Clinical training in the United Kingdom is highly effective at producing technically accomplished and clinically safe practitioners. It does not, however, reliably produce system-literate leaders. Over the past decade, national leadership fellowships and academy-supported programmes have sought to address this gap, offering clinicians immersive experiences of policy, strategy and organisational leadership. These initiatives have demonstrable value for individual participants [1]. The question is whether they are sufficient to change the environments to which those participants return.

Filling the leadership development gap through out of programme experiences 
Attending the Faculty of Medical Leadership and Management conference in 2026, I was struck not only by the confidence of fellowship alumni, but by the social architecture of the environment itself. Residents who had undertaken national fellowships were positioned alongside chief medical officers and senior executives as intellectual equals, contributing to strategic conversations rather than merely observing them. The hierarchy felt noticeably flatter than in most clinical placements, conveying that these clinicians were trusted participants in system leadership.

What became apparent was the degree to which these developmental spaces remain structurally distinct from the clinical environments in which most doctors practise. Evaluation literature hints at this tension: almost half of fellows report difficulty transitioning back into clinical training, describing indifference or hostility towards their newly acquired skills [1]. The fellowship year is transformative, but the workplaces to which they return often remain unchanged.

This disjunction became concrete when a resident returned to our department following a year as anNHS England Medical Director’s Fellow. He had contributed to national strategy, worked closely with senior leaders and been treated as a valued interlocutor. Within weeks of returning to theatre, he was re-embedded in a training hierarchy that neither recognised nor accommodated his expanded perspective. The challenge was not resuming clinical work, but the absence of any structure through which he could continue to engage with system-level issues.

Developing an embedded leadership development infrastructure 
It was this absence that prompted a small group of Anaesthetists – consultants and residents together – to design what became the Generic Professional Capabilities (GPC) Hub in South-East London [2]. It was not a theoretical innovation, but a pragmatic response to the gap between curricular aspiration and workplace reality. The 2021 Anaesthesia Curriculum [3], aligned with General Medical Council requirements [4,5], strengthened expectations in non-clinical domains including leadership, quality improvement and patient safety. Yet rotational training fragmented continuity, projects dissipated, and engagement with leadership remained episodic.

The ambition of the Hub was to create a base layer of infrastructure within routine clinical training that would make leadership participation visible, continuous and legitimate. A shared FutureNHS workspace mapped projects across rotations. Resident leadership roles were defined, structured handover processes introduced, and early career consultants allocated programmed activity time to oversee and sponsor this work. Residents were deliberately connected to provider and sector leadership forums.

Over four years, this infrastructure has become more embedded. Early career Consultant Anaesthetists across several trusts in South-East London now oversee local hubs, and the model has expanded into neighbouring organisations. This growth has not been driven by central directive, but by recognition that curricular expectations require structural support to be realised consistently.

Experience developing this embedded architecture has reshaped how our group view national leadership policy. The difficulty with relying predominantly on immersive fellowships is not that they lack impact, but that they operate largely parallel to the clinical workplace rather than transforming it. While shaped from within the leadership domain, they do not automatically reshape the clinical microcultures in which professional identity is formed.

In contrast, early career consultants and senior residents embedded within frontline services occupy a distinctive position. They understand local norms and pressures while retaining influence within training structures. When they curate leadership opportunities locally – mapping projects, securing protected time, facilitating handover and creating access to organisational forums – they are not creating a parallel leadership space, but altering the fabric of clinical training.

Selective fellowships cultivate depth. Embedded infrastructure cultivates breadth. The two are interdependent. Leadership programmes are more likely to have sustained impact when the environments to which participants return can absorb and amplify their learning. Conversely, residents engaged in local leadership activity are better positioned to benefit from fellowship opportunities.

Building leadership capability in the medical workforce
From a policy perspective, the implication is clear. If distributed capability is essential to long-term transformation, investment must extend beyond selective leadership development into the everyday architecture of clinical training. This includes resourcing early career consultants, building infrastructure to sustain continuity across rotations, and embedding access to organisational leadership within routine posts. Such investment does not replace fellowships; it ensures their impact is not confined to exceptional periods out of programme. The growing pool of fellowship alumni is well placed to support this work, helping create the conditions within clinical workplaces that were often absent during their own training. Funding such infrastructure may operate at a fraction of the cost of external fellowships.

The persistent framing of clinician and leader as distinct tracks is increasingly untenable. If the health service requires clinicians capable of leading within their own contexts, leadership must be recognised as an intrinsic dimension of medical professionalism. Policy that focuses only on developing exceptional individuals will leave the clinical workplace structurally unchanged. Policy that invests in both selective depth and embedded breadth stands a greater chance of achieving durable cultural change.

Acknowledgements
The Generic Professional Capabilities Hub has been supported by departments of Anaesthesia across South-East London, Kent, Surrey and Sussex. Dr Chris James, whose experience returning to training from the NHS Medical Director’s Fellowship is described above, was a co-founder of the GPC Hub.

References

1. McKimm J, Hickford D, Lees P, et al. Evaluating the Impact of a National Clinical Leadership Fellow Scheme. BMJ Leader. 2019;3:37–42.
2. Millar KR, James C, Headon H, et al. Generic professional capabilities hub: developing leadership and management skills in trainees BMJ Leader 2024;8:171-173
3. RCoA. 2021 Curriculum for a CCT in Anaesthetics, Available: https://www.rcoa.ac.uk/ sites/default/files/documents/2023-02/2021
4. GMC. Generic professional capabilities framework. London: General Medical Council; 2017. Available: https://www.gmc-uk.org/education/standards-guidance-and-curricula/standards-and-outcomes/generic-professional-capabilities-framework
5. GMC. Excellence by design: standards for postgraduate curricula. London: General Medical Council; 2017. Available: https://www.gmc-uk.org/education/standards-guidance-and-curricula/standards-and-outcomes/excellence-by-design

Authors

Joe Lipton

Consultant Anaesthetist, Guy’s & St Thomas’ NHS Foundation Trust

Hannah Headon

Anaesthesia Resident, Princess Royal University Hospital

Anna Jones

Reader in Clinical Education, King’s College, London