Fiona Pathiraja: Investing in future clinical leaders

Fiona PathirajaFor a medic still just under thirty, I have deviated from the traditional medical career path several times. Working as a healthcare management consultant, setting up a start up enterprise and being on secondment to the Department of Health have broadened my understanding of the healthcare landscape.

The controversy over the planned NHS reforms has got me thinking about clinical leadership.  Empowered clinical leaders will be crucial to implementing the reforms and the NHS should look to other industries for lessons on developing future leaders.  Whilst junior doctors are treated as bottom of a hierarchy, their private sector counterparts are nurtured, trained and valued. Retaining and investing in talent is big business. Other industries wouldn’t dream of labelling the next generation of leaders with the pejorative term “junior.” Yet this is exactly what we do to future medical leaders.

As an avid Twitter user, I crowd-sourced opinion on this issue with the following tweet: “Why do McKinsey associates feel more valued than NHS junior doctors?” Responses came from a wide range of medical and managerial colleagues – one notable theme was the greater sense of organisational identity and belonging, and greater respect from seniors in the private sector. Even the most junior management consultants feel they have a stake in their organisations.  They are viewed as bringing a fresh perspective to problems as opposed to being inexperienced beginners.

My own experiences support this. One day I was a junior doctor at a London teaching hospital and the next, I was in a plush management consultancy office with a company laptop, Blackberry and business cards.  Where I once struggled to get a hospital manager to listen to my audits, I was now working with senior healthcare clients including PCT executive boards and the Department of Health. Even as someone new to the job, I felt my opinions were important to the managing director of the firm. Most junior doctors never have the opportunity to speak with the chief executive of their trust, let alone contribute to transformational change initiatives.

Why does any of this matter? At a time of financial restrictions and uncertainty, clinical leadership needs all the energy and knowledge capital it can source.  Many junior doctors are driven, interested in making a difference and experienced in healthcare at the front line. There are benefits for all involved if juniors are engaged, rather than being told to wait until they’ve “grown up” before they can create system change.  Several national leadership and management schemes now exist for juniors looking to develop these skills and a few enlightened chief executives have set up local training programmes to incentivise young doctors to lead from the frontline.

In financially constrained times, it is easy to forget the long game. However, the NHS must invest in its future clinical leaders. Management consultancies are paid vast sums of money to streamline NHS processes and reduce waste. Junior doctors on the frontline are in a position to notice daily system inefficiencies and often have innovative ideas to improve productivity. Perhaps it’s time we consulted them for a change.

Fiona Pathiraja is navigating a medical portfolio career. She has worked as a junior doctor, management consultant, entrepreneur and most recently as clinical adviser to the NHS Medical Director at the Department of Health. Follow her on Twitter @dr_fiona

  • Andy Cowper

    Good blog, making an interesting point about why the NHS management hierarchy gave itself a permission to listen to you as an external, 'big brand' management consultant which it did not seem to afford you as a young doctor starting an NHS career.

  • anon

    Excellent piece. Couple of things it made me reflect on:

    – There's a lot of talk and debate about 'clinical' leadership, which tends to mean leaders who are also clinicians. What do you think about the artificial distinction between leaders based on their job…nobody talks about administrative leaders, or portering leaders, or even 'managerial' leaders. Agree that good leadership will be crucial, but by elevating leadership from one group over another it feels to me that proper integrated team working will be an uphill struggle

    – From my experience the innovation and enthusiasm shown by Junior Docs is as often held back by their consultant than it is by 'managers' (some of whome may also be Drs or nurses btw). It is the same prejudice that stops senior managers from listening to junior administrators about processes and systems. The problem of orgs not using their own frontline staff to drive innovation is a massive OD challenge. It needs passionate people to make it a priority if the NHS is going to meet the £20bn challenge over the next few years.

  • Katy

    Really interesting post. I completed a management training scheme outside of the NHS and then joined a PCT. I was shocked at the hierarchy within the PCT and little respect that was given to those just starting off their career at the NHS. This contrasted to my previous organisation, where I felt my opinion was valid and that I was a developing leader of the future.

    Given that many doctors have found themselves in management positions, with little training in the area, I wonder what's being done in medical schools to ensure that the future clinical leaders have some knowledge in this area before they're thrown in at the deep end.

  • Couldn't agree more!

    Part of the problem with 'juniors' not feeling part of an organisation is due to the rapidity with which they rotate onto another Trust. It results in them never really feeling they are a valued part of an organisation and they have difficulty in developing the working relationships they need to be able to make a real difference on a local level in relation to systems, organisation and operations.

  • Nimalpathiraja

    Interesting indeed! I do agree with what you say why NHS is hiring management consultants. It is indeed true for many organizations not only to NHS. Other government departments and QUANGOS do that too. The point is that they know what they want to do so they get someone else to say it so it looks more credible. So management consultants are laughing! Nevertheless, it is good to get the views of the people at the coalface. If one can change these things, that would be good.

  • I think you raise a very important point about the disempowerment of young doctors in the NHS. It is ironic that you can be copying out blood results from a computer screen one day into the ‘bloods folder’, and at the same time be highly employable by organisations that would propel you to assisting to set an entire NHS organisations strategy.

    Perhaps the biggest problem is epitomised by the title ‘junior doctor’ and we would do well to redesign the system in such a way as it would become obvious this title was inappropriate. What we really want is a system that nurtures executive apprentices.

    In retrospect I can see what an extraordinary move it was for Liam Donaldson to initiate a clinical leadership scheme and take seriously the views and skills of young doctors. I hope future Chief Medical Officers will continue to make this nurturing of clinical leadership a priority for the future.

  • Rebecca Long

    This is an interesting post. However I do wonder about juniors getting involved with leadership. Will they have time now that the working week is just 48 hours? If leadership and management want to be taken seriously, it needs to be set up right from medical school. Junior doctors aren't trained to lead. Like in the military, medicine needs to learn to take leadership seriously and this won't happen unless the people at the top recognise that we need to train leaders – not just expect a few leaders to arise out of the ashes of a group of junior doctors who have been disillusioned.

  • BenB

    Interesting post Fiona.

    The medical profession is still beset by hierarchy and a system of seniority based largely on years in service rather than actual competence. Thankfully, the hierarchical division between doctors and other health professionals has blurred in recent years, but it still is very much alive within the medical profession itself.

    Apart from stifling innovation and creativity in service design and provision, the culture of deference also impacts on the quality and safety of medical care. Many other industries have long ago realised this – witness the rise of “Crew Resource Management” in aviation, in recognition of the fact the fact that idea that “the captain always knows best” costs lives.

    Leadership is perhaps not the best word for what is needed. Certainly leadership is required (and not just from those who have been in the job longest) but also a culture of collaboration and teamwork that encourages creativity, confidence and assertiveness in those traditionally seen to be “juniors”.

  • Paul Rutter


    You make some very nice points, essentially about empowering and valuing front-line staff, and developing culture and practices that ensure their perspective is heard.

    I understand the link with clinical leadership to an extent, but I can't help but feel that the CL buzzword is muddying the waters not just here, but across a wide range of different current debates. Your point here is entirely cogent and logical without referring to 'clinical leadership', more so in fact. Nobody really seems clear what they mean by CL. It's a bit of a catch-all. I think it is more useful to remain concrete ('train doctors in management' / 'change the term junior' / 'more doctors in management posts' / 'GPs should commission'). These are all quite distinct debates.

    I don't particularly think that the NHS should empower its staff because they are “the next generation of leaders”. It should do so because this is valuable and motivationally important in itself.

    Thanks for raising this. I look forward to your next blog


  • Fiona Pathiraja

    Hi Paul, thanks for your support on the blog! Much appreciated. Yes, I agree that the concept of 'clinical leadership' is somewhat fudged in the NHS at the moment. Clinical leadership should include other professions and have a broad base. However, I do feel that the medical profession feels that it needs to apologise for 'medical' leadership. I don't think we can wait for this – we need to actively harness talent if the NHS is to survive difficult financial times.

  • Fiona Pathiraja

    Hi Ben. Thank you for your post. Deference is so deeply ingrained in the medical profession and yes, it does stifle innovation and perhaps even reduce productivity. I wonder if this culture will prevail when we are consultants? Aviation is an excellent example of where medicine and healthcare can learn from – their work on human factors and behaviours is transferable to operating theatres and wards in the NHS. I agree leadership is not the best word but I'm struggling to find another word that encapsulates all these concepts. Ideas welcome! F

  • Fiona Pathiraja

    Hi Dougy. Thank you for this comment. Yes, the 'junior doctor' tag comes with many negative connotations. Question is, what could we use as a suitable alternative? Young doctors? Trainees? Neither of those sit well with me.
    I agree that Liam Donaldson took a calculated risk in setting up the Chief Medical Officer's Clinical Advisers scheme. Indeed, you and I have both benefited from his vision and energy around clinical leadership and young doctors. I am glad that the scheme now has a new home (the Faculty of Medical Leadership and Management) and a new sponsor/steward (Sir Bruce Keogh, NHS Medical Director). I hope that the new NHS commissioning board will continue to recognise the potential in the junior doctor workforce and encourage them to lead from the frontline. F


    Thanks for this thoughtful and thought-provoking blog. I think BenB hit the nail on the head (or made the correct diagnosis to keep with medical metaphors) by raising the hierarchy/deference issue. Medicine continues to be 'eminence-based' in many ways despite the lip service to 'evidence-based'.

    At the same time, as folks trained in medicine, we need to be aware that system change is not straightforward. Change has its own discipline and doctors can't expect to come up with a good idea and expect it to take off magically! Read Kotter in Harvard Business Review (or his book) about 'Transformational Change'. Implementation Science is a major frontier that is not covered in medicine.

    Fiona, you and folks like Emma Stanton and many others are key leaders in the 'clinician leadership' field — this parallels the innovation of clinician-researchers.Not every clinician can, or wants to, contribute as a leader in research but there are many examples of folks how have. Combining two disciplines is a classic approach to innovation – think biology and engineering leading to bioengineering. Underpinning these creative environments is the science of transdisciplinarity and Prof Daniel Stokols from UC Irvine is a remarkable leader in this field.

    My last point is that the 'macro-environment' needs to be conducive to both individual's efforts and those of teams (See Hackmann on how teams work). Fiona you raise the point that the NHS must invest in leadership and it would be a good idea to include doctors among those it invests in. Otherwise the macro-environment will be a limiting factor for the type of healthy change the governments are looking for.

    Thanks again for your post and I look forward to your next!

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