Summary of the impact

Around the world policy initiatives have aimed to increase the engagement of clinicians in the management of health services and research has shown that this contributes to improved patient healthcare. Research led by Professor Ian Kirkpatrick at Leeds University Business School (LUBS) has identified obstacles to this engagement and proposed ways to overcome them. The findings have been distilled into training and educational material which has been delivered to National Health Service (NHS) staff and guidance which has been used by NHS organisations to improve practice. Collectively, this work has contributed to improved and more efficient patient healthcare in several NHS trusts.

Underpinning research

Although research has demonstrated that increased clinical engagement in the management of health services can contribute to improved patient care, less is known about how the obstacles to such engagement can be overcome in practice. This has been the focus of research carried out at LUBS.

The early phase of this research, led by Professors Ian Kirkpatrick (LUBS, 2000 - present) and Terry McNulty (LUBS, 2000-2006), assessed the impact of public-management reforms on health service professions. This research was designed to understand the obstacles to reforms, specifically those aimed at turning doctors and other professions (such as Social Workers [1]) into managers [2]. Publications included New Managerialism and the Service Professions (Kirkpatrick, Ackroyd and Walker, 2005, Palgrave).

Research by McNulty (with Ewan Ferlie, Imperial College Management School) also looked at how clinical professionals responded to change and the difficulties of establishing new hybrid professional-manager roles [3]. The latter were hamstrung by limited resources, inadequate communications with staff, and the skills of doctors (who often had little prior knowledge or experience of management).

Building on this work Professor Kirkpatrick then led an inquiry, commissioned by the Centre for Innovation in Health Management (CIHM) at the University of Leeds, which was designed to address how obstacles to greater clinical engagement (elaborated in earlier studies) could be overcome and therefore how performance itself could be improved.

This Inquiry in 2006 examined the relationship between medicine and management and the conditions which facilitate more effective working [4]. The research identified specific conditions and policies in an organisation which supported greater levels of clinical engagement, with positive results for the efficiency and quality of services.

Building on this work, a second follow on CIHM study in 2008, led by Dr Gianluca Veronesi and Professor Kevin Keasey (at LUBS, respectively 2006 - present day; 1989 - present day) looked more specifically at relationships between clinicians and non-clinicians at the board level in NHS organisations. This also outlined conditions and policies that helped to overcome obstacles to clinical involvement in decision making and [5] at how these might enhance performance [6].

The final stage of research is on-going and has extended in two areas. The first has aimed to deepen understanding of the conditions and policies that supported clinical involvement in management. A two-year knowledge transfer partnership (KTP) with Leeds Teaching Hospitals NHS Trust and NHS Leeds (i) (ii) was followed by a Health Foundation-funded project (iii) led by Rebecca Malby and Professor Richard Thorpe (at LUBS respectively, since 2006 and 2003). The second area of work as been on the relationship between increased clinical engagement in health services and the impact that this can have on hospital performance in the EU and non-EU nations. This research work has been funded by a major EU grant (iv). This research has been extended to look at the link between clinical leadership and hospital performance in Australia, Canada and the UK (v).

References to the research

Research grants

(i) Kirkpatrick, I. and Vincent, S., Knowledge Transfer Partnership, (2008-10), `Enhancing the Effectiveness of Clinical Directorates', £130,000, Economic and Social Research Council, Northern Way and Leeds Teaching Hospital NHS Trust

(ii) Kirkpatrick, I. and McCabe, C., Knowledge Transfer Partnership, (2010), `Delivering a health promoting hospital: challenges and opportunities', £29,000, NHS Leeds and Technology Strategy Board

(iii) Malby, R. and Thorpe, R., (2008-09), Effective Leadership Development Interventions, Health Foundation

(iv) Kirkpatrick, I., (2010-14) `Enhancing the role of medicine in management in European health systems' €400,000, European Science Foundation COST Action IS0903

(v) Kirkpatrick, I. (PI), Veronesi, G., Ross, D.M. and Short, S., (2011), `Navigating from below: patients shaping health systems to address non communicable diseases' £11,000 WUN Researcher Development Fund (in partnership with colleagues at Universities of Sydney and Alberta)

Details of the impact

This research has been widely disseminated to health professionals in a number of NHS Trusts through conferences, policy groups, workshops and the CIHM network. Communication with over 300 top-level decision-makers has been maintained through CIHM's national network of NHS trusts. Members have access to the inquiry reports and toolkit (see below), and attend events, for example publicizing the latest research results on clinicians' role on NHS trust boards and links with performance. CIHM Director, Becky Malby, was also recently included as an `eminent thinker' in a meeting with Sir David Nicholson, NHS Chief Executive for England, which aimed to discuss the options for NHS reform, including strategies for more fully engaging doctors (particularly GPs) in managing services. More specifically, this research has had an impact in two main ways:
through organizational change initiatives and through training and education.

Organisational Change Initiatives

The two National Inquiries described in Section 2 [4, 5] fed into the development of a Toolkit for `Developing Productive Relationships between Management and Medicine'. This toolkit, designed to help overcome barriers to clinical involvement in management has been used across the NHS in organisational development projects. The Hertfordshire, Shropshire and East Riding Primary Care Trusts, for example, used it as part of work with the CIHM in 2009 and 2010 to improve clinical engagement for practice-based commissioning. In each, CIHM worked with 20 lead clinicians and 100 community GPs¹ [A]. An online version of the toolkit - http://www.cihm.leeds.ac.uk/drmgrtoolkit - is also now available. Since May 2012, a total of 62 NHS trusts and clinical commissioning groups (CCGs), the NHS Improvement Agency and one hospice have used it. CIHM maintain a register of toolkit users [B].

CIHM has also worked with Leeds Medical Senate (representing CCGs locally) to improve clinical engagement. Leeds' three new CCGs are using the inquiry research to underpin their Commissioning for Quality and Innovation activity and early results are promising. According to the Chair of NHS North CCG, "Utilising the University of Leeds National Inquiry into Management and Medicine...has directly led to robust relationships being developed...leading to direct improvement in patient care and more efficient working" [C].

A related initiative (focusing on organisational change) was a Knowledge Transfer Partnership (KTP) with Leeds Teaching Hospitals Trusts (LTHT) (2007-10) [D]. Building on the toolkit, this aimed to improve Clinical Directors' willingness to engage in the leadership of the trust. The KTP aimed to design and implement a change intervention that would incentivise clinicians to engage, and lead to improved performance at individual and directorate levels. The programme was designed and delivered to approximately half the clinical directors (17 delegates [D]), with beneficial effects on the trust. The Medical Director of Leeds Teaching Hospitals NHS Trust said: "The KTP has been immensely useful for the Trust in moving forward with our strategy of continually delivering improved levels of service." [E].

Professional Development: Executive Education and Training

The research has been distilled into training and educational courses which have been delivered to hundreds of NHS staff via different programmes.

A high profile example of this work is The Darzi Fellows Programme, which was run by the CIHM in 2009-10 and 2012-13 [F], [G]. This programme drew extensively on the research from the two Inquiries [4, 5] and included modules focusing specifically on the theory and practice of clinical management and how to strengthen it. So far the programme has been completed by over 80 clinical professionals (the majority being doctors) and the feedback has been outstanding¹. According to one participant: "I truly believe that the energised, forward-thinking, confident clinician I've become is testament to the seeds sown and nurtured during my Darzi year" [H]. Participants also reported that their employer benefitted from their participation in the programme.

In a similar way, the research arising from the Inquiries has fed into training programmes for other large health organisations. These include: a 2010-11 set of executive education programmes for doctors learning to be managers (including two for clinical directors at Leeds Teaching Hospitals NHS Trust, and Rotherham NHS Foundation Trust), the Leeds-wide Senate Programme (for 26 senior doctors) and a practice-based programme for commissioning leads (90 GPs)¹.

This training has also had an important regional dimension. The toolkit was utilised by the CIHM in its work with NHS Yorkshire & Humber (population 5.23 million), specifically the Leading Transformation Programmes. These have involved 95 senior NHS clinicians and managers attending two training programmes¹. The first (April - March 2012) helped senior professionals communicate ideas and change within their organisation, focusing in particular on how obstacles to clinical engagement with management could be overcome. The second (April - November 2012) had a similar focus, although targeted to the specific policy context of the management of services for people with long term conditions [I].

The feedback received from practitioners has been excellent. A Senior Leadership and Organisation Development Consultant of Health Education Yorkshire and Humber said: "There is considerable evidence that this research and the resulting knowledge transfer and engagement with practice has greatly benefitted the NHS by bringing about the means to improve services for the good of our patients." [I]. Evaluations from these programmes also show a new, more effective relationship being formed between doctors and managers, changing attitudes and generating service improvements [I].

This research has had an impact in the upper echelons of the NHS elsewhere in the north of England, having been distilled into training programmes which were delivered in partnership with the NHS North West [J]. The CIHM utilised the findings of the two national inquiries and incorporated them into a series of Board Level Director Leadership Programmes. Around 300 NHS Directors (including aspiring chief executives) participated in these events¹. The NHS has confirmed that the course helped facilitate interpersonal relationships and improve communication between doctors and managers, gave staff the tools to better understand their organisation, and proposed methods to enable leaders to bring about organisational change more effectively. The Director of NHS North West Leadership Academy said: "We are confident to say that from the evidence gathered, the Directors' leadership programmes have had a positive and lasting effect on the delivery of healthcare in the North West region." [A].

¹ CIHM programme registration records confirm delegate attendance on all programmes.

Sources to corroborate the impact

[A] Letter of testimony from Director, NHS North West Leadership Academy (formerly Interim Director)

[B] Database of users of the CIHM toolkit to May 2012 to March 2013 (confidential — contains names and contact details)

[C] Letter of testimony from the Chair of NHS Leeds North Clinical Commissioning Group regarding the work with Leeds Medical Senate

[D] Assessment of the KTP with Leeds Teaching Hospitals NHS Trust

[E] Letter of testimony from Medical Director, Leeds Teaching Hospitals NHS Trust

[F] Stoll L., Foster-Turner J., Glenn M. (2010), Mind Shift: An Evaluation of the London `Darzi' Clinical Leadership Programme, Institute of Education, London - including case studies on the change projects undertaken by the Fellows

[G] Selection of case studies by participants on the Darzi Fellows programme

[H] Letter of testimony from practising doctor, former Darzi Fellow

[I] Letter of testimony from Organisational Development (OD) & Leadership Consultant, NHS Yorkshire and Humber

[J] NHS North West Leadership Academy, Interim Report on Findings from Research into the Effectiveness of Academy Programmes, Report by Aston Business School, October 2011, see all references to Work Stream 3 which was delivered by Leeds.