, F. (2013) Clinicians on the board: What difference does it make?, Social Science & Medicine, 77, pp. 147–155.

West, M., Armit, K., Loewenthal, L., Eckert, R., West, T., Leed, A. (2015): Leadership and leadership development in health care. The Evidence Base. Faculty of Medical Leadership and Management, The King’s Fund and the Center for Creative Leadership. Kings Fund

Wilson, L., Orff, S., Gerry, T., Shirley, B. R., Tabor, D., Caiazzo, K. and Rouleau, D. (2013), Evolution of an innovative role: the clinical nurse leader, Journal of Nursing Management, 21(1) pp. 175-181.