Clinical leadership: the elephant in the room

international journal of health planning and management

Int J Health Plann Mgmt 2009; 24: 290–305.

Published online 4 September 2008 in Wiley InterScience

(www.interscience.wiley.com) DOI: 10.1002/hpm.959

Clinical leadership: the elephant in the room

John Edmonstone1,2*,y

1Centre for Health Planning & Management, University of Keele, UK2MTDS Consultancy, Old School House, Littlethorpe, RIPON, North Yorkshire HG43LG, UK

SUMMARY

The article explores the concept of clinical leadership in the National Health Service in the UKby seeking to establish a workable definition and by contrasting it with managerial leadership,focussing on the ‘disconnected hierarchy’ in professional organizations. It proposes that theproblems faced by clinical leadership relate to the current nature of general management in theNHS and concludes by suggesting that clinical leadership is the ‘elephant in the room’—oftenignored or unaddressed. Copyright # 2008 John Wiley & Sons, Ltd.

key words: clinical leadership; general management leadership; professional practice;

challenges for clinical leadership

‘Clinical leadership . . . . . has always existed and will always exist, whether it is

acknowledged or not, and no matter what structures the NHS places around it’.

(Reader, 2006)

‘There is no such thing as clinical leadership and to say that it exists is both

elitist and divisive. All that matters is general management leadership and

clinicians should simply accept this’. (NHS Organisation Development

Manager)

As the first comment above suggests, clinical leadership has probably existed

within the National Health Service (NHS) in the UK since its foundation in 1948 and

from then until now has played roles of both a catalyst and a block to innovation and

change. This article explores the concept of clinical leadership by seeking to

establish a workable definition and by contrasting it with managerial leadership,

focussing on the ‘disconnected hierarchy’ in professional organizations. It considers

whether the problems currently faced by clinical leadership may be caused by the

nature of general management in health care and relates clinical leadership to the

development of professional practice. It concludes by suggesting that clinical

leadership is the ‘elephant in the room’—often ignored or unaddressed, but crucial to

the success of health care.

*Correspondence to: J. Edmonstone, MTDS Consultancy, Old School House, Littlethorpe, Ripon, NorthYorkshire, UK. E-mail: [email protected] Research Fellow; Director.

Copyright # 2008 John Wiley & Sons, Ltd.

CLINICAL LEADERSHIP: THE ELEPHANT IN THE ROOM 291

WHAT IS CLINICAL LEADERSHIP?

A recent review of health care and business leadership concluded that the search for a

single definition of leadership in health was fruitless (and perhaps even irrelevant)

because an appropriate choice of definition depended upon the theoretical,

methodological and substantive aspects of leadership being considered (Vance and

Larson, 2002). Moreover, (and as this article reveals) the notion of clinical leadership

is a ‘contested’ one, which can be see from a purely managerialist perspective as an

illegitimate, deviant and elitist activity. The second comment at the head of this

article illustrates this viewpoint. A milder variant of this perspective would regard

clinical leadership as simply an instrumental means of achieving managerial ends. So

seeking a consensual definition of clinical leadership can be a difficult activity.

From a nursing perspective Malby (1998) asked whether the term ‘clinical

leadership’ simply referred to anyone in a clinical role who exercised leadership;

whether it was a job title (and if so, what sort of job it could be?) or whether it was

simply shorthand for the Nurse Executive Director role. She concluded that clinical

leaders were simply leaders with a clinical background.

Other work on this topic (Edmonstone, 2005) agreed in part with Malby’s

conclusions and suggested that clinical leadership was ‘leadership by clinicians of

clinicians’. Clinicians were defined as front-line (i.e. interacting with patients) health

care professionals (principally doctors, nurses and the allied health professions), so

clinical leadership was not simply a surrogate for medical leadership, but was more

inclusive. Clinical leaders were defined as all those who retained some clinical role,

but at the same time took on a significant part in matters of strategic direction,

operational resource management and collaborative working with colleagues in their

own and other clinical professions, with health care managers and with other

managers and professionals in other agencies (such as social care). That definition

excluded those clinicians who had become full-time general managers in health care

organizations. While recognizing that clinical leaders could be either selected (by

managers) or elected (by their peers) or some combination of both, they tended to:

� U

Co

se persuasion, rather than hierarchical power to manage the tension between the

hierarchical management system and the clinical ‘expert system’.
� P refer an approach to change which was evidence-based and planned, using
consultation, clarification and a choice between options.
� F eel more comfortable with a reflective practice/professional artistry approach to
health care than a technical-rational one (see below).

Clinical leadership is, however, a problematic concept. Clinicians have competing

(and sometimes incompatible) responsibilities as both leaders and clinical providers

(Fitzgerald et al., 2006) and are subject to conflicting expectations from a diverse

role set. This is exacerbated by the need of many clinical leaders to maintain a

substantial clinical workload in order to maintain the respect of their peers (Bruce

and Hill, 1994; Fitzgerald and Dufour, 1997; Schneller et al., 1997).

Debate over such matters is becoming more relevant and urgent. For some years

now the Royal College of Nursing (the professional nursing trades union in the UK)

pyright # 2008 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2009; 24: 290–305.

DOI: 10.1002/hpm

292 J. EDMONSTONE

has run a Clinical Leadership Programme; a number of first and second-degree

programmes in clinical leadership are either being offered or are under development

in UK universities and many NHS employers have designed and are running local

clinical leadership programmes. Yet a recent survey of NHS Medical Directors

(Nolan, 2006) indicated that 90% of them believed that there was no proper career

structure to encourage medical staff to become clinical leaders; 80% said that the role

was not an attractive career option for doctors and 43% did not even have a personal

development plan.

CLINICAL AND MANAGERIAL LEADERSHIP

One fairly straightforward approach to this issue is to compare and contrast clinical

leadership with health care managerial leadership (Edmonstone, 2005). Historically,

managerial leadership in health care has had a corporate (or macro-view) focus on

the overall needs of the organization, with managers appointed through a process of

competitive selection and operating within given policies and procedures in order to

achieve targets. The ‘default position’ of managerial leaders in most large public

bureaucracies is that their ability to influence others is typically founded upon their

position power (their role and status within the managerial hierarchy) and that they

operate through what have been termed ‘superior–subordinate relationships’

(Jacques, 1976) with their followers who are managerially accountable to them.

Clinical leadership, by contrast, has always had a prime (micro-view) focus on the

patient, client group or service, with clinical leaders either appointed bymanagement

or elected (formally or informally) by their professional peers. Clinicians are trained

to think in a quite specific way, with a strong emphasis on individual responsibility.

Doctors, in particular, often come into leadership roles for reasons other than career

advancement—originally often by ‘accident’, but more typically (and recently)

through choice, often in order to protect or advance their clinical area. Even in the

instances where clinical leaders are appointed by managers, there is a need for them

to enjoy the respect and trust of their colleagues, with whom they typically have a

collegiate, rather than a hierarchical relationship, with an emphasis on achieving

change through debate, persuasion and negotiation. They are therefore accountable

to both management (in situations where they are appointed) and formally or

informally to their peers (who typically continue to regard them as representative of

their views and interests). Theymay use the position power associated with their role,

but the stronger source of their influence lies in their personal power (OHM, 2003).

Such personal power is based upon their perceived credibility and integrity, together

with the continuing trust of their colleagues. These factors allow them to become

opinion-formers in their own right. Clinical leadership has therefore often been

characterized as ‘influence-ship’.

A similar distinction can be made when addressing the issue of ‘fairness’ in health

care (Montgomery, 2000). For clinical leaders fairness is usually defined at micro

(i.e. individual patient or patient group) level, while for managerial leaders

definitions of fairness pertain to populations of patients or whole communities.

Copyright # 2008 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2009; 24: 290–305.

DOI: 10.1002/hpm


Clinical professionals like to present themselves as ‘knights’—seeking to advance

and promote the health and welfare of the communities they serve, while their critics

typically present them as ‘knaves’—seeking to pursue sectional interest and to

preserve and enhance their privileges (Le Grand, 2003). This can be seen as a false

either/or distinction—it is more likely that clinical professionals (like other social

players) seek to do both.

MANAGERS, CLINICIANS AND THE DISCONNECTED HIERARCHY

Health care organizations are professional organizations (Mintzberg, 1979) where

front-line clinical professionals possess a high degree of control. Accordingly, the

ability of managers in such organizations to directly influence clinical decision-

making is more constrained and contingent than in other kinds of organizations

(Ham, 2003) and because decision-making within clinical professions is typically

collegiate in nature, there is a premium on leaders with professional backgrounds

leading any change. Clinical professionals form what Mintzberg (1983) has called

the ‘operating core’ of health care organizations. What clinical professionals control

in health care is what Marxism would typify as the ‘means of production’.

Attention has been drawn to what is termed the ‘disconnected hierarchy’ in health

care—a disjunction between those who are responsible for front-line management

and those who deliver front-line services (Best, 1999). This is, in effect, an inverted

power structure in which people at the ‘bottom’ generally have greater influence over

decision-making on a day-to-day basis than do those who are nominally in control at

the ‘top’. As a result, the role of managers (particularly at, or close to, the front-line)

can often therefore be to lend support to clinicians in making changes, through the

provision of finance, time and other resources.

Earlier, similar views were expressed by Lipsky (1980) when considering the

importance of discretion in bureaucratic organizations and the ways that ‘street-level

bureaucrats’ (service providers who work face-to-face with their clients, such as

doctors, nurses, therapists, lawyers, teachers, social workers and police) undertook

their work. Discretion rather than prescription was seen to be a key feature of their

work, partly because they operated in complex situations which could not easily be

reduced to programmatic formats; partly because the situations they encountered

might require compassionate treatment, and partly because the exercise of initiative

in itself could inspire the trust of clients both in the individual professional and in the

agency he or she represented.

THE PROBLEM OF GENERAL MANAGEMENT

Research on innovation in health care in the UK by Roffey Park Institute (Shelton

and Syrett, 2003) suggests that health care managers feel that they alone are

obligated to originate creative thinking that leads to innovation, rather than to

identify, champion and support it. Managers do not feel mandated to undertake a

supportive role to clinicians and that it is, in fact, discretionary for them to do so—

either because they believe they are paid to ‘know it all’ or because they are


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294 J. EDMONSTONE

preoccupied with short-term targets and more immediate corporate priorities, and

thus avoid promoting such thinking. It has been suggested (Learmonth, 2001, 2003)

that NHS chief executives in particular construct an unrealistic image of themselves

as heroes and that researchers on management and organization in the NHS have

repeatedly failed to question the elitist assumptions inherent in its division of labour.

In research conducted for the former NHS Leadership Centre in England (but not

well-publicized) it appeared that chief executives alone were not personally

significant in changing the performance of their organization and had very little to do

with how their organization as a whole functioned (Dawes, 2002)—rather it was the

collective leadership ‘gestalt’ or mind-set which was instrumental—a form of

organizational capacity.

An example of this managerialist approach in action may be the creation and

implementation of the Leadership Qualities Framework (LQF) which is intended to

provide a template for all leadership (managerial and clinical) within the NHS in

England. Versions of the LQF have also appeared in the health care systems of the

other three UK countries. Based on 150 in-depth structured interviews with chief

executives and Executive Directors only, it asserts that certain key characteristics,

attitudes and behaviours can be identified, measured and developed to which all NHS

leaders should aspire. It therefore assumes that leadership is a senior management

preserve (Neath, 2007). At the very least it raises questions about how such results

can be generalized to leaders at all levels and in all settings. Such research, it has been

suggested (Bolden et al., 2006) is informative, but it is not definitive. It may well

have captured qualities which are descriptive (of behaviours associated with people

in ‘top’ jobs) but which are presented as prescriptive (a list of ‘oughts’). Such

descriptions tend to oversimplify and may well prove of limited practical

applicability within the climate of complexity, interdependence and fragmentation

that characterizes multi-disciplinary organizations like those in health care.

Moreover, such an approach seems to represent a return to older ‘psychologistic’

trait-based theories of leadership which assumes that leadership exists within

individuals rather than in the relationships between them—a form of ‘naı̈ve

reductionism’ (Heifitz, 1994; Wilson and Chesterman, 2003) where the means to

understand things is to reduce them to their component parts, rather than see them

holistically and in an emergent fashion.

Such approaches as the LQF also tend to support a move towards uniformity in

leadership, yet the public sector in the UK as a whole (and health care in particular)

has much more pluralistic cultures than many private sector enterprises (Attwood

et al., 2003) and a key leadership challenge seems therefore to develop processes

whereby people can listen to and respect each other’s perspectives across divides of

history, tradition, culture, education and so on. Vibrant organizations tend to draw

their strength from the variety of perspectives and beliefs held by professionals and

managers working both at the ‘front-line’ and on more strategic issues. Such

diversity—an emphasis on the ‘unusual suspects’—is valuable because innovation

and learning are the products of such differences. No one learns anything without

being open to contrasting viewpoints (Heititz and Laurie, 1997).

The essentially managerialist orientation embodied in the LQF is problematic

because recent research does suggest a positive relationship between effective


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leadership and the performance of NHS organizations (Borrill et al., 2001), with the

major influencers being both senior managers (who set strategic direction) and more

immediate and local clinical leaders. The former have a greater impact on

performance measures such as ‘star-ratings’ and the level of patient complaints,

while the latter make a greater impact on clinical governance ratings, job

satisfaction, staff well-being and a low intention to leave. Similarly, Mannion et al.

(2005) have highlighted important cultural differences between high and low-

performing health care organizations and suggest that leadership is of paramount

importance, asserting that strong and empowered clinical leaders are an essential

element in the former—but working as facilitators, rather than ‘enforcers’.

This notion of ‘omnipotent’ senior management is still relatively recent—earlier

thinking about health care suggested the existence of three quite distinct and self-

sustaining ‘domains’—professional, managerial and governance which were only

loosely-coupled together (Edmonstone, 1982). The advent of general management in

the NHS during the 1980s sought to make the professional domain subordinate to the

managerial domain (Edmonstone, 1986) and this is exemplified in the general

management ‘ideology’ propagated at the time. Some of the quotes below indicate

this change:

‘Management has a proper responsibility for the direction, quantity and quality, as

well as the cost of care.’

‘Coping with professional tribalism presents some of the biggest challenges to

management.’

‘Managers cannot, therefore, avoid involvement in questions of professional

practice.’ (NHSTA, 1986)

The adoption of this world-view represents an adherence to a unitary, rather than a

pluralist view of organizations (Burrell and Morgan, 1979), as shown in Figure 1.

While this world-view has its origins for health care in the evolution of general

management in the NHS in the 1980s, it received a further strengthening with the post-

1997 emergence of clinical governance, which made chief executives (and thus also

those accountable to them) responsible for the clinical as well as the financial

performance of their organizations. Such changes are part of an international

phenomenon which is rooted in the perceived crisis in healthcare funding and

subsequent attempts to improve efficiency (Fitzgerald et al., 2006). They are also

reflective of a general increase in the systematization of medical knowledge, an

increasing focus on providing incentives for clinical work, changes in state regulation of

medicine (Davies and Harrison, 2002), declining autonomy of professionals (Schneller,

2001), a rising emphasis on inter-professional working (Braithwaite and Westbrook,

2005) and shifting role boundaries between professionals (Humphris and Hean, 2004).

Yet chief executives and other senior managers in the NHS have largely been

drawn from those with an administrative and financial background, rather than a

clinical one, and thus have often lacked legitimacy in the eyes of clinical

professionals. There is little history and tradition of clinical professionals entering

NHS general management and no clear planned and thought-through career paths for

them to do so—unlike many health care systems in other parts of theworld or private


DOI: 10.1002/hpm

Unitary View Pluralist View

Interests Places emphasis upon the Places emphasis upon the achievement of common diversity of individual and group objectives. The organisation interests. The organisation is is viewed as being united regarded as a loose coalition under the umbrella of common which has but a remote interest goals and striving towards their in the formal goals of the achievement in the manner of a organisation. well-integrated team

Conflict Regards conflict as a rare and Regards conflict as inherent and transient phenomenon which in-eradicable characteristic of can be removed through organisational affairs and stresses appropriate managerial action. its’ potentially positive or Where it does arise it is usually functional aspects. attributed to the activities of deviants and troublemakers.

Power Largely ignores the role of power Regards power as a variable in organisational life. Concepts crucial to the understanding of the such as authority, leadership and activities of an organisation. control tend to be preferred means Power is the medium through of describing the managerial conflicts of interest are prerogative of guiding the alleviated and resolved. The organisation towards the achieve- organisation is viewed as a ment of common interests. as a plurality of power-holders drawing their power from a plurality of sources.

Figure 1. Unitary and pluralist views of organizations

296 J. EDMONSTONE

sector multi-national organizations where it is understood that senior positions will

be filled by the major professional groups, and where there are planned career

progression systems (and appropriate remuneration) to enable this to happen.

Taken to its extreme, the unitary managerialist viewpoint denies the existence of,

and any legitimacy for, clinical leadership and emphasizes instead a single source

and locus of control (general management); a single identity and loyalty focus (the

employing organization rather than the clinical profession) and adherence to a single

set of common objectives. In this manner leadership is simply conflated with

management, although it is now well-established that (at the very least) they pertain

to conceptually distinct phenomena, but with an overlap in practice—i.e. leadership

is exerted by both clinical and managerial leaders. Practical manifestations of this

view can include the exclusion of clinical leaders from decision-making processes, a

lack of practical support for their leadership roles and indifference to their

contribution at both strategic and operational levels—essentially antagonism to the

very notion of clinical leadership itself (Forbes et al., 2004). The limiting of clinical

leadership to purely operational matters has also been more noted recently where a

managerial ‘architecture’ of structures, roles and processes may sometimes be

created but with roles for clinical leaders which are effectively cosmetic, rather than

real—a form of tokenism (Fitzgerald et al., 2006).


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The origins of this unitary managerialist view may well lie in the way that public

sector leadership is defined in the UK. VanWart (2003) suggested that it could almost

totally be typified as ends-driven, focussing only on the achievement of specific

performance targets—a ‘bureaucracy of specifications, monitoring and reporting’

(Seddon, 2002a). This exemplifies the command-and-control approach to running

organizations (Seddon, 2003) which is increasingly being abandoned by most

organizations which deliver services. The world-view of politicians may well be the

driving force here (Russell, 2006) (although there is also a case that the problem

extends far beyond politicians and into UK society as a whole, as this particular form

of leadership has become so romanticized (Meindl et al., 1985), with the immediate

impact being on chief executives (Blackler, 2006) but ultimately also on both

managerial and clinical leaders. The charge is that politicians believe that targets

motivate but as has been pointed out (Seddon, 2002b) they simply motivate people to

be seen to be meeting their targets, which is not the same as being motivated to do a

better job and to improve the work on which they are engaged—sometimes called

‘Hitting the target but missing the point’. Inherent in command-and-control is an

assumption that people cannot be trusted on their own to do what is required.

Hierarchy and close supervision are therefore necessary to tell them what to do. As a

result, in a self-fulfilling prophecy, fear-driven hierarchical organizations portray

their staff as untrustworthy opportunists–and the proponents of command-and-

control can then say ‘I told you so.’ (Caulkin, 2006) Similarly, it has been pointed out

(Paton, 2006) that there is a profound dissonance between the leadership skills

required for charismatic leadership of a political party (and indeed government) and

the skills required to lead complex organizations and enact effective policy.

Organizational mergers, the introduction of market mechanisms into the NHS in

England and downsizing to reduce financial deficits all encourage a reversion to

command-and-control ways of working (Chapman, 2004) and the emergence of

proposals to model health care leadership on the armed services (Carlisle, 2006) or

double the numbers of (non-clinical) graduate management trainees (HSJ, 2006).

Command-and-control approaches tend to see change in organizations as being

‘programmatic’—episodic, project-based and with a distinct beginning, middle and

end (Beer et al., 1990; Edmonstone, 1995); operating to (often unstated) hierarchical

assumptions involving ‘cascading’ change; focussing on ‘infrastructure’ (policies,

structures, systems) and brought about by normative/re-educative strategies (Chin,

1969)—sometimes described as ‘training people into submission’.

Instead of the unitary, command-and-control assumptions which underlie

general management it has been suggested (Bate, 2000) that professional

allegiances and tribalism are too strong to develop a single harmonious overarching

culture and that health care is best organized through a kind of ‘regulated

pluralism’ based upon shared understandings—and from this the development of

some sense of shared responsibility. Yet this regulated pluralism may be in danger

of being eroded:

‘There are already signs of a ‘‘lost tribe’’ of clinician leaders who were once . . .

Co

enthusiastic champions. . .but who the system has appeared to discard’.

(Reader, 2006)


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298 J. EDMONSTONE

CLINICAL LEADERSHIP AND PROFESSIONAL PRACTICE

Where decision-making is collegiate, clinical leaders need the time and space to

work with colleagues to review established clinical practice and to introduce new and

more effective ways of delivering services. Clinical leadership can thus be seen to be

about facilitating evidence-based practice and improved patient outcomes through

local (i.e. front-line) care (Millward and Bryan, 2005). Clinical leaders are therefore

likely to subscribe more comfortably to the evidence-based ‘reflective practice’ or

‘professional artistry’ models of health care rather than the ‘scientific-bureaucratic’

or ‘technical-rational’ one (Fish and Coles, 1998; Davies and Harrison, 2002), which

managers typically identify with. This is shown in Figure 2.

Health care managers typically support greater systematization of clinical work

through the use of such tools as clinical guidelines, yet many clinicians do not regard

such guidelines and related initiatives as useful tools in improving quality care and

may resist them because they are perceived as hampering clinical freedom and

impeding local practice (Davies et al., 2007). Moreover, a seminal study (Fitzgerald

et al., 1999) suggested that there was no strong relationship between the evidence-

based and a rate of adoption of innovation and that, as the general management

process played only a marginal role in the change process, that there was a need to

embed change within the clinical professions themselves.

With the earlier ‘knights/knaves’ caveat, professional practice can be seen to have

the following attributes (Higgs et al., 2003):

� I

Co

t is always incomplete—professionals never know everything there is to know

about a particular clinical problem.
� I t evolves through collaborative relationships with professional colleagues (in a
range of disciplines) and with patients and their carers.
� I t involves professional judgement which opens professionals up to taking risks
and thus to risk being wrong.
� I t is based more upon uncertainty than upon total expertise—thus requiring the
courage of honesty.
� I t involves a spiritual dimension—because most human beings, whatever their
culture, accept the idea that we are in some way constituted of mind, body and

spirit.
� I t opens professionals up to moral answerability—in working with vulnerable
people, professionals are morally accountable for their conduct.
� I t espouses moral and ethical approaches to practice and demands from pro-
fessionals an endless critical examination of their beliefs—this involvement in

continual research and critique of one’s own practice

This means that clinical professionals effectively:

� R
ead (or interrogate) a particular unique clinical situation, and respond creatively
to what they see (using reflection on previous experiences).
� D raw upon a variety of approaches. � L earn by experiment.

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Technical-Rational View Professional Artistry View

Follows rules, laws, routines and Starts where rules fade. Sees patterns prescriptions and frameworks

Uses diagnosis and analysis Uses interpretation and appreciation

Wants efficient systems Wants creativity and room to be wrong

Sees knowledge as graspable and Sees knowledge as temporary, permanent dynamic and problematic

Theory is applied to practice Theory emerges from practice

Visible performance is central There is more to it than surface features

Setting-out and testing for basic There is more to it than the sum of competency is vital the parts

Technical expertise is all Professional judgement counts

Sees professional activities as masterable Sees mystery at the heart of professional activities

Emphasises the known Embraces uncertainty

Standards must be fixed. They are That which is most easily fixed and measurable and must be controlled measurable is also often trivial – professionals should be trusted

Emphasises assessment, performance Emphasises investigation, reflection appraisal, inspection and accreditation and deliberation

Change must be managed from outside Professionals can develop from inside Quality is really about the quantity of that Quality comes from deepening which is easily measurable insight into ones’ values, priorities and actions

Technical accountability Professional answerability

Professionals should be trained for The development of professionals instrumental purposes is intrinsically worthwhile

Figure 2. Two views of health care


� W

Co

ork by trial and error—but systematically.
� T urn instinct into insight by thinking about what they are doing as they work, and
arguing about it in their mind as they do so (theorizing about practice during

practice). (Higgs et al., 2003)

The reflective practice/professional artistry approach tends to emphasize

incremental rather than ‘big-bang’ change (Neath, 2004); practical evaluation of

change initiatives and a focus on shared or distributed leadership (rather than on


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300 J. EDMONSTONE

‘heroic’ individuals (Senge, 1999; Wilkinson, 2007)) operating through multi-

professional teams (Borrill et al., 2001) and engaged in:

‘acts of leadership which may be expressed in any organizational role’. (Pratt

et al., 2007)

Yet the impatience of senior managers and politicians (who wish to see quick

results) with this approach risks a widening gulf between them and clinical leaders.

DISAGGREGATING CLINICAL LEADERSHIP

It is also important to emphasize that clinical leadership is not necessarily a

‘monolithic’ entity—there are important differences based upon professional sub-

groups and an emerging divergence across the four health care systems in the UK.

For example, in research conducted by Durham University (CCMD, 2006) on

clinical professional leaders’ attitudes to NHS reform secondary care medical

leaders held mixed opinions about the reform agenda, while primary care medical

leaders were ambivalent about all aspects of the reforms. Nurse and allied health

professions clinical leaders, by contrast, tended to support the reform directions. The

research concluded that responses to the reform agenda tended to be driven by how

each professional sub-group conceived of the nature of clinical work, particularly the

extent to which they conceptualized clinical work on a more aggregated (or

systematized) rather than individualized basis, and the degree to which they accepted

power imbalances within health care as natural, normal and right.

Similarly, clinical leadership is taking different forms in all four UK countries as

the health care systems increasingly diversify (Greer, 2004; Greer and Rowland,

2008). Within the NHS in England managers and the market are said to be the

guiding forces, while in Scotland the clinical professions are seen as being in the

driving seat. This suggests that the nature and profile of clinical leadership in

Scotland will, over time, differ considerably from clinical leadership in England.

At the very least, therefore, clinical leadership would appear, up to now, to have

been somewhat inchoate and fragmented, with collaboration premised on short,

unstructured and opportunistic interactions (Reeves and Lewin, 2004) and with

strong social boundaries between doctors, nurses and therapists, even where they

share multi-professional team membership (Ferlie et al., 2005). Recent research by

the Health Foundation (Davies et al., 2007) commented that:

‘Different health professional groups largely inhabit separate hierarchies and

networks, often with surprisingly little inter-communication’.

Indeed, working between clinical professionals has been described as

‘knotworking’—based on continually establishing and re-establishing links via

brief interactions (Engestrom et al., 1999).


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Moreover, the development of any collective clinical leadership might also be seen

as a challenge to the historical hegemony of both managers and doctors by nurses and

allied health professionals—and this has led to expressed fears that the NHS is in

danger of having ‘too many chiefs’ (Russell, 2001) where egos rather than issues are

predominant, inhibiting rather than enabling effective inter-professional collabor-

ation and care (Curtess, 2001). However, such comments about clinical leadership

probably reflect a viewpoint based within the historical hegemony of senior

managers and senior doctors (and are possibly indicative of their anxieties), rather

than an emphasis on effective delivery of front-line health care, which is the focus of

clinical leadership. Recent initiatives intended to generate greater medical

involvement in leadership (Clark and Morgan, 2006) might be seen as an attempt

to re-establish such medical hegemony.

THE ELEPHANT IN THE ROOM

Clinical leadership can therefore be seen in the UK NHS as the ‘elephant in the

room’—it is large and significant—an obviously important entity that is often ignored

or goes unaddressed for the convenience of other interested parties; principally general

managers and politicians of all persuasions who (consciously or unconsciously)

operate to a command-and-control model of leadership. Health care cannot operate

without effective clinical leadership and (following the principles of Appreciative

Inquiry (Edmonstone, 2006)) a recent study has focussed on where clinician-

management relationships are productive and has suggested that this is marked by:

� Open, participative and inclusive modes of communication—Frank and frequent

dialogue, transparency and a willingness to admit mistakes. An acceptance that

difference, disagreement and conflict can be both necessary and useful.� Collaborative leadership styles (both clinical and managerial)—A departure

from traditional leadership notions based on elitism, patronage and position

power and a move towards managers adopting a facilitative/enabling role to

support clinical self-management and add value to clinical work. This implies

rejection of the ‘heroic’ general management leadership model and an

acceptance that leadership is increasingly practiced within teams or communities

(Brooks, 1996; Denis et al., 1996; Denis et al., 2001; Neath, 2004; Wilkinson,

2007) and that a shared, collective, dispersed or distributed leadership approach

is therefore necessary. Recent confirmation of the significance of this approach

has focussed on:

‘the utility and effectiveness of small core groupings of collective leadership. . . .

Small groups who worked effectively together, who collaborated and consulted

with each other and who had respect for each others’ viewpoints’. (Fitzgerald

et al., 2006)

There is also a parallel role for clinical leaders as ‘interpreters’—making sense of

the managerial agenda for clinicians and making sense of the clinicians’ agenda for

managers.


DOI: 10.1002/hpm

302 J. EDMONSTONE

� Greater clinical input into managerial decision-making at all levels—Non-

cosmetic structural arrangements with real delegation of responsibility to clinical

leaders, together with the agendas of NHS organizations reflecting clinical

concerns to a far greater degree than hitherto (OPM, 2006); Watkins et al., 2006).� A shared focus on the centrality of managing the means of production—A

recognition that productive relationships were only possible if management was

centrally focussed on the delivery of services.� Ensuring continuity over time—Being in it for the long-term—the willingness of

chief executives and senior managers to ‘stick around’ rather than move on.

Continuity of senior management also ‘buys time and space’ in which clinicians

can be creative and provides ‘cover’ from inappropriate challenge and

steadfastness in the face of loss of nerve (Pratt et al., 2007)� Appropriate investment in organization development—Developing capacity and

promoting cultural change and an emphasis on appropriate selection, training and

development, coaching and mentoring (Kirkpatrick et al., 2007). Although there

has been some major investment in certain medical leadership roles, other clinical

professions have not benefited to the same degree (Neath, 2007) and nor have

support staff to clinical leaders (Millward and Bryan, 2005). There is little evidence

of seeking to learn from the experience of previous leadership development

initiatives (Edmonstone, 2008; Edmonstone and Western, 2002). Moreover,

organization development in the NHS has been characterized as:

‘a largely reactive process attempting to implement, accommodate and at time

ameliorate the impact of externally-drive policy initiatives’. (Spurgeon, 1999)

and focussed on delivering short-term performance targets at the expense of

evaluation and sustainability (Hardacre, 2005).

Clinical leadership alone is, of course, unlikely to be any kind of panacea, but

needs to be:

‘developed alongside other strategies and has to be supported and valued by

strategic leaders at all levels in the NHS, including those at the very top’. (Ham

and Dickinson, 2008)

ACKNOWLEDGEMENTS

The author thanks the following for comments on earlier drafts of this article;

Dr Marion Bain, Medical Director, Information Services, National Services Scot-

land. Dr Sheila Peskett, Senior Fellow in Clinical Management, Centre for Health

Planning & Management, University of Keele

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Clinical leadership: the elephant in the room