Chris Ham: Medical leadership must move from the margins to the mainstream

A new report from the health services management centre at the University of Birmingham and The King’s Fund, funded by the National Institute for Health Research, provides a comprehensive and up to date picture of the state of medical leadership in NHS trusts today.

Thirty years after the Griffiths report set out a vision of doctors taking control of budgets and services, our report finds that much remains to be done to realise this vision. In most of the trusts we studied, a small minority of doctors were involved in leadership, and most of those committed only one day a week to these roles. It is hard to escape the conclusion that medical leadership remains a minority interest on the margins of the NHS.

Many factors can be invoked to explain this: the preference most doctors have for clinical work, lack of adequate training and support, the absence of defined career paths, and a culture within the NHS that fails to value and reward those taking on leadership roles. There is also often a gulf between medical leaders and their colleagues who choose to focus on service provision, education, and research. In our study this was described as an “engagement gap” that trusts were seeking to bridge.

There are clear echoes of Robert Francis’ warnings of doctors and other clinicians being disengaged from management and of the risks this poses to the quality and safety of patient care. Failure to involve more doctors in leadership also represents a major missed opportunity in the light of evidence linking medical engagement with positive organisational performance. For all of these reasons, our report provides a wake-up call at a time when the NHS is facing unprecedented financial and service pressures.

The government’s initial response to the Francis report includes a commitment to support clinicians to take on leadership roles and this is a welcome first step. In addition, every NHS trust needs to attach high priority to medical leadership and engagement and to commit time and resources to making it happen. This includes investing in the development of medical leaders and pairing them with experienced managers to create partnerships that are found in high performing healthcare organisations like Mayo Clinic and Kaiser Permanente.

Above all, there is a need to move beyond the perception that doctors who go into leadership roles are going “over to the dark side.” This can be done by attracting credible individuals into these roles, rewarding them both financially and in other ways, and supporting them through expert mentoring and coaching. Becoming a medical leader must become seen as a prize to be won rather than a burden to be borne in organisations where there is an expectation that those in leadership roles are among the brightest and the best.

A few NHS trusts are moving in this direction, but most have a long way to go. Roy Griffiths’ arguments remain as valid today as they were when his report was written and they have been reinforced by many others over the years, including Ara Darzi in his vision of high quality care for all. The NHS cannot afford to wait another 30 years to ensure that medical leadership moves from the margins to the mainstream.

The Fund has long been involved in supporting the NHS to develop medical leadership and we are reviewing our leadership programmes in the light of current reforms to the NHS. We will be refreshing our established programmes as well as offering new opportunities that take account of the findings of our report and our experience of working with a wide variety of NHS organisations. More details will be available on our website in the summer.

Chris Ham is the chief executive of the King’s Fund.

This blog also appears on the King’s Fund website at