Leadership developmentfor clinicians: what arewe trying to achieve?Judy McKimm, Dean and Professor of Medical Education, Swansea University MedicalSchool, Swansea, UKTim Swanwick, Dean of Professional Development, London Deanery, UK

SUMMARYBackground: The role of all healthpractitioners is changing as aresult of social, technological anddemographic shifts, and cliniciansare increasingly required to par-ticipate in leadership activities.Worldwide, there are emergingexamples of policy agendas, pro-fessional standards and compe-tency frameworks and approachesto leadership development forclinicians.Context: This article looks atwhat leadership developmentprogrammes for cliniciansare trying to achieve, the ratio-nale behind them and the out-comes that are deemed to be

important. It offers a criticaldescription of competency frame-works and their use in practice.Innovation: The UK, along withother Western countries, hasembedded leadership and man-agement learning outcomes intoprofessional frameworks for stu-dents and qualified clinicians.There is increasing recognitionthat leadership development isbest rooted in work-based activi-ties, reflecting the realities ofclinical life, with an emphasis onlearning across the education andtraining continuum.Implications: If leadership isdeemed to be relevant ‘at alllevels’, then ‘leadership develop-

ment’ must be addressedthroughout the education andtraining undertaken by healthprofessionals. Leadership as atopic is gathering momentum asa key curriculum area. Buteffective clinical leaders andmanagers need to be nurturedand supported by the organisa-tions and health systems withinwhich they work and learn.Although a wide range of lead-ership development activitiesexist for individuals, withoutsystem-wide change theseinitiatives may not produce themost effective ‘leadership’, northe health improvements towhich they aspire.

There isincreasingrecognition thatleadershipdevelopment isbest rooted inwork-basedactivities

Leadership

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INTRODUCTION

Twenty-first century healthcare professionals will berequired to practice in very

different ways from their prede-cessors, responding to increasedcomplexity, demographic change,technological advances, globaleconomic trends, and increasedpatient involvement andaccountability.1 There is wide-spread recognition that the futureroles of clinicians will need tobe orientated towards the deliveryof systems of health care withinfinite resources, focusing ondisease prevention and healthpromotion within whole popula-tions, rather than the treatmentof illness in individuals. Beyondthis, there is also a wider societalremit. Health care professionals –doctors in particular – are amongthe most trusted members ofsociety. In 2010, a Royal Collegeof Physicians (UK) working partyidentified that doctors need toact to enrich public understand-ing of difficult or contentiousissues, and to be innovators andintegrators of new knowledge andchange processes.2 Against thisbackdrop, and a policy agendathat stresses the importance ofclinical leadership to organisa-tional performance, a wide rangeof development programmes haveemerged.3 In several countries,professional standards at bothundergraduate and post-qualifi-cation stages include learningoutcomes on leadership.4,5 In theUK, these are underpinned by aspecific medical leadershipcompetency framework.6

This article is the second in ashort series that provides anintroduction for clinical teachersabout the issues and currentdevelopments concerningclinical leadership. Our first arti-cle looked at the policy back-ground, leadership theories, andthe importance of clinicalengagement in the leadership andmanagement of health services.7

This article focuses on whatleadership development pro-grammes for clinicians are tryingto achieve. It considers therationale behind leadershipdevelopment, the outcomes thatare deemed important, and acritical description of competencyframeworks and their use inpractice. The third article in theseries takes a closer look at thepracticalities of, and approachesused in, the design and provisionof leadership developmentprogrammes.

WHAT IS LEADERSHIPDEVELOPMENT?

Leadership development as a dis-crete activity emerged from man-agement training andorganisational development pro-grammes in industry. Since the1970s, interest in leadership as a‘discipline’ has gained hugemomentum worldwide, and a rangeof initiatives exist across all sec-tors, designed both to develop andtrain effective leaders, and toproduce organisations equipped tomeet the challenges of constantchange. But as we highlightedpreviously,7 leadership should notbe separated from management:effective organisations needboth. Leadership developmenttherefore includes a range ofcompetencies associated with‘management’, for example anunderstanding of budgets, clinicalgovernance and human resourcemanagement.

Leadership development ini-tiatives in health care settingstraditionally range from 1-dayworkshops for trainees and prac-tising clinicians, throughshort courses, to masters ordoctoral programmes. At under-graduate level, many curriculaand professional standards includerequirements for understandingmanagement principles, healthsystems and teamworking, butmany medical students still feelthey need more management

training.1 In recent years, therehas been a growing consensusthat leadership developmentactivity should be rooted inwork-based activities, and as far aspossible linked to the developmentof the whole organisation. AsMintzberg argues, ‘using theclassroom to develop peoplealready practising management isa fine idea, but pretending tocreate managers out of people whohave never managed is a sham’.8

Put slightly differently, Bush andGlover emphasise the point that‘Leadership development isbroader than programmes ofactivity or intervention. It isconcerned with the way in whichattitudes are fostered, actionempowered, and the learningorganisation stimulated’.9

The rationale for leadershipdevelopment is grounded in theassertion that leadership can belearned. If leadership is anobservable, learnable set of prac-tices, then aspiring and currentleaders need to be identified,trained and assessed, throughboth formal development pro-grammes and a supportive,enabling organisational culture.But as Storey counsels, there arerisks in seeing leadership devel-opment as a ‘panacea and theanswer to an array of intractableproblems’.10 Organisations andteams need to be structured,funded and supported adequately,and to fit within wider structuresand strategy, if leaders and man-agers are to be able to functioneffectively. All the leadershipdevelopment in the world won’timprove organisational or teameffectiveness if there are funda-mental misalignments in strategyor structure. This highlights theimportance of organisationstaking a holistic approach toleadership and building whatBolden calls ‘social capital’through organisational develop-ment, as well as building ‘humancapital’ through developingindividual leaders.11

Leadershipdevelopment

includes a rangeof competenciesassociated with

‘management’

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PROFESSIONALSTANDARDS, OUTCOMESAND COMPETENCIES

Around the world, reports andpolicy documents highlight theneed for medical and health pro-fessionals to embrace leadership toeffect change and improvement inhealth service delivery. This callhas been accompanied by theimplementation of education andtraining programmes for cliniciansat all levels, by health care pro-viders through in-house training,and by educational and commer-cial organisations. This has led to a(often confusing) plethora ofcompetency frameworks andcurricula models.

Although some programmes inbasic medical education specifyleadership or management asintegral to their graduateoutcomes (e.g. the CanMEDSframework),4 these learning out-comes are not yet widely includedin curricula, other than implicitlyin statements around team,interprofessional and collabora-tive working. Leadership andmanagement development istherefore not a routine feature ofundergraduate medical education.Although there are some encour-aging examples, it is unlikely thatleadership and management willbe added as taught and assessedtopics to an already crowdedtimetable until (or unless)professional bodies responsiblefor accreditation include these intheir expected standards.

In the UK, a proactive approachhas been taken. Professionalstandards at all levels now includereference to leadership (andsometimes management). Forexample, the General MedicalCouncil (GMC) recommendationsfor undergraduate education –Tomorrow’s Doctors – highlights, inthe overarching outcomes forgraduates, that ‘graduates willmake the care of patients their firstconcern...using their ability toprovide leadership and to analyse

complex and uncertain situa-tions’.3 Later in the document, aspart of setting out how graduatesshould work as part of a multidis-ciplinary team, the GMC states thatgraduates should be able to‘demonstrate ability to build teamcapacity and positive workingrelationships and undertakevarious team roles including lead-ership and the ability to acceptleadership from others’.3

Equally importantly, as wedescribed in the first article in thisseries,7 the UK’s National HealthService (NHS) Leadership QualitiesFramework,12 and more recentlythe Medical Leadership Compe-tency Framework,6 have providedUK health professionals and thoseresponsible for leadership devel-opment with a detailed ‘manual’on which to base their activities(Figure 1).13 Guidance has alsobeen published in relation to theMedical Leadership CompetencyFramework, as it applies to under-graduate medical education.14

This has been endorsed by the UKMedical Schools Council, whosechair writes in the foreword to thedocument that ‘It is importantthat leadership learning is incor-porated within the mainstreamcurriculum rather than regarded assomething additional or evenperipheral to that core’.

The UK Foundation Programmeand speciality curricula also incor-porate competencies around clini-

cal leadership and management,but despite this many trainees stillfeel that they lack skills and thetime to gain appropriate manage-ment experience.15 To addresssuch issues, and to enhance med-ical engagement in NHS manage-ment, the National LeadershipCouncil (UK) has sponsored anumber of fellowships in clinicalleadership across the country,16

strategic health authoritiesthrough their postgraduate dean-eries are providing a range ofleadership development initiatives(see for example http://www.leadership.londondeanery.ac.uk) and the Academy ofMedical Royal Colleges launched anew Faculty of Medical Leadershipand Management in 2011 (http://www.aomrc.org.uk). Elsewhere inthe world, similar frameworks havebeen developed.

The Danish Medical Associa-tion identifies five core leadershipcompetencies for consultants:13

• personal leadership;

• leadership in a politicalcontext;

• leading quality;

• leading change;

• leading professionals.

The Health Care Leaders Asso-ciation of British Columbia hasdeveloped a framework that‘aligns and consolidates the com-petency frameworks and strate-gies that are found in Canada’shealth sector and other progres-sive organisations’.17 The ‘LEADS’Framework includes the followingareas:

• lead self;

• engage others;

• achieve results;

• develop coalition;

• systems transformation.

In the USA, the National Cen-ter for Healthcare Leadership hasdeveloped a Health LeadershipCompetency Model in conjunctionwith the Hay Group (Figure 2).18

Figure 1. The UK Medical Leadership

Competency Framework.6 Figure reproduced with

permission from NHS Institute for Innovation

and Improvement

It is unlikelythat leadershipandmanagementwill be added astaught andassessed topicsuntilprofessionalbodiesresponsible foraccreditationinclude these intheir expectedstandards

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Healthcare Workforce Australiais in the process of establishingits strategic framework, whichincludes a commitment to‘national competency frameworks,national health leadership devel-opment, workforce redesign andinterprofessional practice’.19

Whereas competency frame-works are very useful in enablingagreement on core leadership andmanagement skills, and in pro-viding a language about which tospeak of such activities, they donot provide the whole picture,particularly in consideringcontextualised performance. Anumber of writers have suggestedthat the competency approachcontains fundamental flaws: itsupports and reinforces ‘trait’theories; it diminishes leadershipto a reductionist set of frag-mented skills; and it focuses onpast or current performance, andthus has little predictive valueand struggles to take account ofsituational or complex organisa-tional factors.20,21 A risk, there-fore, for leadership developmentis that addressing leadership

competencies without a widerperspective may result in limited,mechanistic and ‘tick box’approaches aimed at improvingshort-term individual compe-tence, and not developingsustained leadership potentialand performance within wholeorganisations or systems. Assess-ment is therefore a key challengefor educators and clinicians.

The design and implementa-tion of leadership developmentactivities is influenced by theperceived needs of the partici-pants, their experience and stageof learning, and the needs, cul-ture and prevailing strategies ofthe organisation. One of the coreaims of leadership development isnot only to improve the individ-ual’s competence, but also toencourage employee engagementin all aspects of the organisation.This is not dissimilar to clinicalpractice: although a student ordoctor might be technicallyskilled, their lack of understand-ing and empathy with colleaguesand patients might mean thatthey are not a very good clinician,

and that their impact on patientcare is negative. Conversely,another doctor may be less com-petent technically, but showshigh-level communication skillsand creates a supportive atmo-sphere. The most competent cli-nician (as with the mostcompetent leader) is one thatcombines technical competencewith an engaging approach thathas a positive impact on themotivation and wellbeing ofothers. In clinical leadership,this is the sort of leadership thatwill lead to the highest levels ofteam and organisationaleffectiveness.22

CONCLUSION

It appears to be vital to startleadership development early ineducation and continue thisthroughout a doctor’s career.There is no doubt that the UK’sMedical Leadership CompetencyFramework and other initiativeshave set the scene not only fordeveloping a future generation ofdoctors as effective leaders andfollowers, but also in enablingdoctors to take a more proactiveleadership role in health caredelivery. As the impetus fordeveloping doctors as leadersgrows, a plethora of initiatives,including training courses, fel-lowships, development schemes,mentoring, coaching and memberorganisations, have arisen. Wehave highlighted that these ini-tiatives in themselves – particu-larly if they focus simply on ‘tickbox’ competencies – will notensure that doctors become betterleaders and that health care willimprove. Effective clinical leadersand managers need to be sup-ported and nurtured by theorganisations and the healthsystems within which they workand learn. As Warren and Carnellnote, this requires the embeddingof long-term development oppor-tunities, including mentoringrelationships, professional net-working and experiential learn-ing.23 In our next article, we willexplore the range of leadership

Figure 2. National Centre for Healthcare leadership: Health Leadership Competency Model.21 Rep-

rinted with permission from the National Center for Healthcare Leadership (http://www.nchl.org)

Leadershipdevelopment

[should start]early in

education andcontinue thisthroughout a

doctor’s career

184 � Blackwell Publishing Ltd 2011. THE CLINICAL TEACHER 2011; 8: 181–185

development opportunitiesavailable, and consider the bene-fits and disadvantages of differentapproaches.

Proposed future topics:

• Designing effective leadershipdevelopment

• Leadership in practice: chal-lenges and solutions

• The clinical teacher asleader: educationalleadership

Further readingDickenson H, Ham C. Engaging Doctors in

Leadership: A review of the literature.

Birmingham: NHS Institute for Innovation

and Improvement, University of Birming-

ham and Academy of Medical Royal

Colleges; 2008.

Stanton E, Lemer C, Moutford J, eds.

Clinical Leadership: Bridging the divide.

London: Quay Books; 2009.

Swanwick T, McKimm J, eds. ABC of

Clinical Leadership. Chichester: Blackwell

Publishing Ltd; 2011.

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Corresponding author’s contact details: Judy Mckimm, Dean and Professor of Medical Education, College of Medicine, University of Swansea,Grove Building, Singleton Park, Swansea, SA2 8PP, UK. E-mail: j.mckimm@swansea.ac.uk

Funding: None.

Conflict of interest: None.

Ethical approval: This article did not rely on research data, and therefore ethical approval was not necessary.

Effectiveclinical leadersand managersneed to besupported andnurtured by theorganisationsand the healthsystems withinwhich they workand learn

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