WHAT MAKES A TOP MEDICAL DIRECTOR?

/ 2016

PART OF HUNTER HEALTHCARE’S INSIGHT FOR SENIOR NHS LEADERS SERIES 2016
 Contents

Top medical directors

Medical director –
Introduction Executive summary – behaviours and
clinician or manager?
qualities

3/ 4/ 5/ 10/

Using qualities and Supporting the next

Engaging staff in the
skills to create an generation of medical Conclusion
strategic vision
improvement culture directors

14/ 16/ 18/ 22/

References

23/

Contents / What makes a top medical director? 2/

 Introduction

The role of NHS medical director became The HSJ and Hunter Healthcare survey shows encouragingly high
levels of enthusiasm for the role but workload, regulatory burden
a statutory board position nearly 30 years and political interference rank highest among the negatives
ago, since when it has become highly – maybe it is time to do something about them? Competition
remains low for medical leadership posts and there is a constant
complex, challenging and crucial to the threat that directors might simply return to a clinical life if these
continuing drive to improve the quality of concerns are ignored.
care offered to patients. This report is a
In short, medical directors, suitably equipped, are an essential
timely review of how the role has evolved part of a health service aspiring continuously to improve value and
and offers a template for the further quality of care. This report indicates that the NHS is fortunate in
having a highly engaged and positive cohort of medical directors.
development of this important position It also suggests that the NHS must back its repeated affirmation
of the value of clinical leadership with action to allow medical
directors to maximise their effectiveness.
The 2013 Francis Report1 called for healthcare management
and leadership to be treated as a profession, citing among
the benefits enhanced recruitment and public assurance. Peter Lees, chief executive and medical director, Faculty of
The report commended the establishment of the Faculty of Medical Leadership Management
Medical Leadership and Management, which has done much
to professionalise medical leadership and has addressed a
recommendation of the 2015 Report of the Morecambe Bay
Investigation2, by developing clear national standards that set out
the professional duties and expectations of clinical leads at all
levels. Recent research suggests that greater medical involvement
at board level is associated with higher quality, which underlines
the importance of medical directors.

As roles evolve, it is important that the system takes time to

reflect on progress and makes necessary improvements to
enable optimal effectiveness. This report is a valuable part of that
process and, while its findings are largely reassuring, the positive
messages should not obscure the identified issues that may be
impeding the work of many medical directors. It is pleasing to see
that the average time spent in post is relatively high, given that
performance and quality are helped by longevity in leadership.

Introduction / What makes a top medical director? 3/

 Executive summary

The medical director role is one of the most

varied in NHS management and reflects
the breadth of organisational structures
across the health sector. It is also of
great significance for the NHS as it looks
towards its next generation of leaders

This report combines the results of a joint HSJ Hunter Healthcare However, given the importance of the role, there are impediments
survey of medical directors, including more than 50 conversations to the development of the next generation of medical directors.
with medical directors working across acute, community and The majority of the medical directors we spoke to had set out on
mental health organisations of varying size throughout the UK. their careers with the aim of developing their clinical expertise.
Our focus was to begin to understand the common elements that They become consultants within a given specialty, and often find
make a top medical director, to gain insight into the everyday themselves on the path towards becoming a medical director
pressures these individuals face and ask how we might support without having deliberately taken it. The route to being appointed
the next generation of medical leaders. on the board is not always actively pursued, with many of those
interviewed commenting that opportunities simply arose or even
We found the role is often shaped by the demands of the that they fell into a particular role having being asked to help out.
organisation. A medical director is much more than just a
clinically informed voice on the board, whose role is to bring the Our survey found that 42 per cent of medical directors are in
front line of healthcare service into the boardroom. They provide the job for between five and 10 years; 46 per cent last between
key pointers for the strategic direction of the trust, particularly two and five years. Although these figures could be seen as
with regard to clinical practice, while communicating the strategic encouraging, more can be done to ensure the next generation of
vision to frontline staff. medical directors is primed to step into the role and prepared to
stay there.
The best medical directors combine several qualities – personal
resilience, integrity, honesty, openness and the ability to
communicate effectively with a wide range of people from staff
to patients and the public. They use these qualities to ensure
that staff are engaged in the organisation’s vision and are able to
create a culture of improvement.

Executive summary / What makes a top medical director? 4/

 Medical director – clinician or manager?

Today’s medical directors must decide whether or not to continue with clinical practice
alongside their board responsibilities and the decision is often influenced by many
factors

Today’s medical directors face numerous challenges which, While many medical directors see maintaining clinical practice
as Stephen Kratz points out in The Changing Role of Medical as the only way to remain credible among fellow clinicians and to
Directors3, is because they have an extensive range of keep up to date with patient care, others perceive juggling clinical
responsibilities and a greater external focus with substantial work and leadership as a barrier to being able to give the board
involvement in strategic issues. role their full attention. Some argue that clinical practice is simply
a “comfort blanket”, representing familiar territory in contrast to
Far from simply representing a clinical voice on the board, the role the uncertainties of the board.
is pivotal in engaging frontline clinicians to help create a culture
of change. However, this inevitably means having a foot in both Writing in the HSJ 4, Dr Oliver Warren and Dr Emma Stanton say:
camps; being a credible clinician and at the same time dealing “We have had concerns for a while that there is an increasing
with numerous management challenges each day. Dr Barbara shift to ‘do’ leadership by moving away from clinical work. This is
Buckley, medical director of The Ipswich Hospital NHS Trust, who clearly nonsense, with leadership being a set of skills, behaviours
has held medical directorships across acute and community and values, not a job description. While you can, and perhaps
providers, says no two days are the same and directors must be should, take time away from clinical work to learn more about
prepared to expect the unexpected. policy, strategy, management and business administration,
these roles bring with them no more leadership challenge than
Furthermore, many medical directors who responded to our clinical work does. We are wary of any suggestion that the way
joint survey with the HSJ described their role as being subject to improve healthcare in the UK is by moving driven and engaged
to the intricacies of the local health economy. They feel the role doctors into full-time non-clinical work.”
is shaped far more directly by the demands of the environment
than is the case with any other executive position. In addition, the Maintaining clinical practice
requirements of the role vary with circumstance, which has led Most medical directors we spoke to are still directly engaged
to a lack of clarity for stakeholders across NHS organisations and in patient care. Maintaining clinical work is a central part of
uncertainty as to what to expect from their medical director. their career; it is something they find enjoyable and intensely
rewarding. Dr Clive Meux, medical director at Oxford Health NHS
This uncertainty can be mirrored by medical directors themselves Foundation Trust, describes his clinical work as the “highlight
with some being unsure of their role and what is expected of of the week” as it provides a chance to work at the front line.
them. The biggest questions for many are whether they should Dr Meux says: “For me, maintaining one day a week of clinical
maintain their clinical practice and what their priorities are. Our practice is very important. It is of both a strategic and practical
interviews found that there isn’t necessarily a right answer and benefit. It gives you much better credibility and a stronger voice.”
there are pros and cons for maintaining clinical practice. Most of
the medical directors we spoke to still practise, but this comes Some 82 per cent of respondents said that a factor in improving
down to a personal decision influenced by a range of factors. job satisfaction was that they found the role of medical director
interesting, with 64 per cent reporting that the work is challenging
One disadvantage of maintaining a clinical role alongside a and rewarding.
board level position is that it can lead to a fragmented working
experience. Dr John Lowes, medical director of Torbay and South Many medical directors expressed the view that a clinical focus
Devon NHS Foundation Trust says he regularly feels feel torn keeps them balanced. Professor Kevin Hardy, medical director
between the two, while Dr Steve Evans, medical director at Aintree at St Helens and Knowsley Teaching Hospitals NHS Trust, notes
University Hospitals NHS Foundation Trust, describes being “pulled that medical directors begin their careers because they want to
in different directions”. practise medicine and that a certain level of clinical practice is

Medical director – clinician or manager? / What makes a top medical director? 5/

 All high profile leadership roles are at times
challenging, lonely and scary. Medical directors are,
by definition, experienced clinicians, and accustomed
to being quick problem solvers. There are many issues
in leadership and management which do not lend
themselves to quick solutions and you sometimes
have to go to bed at night knowing that you have left
a less than perfect situation which cannot be resolved
as quickly as you would like. Furthermore, you bear
the responsibility for the judgement call.
Faculty of Medical Leadership Management, Transitions, 2012

Hunter / What makes a top medical director? 6/

required to stay grounded and retain trust among colleagues at the heart of everything”. The survey found the majority of medical
board level and throughout the organisation. directors (86 per cent) thought the most important focus for any
NHS organisation board was achieving the delivery of safe care.
Dr Kanchan Rege, medical director at Peterborough and Stamford
Hospitals NHS Foundation Trust, believes it is important to The Faculty of Medical Leadership Management is clear about
maintain first-hand experience of the front line to understand the the role of medical director in relation to patient safety.5 It says
issues facing the trust and provide some answers as to how they medical directors should recognise they are “the medical advisor
might be tackled. However, medical director at Rotherham NHS to the board and accountable for patient safety and quality”. The
Foundation Trust, Dr Conrad Wareham, suggests medical directors Medical Leadership Competency Framework 6 says: “It is vitally
should not practise just to keep up appearances, warning important fact that doctors have a direct and far-reaching impact
that trying to manage a clinical practice for which you have to on patient experience and outcomes.”
constantly rearrange appointments around other commitments
can be more damaging than suspending clinical activity. The faculty’s Leadership and Management Standards for Medical
Professionals 7 articulates a set of core values and behaviours
So, medical directors can look to build credibility through effective and says medical directors must motivate and inspire others to
communication. Dr Barbara Buckley observes that 90 per cent achieve high standards and improve services. The faculty is to
of the role involves talking to people, thus medical directors can launch certification of medical leaders this summer, allowing
retain a presence at the front line by spending time listening to them to gain a qualification and benchmark themselves against
their colleagues’ concerns and seeking input. approved standards.

Effective workforce relationships Dr Steve Evans points out that clinical practice allows medical
Effective relationships with the workforce are a vital part of the directors to maintain high clinical governance standards and also
role of medical director. Dr Peter Maskell, medical director at Kent spend time working with the board and management teams to
Community Hospitals Trust says some doctors perceive the role monitor standards of safety across the organisation.
as that of a trade union-style representative to argue the case for
clinicians to the board. This is echoed by Dr Tony Berendt, medical Different organisations, different challenges
director, Oxford University Hospitals NHS Trust. At times, even The opportunity to continue practising can depend on the scale
within his own team, he has felt like a “poster boy” for clinicians. of the organisation. Dr Andrew Catto, medical director at Heart of
The Faculty of Medical Leadership Management warns that it is England Foundation Trust, previously held the role at the much
not unusual for colleagues to see the medical director as their smaller Airedale NHS Foundation Trust. He is well placed to reflect
representative and, as such, accountable to them. “You are not on the different opportunities in these contrasting environments.
but, neither will you last long if you do not command the respect At Airedale, he was able to practise as a stroke consultant, build
of the medical body,” the faculty says. relationships with each of the 95 consultants in his charge and
engage with stakeholders beyond the organisation.
Dr Berendt believes such perceptions can be a symptomatic of
a failing system rather than misconceptions by the doctors. He But his move to a larger trust brought different challenges, since
notes that an effective organisation should not have clinicians the Heart of England has three hospital sites, a community centre
feeling sufficiently hard done by that they need a spokesman. and a chest clinic and is staffed by more than 600 consultants.
It would be a near-impossible task to meet each of those
The survey showed many respondents feel maintaining clinical consultants personally, and effective oversight of the clinical
practice is more important for understanding the patient delivery across such an organisation leaves insufficient time for
perspective. Dr Des Holden, medical director at Surrey and Sussex direct involvement in patient care.
Healthcare NHS Trust, believes medical directors can be “powerful
patient advocates”. The ability to make a difference to patients Local factors can also have a significant impact on the potential
featured strongly as a positive factor among respondents. to continue practising alongside a medical directorship. As Dr
Philip Mitchell at Lincolnshire Community Health NHS Trust says:
Keeping in touch with patients was one of the strongest “You have to think: what’s in the best interest of the role?” and
arguments given for ongoing clinical work as the ability to cite step outside to see the bigger picture. Helping one patient is
personal conversations with patients will carry weight at board rewarding, he says, but the medical director can help the whole
level. And being a patient advocate means medical directors play patient population.
an important part in patient safety and creating a culture of zero
harm. Dr Colette Marshall, medical director at Bedford Hospital Dr Julie Hankin, a former psychiatrist, is medical director at
NHS Trust insists that there should be a zero tolerance policy on Nottingham Healthcare NHS Foundation Trust. For the past two
harm and Dr Umesh Prabhu, who holds the role at Wrightington, years she has also been national advisor for mental health at the
Wigan and Leigh NHS Foundation Trust agrees that “safety is at Care Quality Commission. She feels this has changed her thought

Medical director – clinician or manager? / What makes a top medical director? 7/

processes and says: “I feel maintaining clinical practice would be
an over-commitment. I don’t feel removed from practice or out of
clinical work. I believe being a medical director should be an end
Insight
in itself and more support should be given to help prepare people
for the post.” The decision about whether to maintain clinical practice
is usually based on a number of factors, from personal
There are other aspects to maintaining clinical work that were preference to things that are outside a medical director’s
mentioned by our interviewees. Some felt it helped them build control, such as the size of the organisation. There are
external networks to enhance their footprint and influence drawbacks in terms of being able to commit time and
over a particular health economy. In the academic field and in energy given the day-to-day demands of a board level
education, which can make up a significant part of a portfolio position, and medical directors who still practise talk of
within university and teaching hospitals, both Dr Clive Meux being pulled in two different directions. However, the
and Dr Yvette Oade chief medical officer at The Leeds Teaching benefits are clear in terms of maintaining a link with the
Hospital NHS Trust, believe that such factors are important to help front line and being able to understand and promote the
establish credibility across a wider group of stakeholders. patient perspective.

Job satisfaction
Survey interviewees were asked to give a mark out of 10

4% Scored 2 out of 10
5% Scored 4 out of 10
9% Scored 5 out of 10
36% Scored 7 out of 10
18% Scored 8 out of 10
23% Scored 9 out of 10
5% Scored 10 out of 10

Medical director – clinician or manager? / What makes a top medical director? 8/

Which factors pull the job satisfaction rating down?
67% The regulatory burden is too high

62% My workload is too high

48% I find external pressures (political interference for

example) get in the way of my job

33% My job often overwhelms me

29% My remuneration is too low for the job I do

29% I find my job very stressful

14% I find the internal politics get in the way of work

14% I don’t feel supported by senior colleagues, the wider NHS system or the public

10% My organisation has poor working relationships

0 20 40 60 80 100
% of respondents

Which factors increase the job satisfaction rating?

82% I feel I am making a difference/doing something good for patients

82% I find the work interesting

64% I find the work challenging and rewarding

60% I feel supported by senior collegues, the wider NHS system

or the public

37% I am happy with my financial package

7% I have good working relationships

0 20 40 60 80 100
% of respondents

Medical director – clinician or manager? / What makes a top medical director? 9/

 Top medical directors –
behaviours and qualities
The role of medical director is a complex and difficult one that isn’t suited to everyone.
The Faculty of Medical Leadership Management warns that all high-profile leadership
roles are at times challenging and lonely.5 Medical directors therefore need a
combination of qualities to be able to address and deal with problem as they arise

Personal resilience Integrity

Many in the job talk of the need for resilience because the role Other qualities, such as integrity, are exhibited by top medical
can lead to feelings of isolation and being pulled between factions directors. This means behaving in an open, honest and ethical
– the board, staff and patients. Coping with long hours and a manner. According to the Medical Leadership Competency
high workload inevitably take a toll and medical directors need Framework, doctors show leadership by acting with integrity.
resilience to make tough decisions, yet still remain respected Upholding personal and professional ethics and values while
in their role. However, being resilient is often not as simple as it taking into account the values of the organisation and
sounds. respecting the culture, beliefs and abilities of colleagues are all
important in this. The Faculty of Medical Leadership Management
Aintree University Hospitals’ Dr Steve Evans has been in medical advises that qualities like integrity have to be worked on. “Leaders
director roles for about 10 years and says resilience also are constantly on show and success or failure depends on how
means having the ability to deal with complexity and to simplify others see you. Many of the essential prerequisites such as
situations. He says: “You need to have good resilience and not integrity, trust, respect are hard won, take time and are much
take things personally. Your experience is key to being effective. easier and quicker to lose.”
You need to have credibility with consultant colleagues – they
have to understand that you have done it yourself and know
where they are coming from.” Honesty and openness
The need for openness and honesty was mentioned by many
In the HSJ/Hunter Healthcare survey, personal resilience came of the medical directors we interviewed. They recognise the
joint highest on the list of qualities needed to be a medical importance of the medical director gaining trust of the staff by
director. Almost half of respondents (48 per cent) said it was an being honest. Dr Clive Meux says: “When you meet colleagues
important quality for the job they do. Dr Simon Constable, medical you’re a bit of a grey man, calm, statesman like, important,
director and deputy chief executive at Warrington and Halton collaborative and positive. You take fire from emails or comments
Hospitals NHS Foundation Trust believes patients need clinicians and show the highest possible level of moral behaviour. You
to be resilient, so patients can keep going and bounce back need to be honest at stakeholder meetings and presentations.
themselves. In terms of his own resilience he relies on family, Sometimes, though, honesty doesn’t go down too well.”
friends and colleagues who he can have the genuinely honest
conversation and not worry about what they think of you.
Communication skills
Being a good communicator is an important trait of a top medical
But some medical directors have few people to turn to for support
director. One in five respondents to the survey identified this as an
or help in developing resilience. This is one area highlighted by
important quality. Medical directors are integral to communicating
Monitor and the Trust Development Authority in the 2014 report
the trust’s vision. According to the NHS Leadership Framework,
Supporting the role of the medical director.8 The report quotes
leaders such as medical directors must communicate their
one medical director who says: “Who can you turn to for support
ideas and enthusiasm about the future of the organisation and
as medical director? I will be in the trust for many years to come
its services confidently and in a way that engages and inspires
and will still have to work with my clinical colleagues, who are
others. Inspiring others was the joint-highest quality needed for
impacted by every decision I make, come what may, whereas my
a medical director according to the survey. “I can inspire others”
director colleagues will move on.”
was chosen by 48 per cent of respondents.

Behaviours and qualities / What makes a top medical director? 10/

 Identify the management approaches you consider
most important for the job

64% Not being afraid to have difficult conversations/honest dialogue

59% Holding collegues to account for their actions

59% Spending time networking and influencing

collegues to drive change

54% Being able to identify the most important factor

when faced with multiple factors

27% Prioritising

18% Spending time networking and influencing colleagues to drive change

9% Delegating clearly and insisiting on regular progress reports

9% Setting organisational pace by setting deadlines and applying pressure

0 20 40 60 80 100
% of respondents

Have your previous roles included any of the

following sectors?
46% Private sector (health)

31% Other public sector (outside health)

23% Other

15% Third sector (health)

8% Private sector (Non-healthcare)

8% Third sector (private state)

0 20 40 60 80 100

% of respondents

Behaviours and qualities / What makes a top medical director? 11/

Dr Robert Talbot, medical director at Poole Hospital NHS Listening well, is part of the communications process. Dr Christine
Foundation Trust, agrees that being a good communicator is a Blanchard, medical director at Salisbury NHS Foundation Trust,
critical quality. He says: “You have to be able to communicate says: “You’ve got to be a good listener and take on ideas even
well with people, be open to listening. I sometimes have to make if you don’t agree.” Professor Kevin Hardy at St Helens and
decisions that make me unpopular.” Knowsley Teaching Hospitals, says: “You need to be able to listen.
People will only get on board with a broader vision if they feel as
Bedford Hospital’s Dr Colette Marshall adds a further dimension though they are being listened to and are an active voice in the
to the challenge when she talks of the public-facing part of the process.”
role. “This is a relatively new aspect of the job that we are having
to get used to because many of us haven’t had much experience
communicating performance to the public,” she says. Dr Peter Compassion
Maskell of Kent Community Hospitals Trust agrees, saying the Compassion was also identified as fundamental leadership
external-facing role is crucial when getting patients and the public quality by many of those we interviewed. Dr Umesh Prabhu at
to buy into a future vision. Wrightington, Wigan and Leigh talks specifically about kindness
and compassion as way to engage more broadly with staff. “Staff
An example highlighted by the Leadership Framework is an really want to do their best. You need an organisation that has a
associate medical director who had to rely on his communications values-based staff body, which means that as a medical director
skills to ensure colleagues were implementing basic procedures you also need to be close to staff, praising them and acting
such World Health Organization checklists. The existing climate with kindness and compassion.” Other medical directors talk of
was one where staff failed to recognise the importance of the empathising with staff and patients and how this is now becoming
issue. The associate medical director used meetings to reinforce the driving force for change and transformation within the NHS.
the message, at which real stories could be shared to highlight
the impact of non-compliance on patients. The approach In Building and Strengthening Leadership – Leading with
resonated with the target audience and contributed to improved Compassion 9 NHS England says: “A leader displaying compassion
compliance data, with 95 per cent of WHO checklists being used will win the respect of staff and allow them to deliver good-quality
effectively by staff. care and feel more aligned with the organisation’s objectives. The
leader will be more credible, more authentic and more likely to be
followed.” It calls for leaders not to sit back but to take personal
action to push compassionate leadership beyond being merely a
worthy idea.

Behaviours and qualities / What makes a top medical director? 12/

 Which sector have your found most enjoyable to Which sector have your found least enjoyable to
work in? work in?

89% NHS 44% NHS

11% Other public sector (outside health) 22% Private sector (health)

6% Private sector (health) 11% Private sector (non-healthcare)

6% Private sector (non-healthcare) 11% Third sector (non-health)

6% Third sector (non-health) 11% Management consultancy

0 20 40 60 80 100 0 20 40 60 80 100
Percentage Percentage

Identify those qualities you consider make you most

suitable for your job
48% I have strong personal resilience

38% I am comfortable making decisions

38% I am good at listening

29% I encourage innovation and problem-solving in others

24% I am clear-thinking

24% I am good at talking/articulating a vision or ambition

19% I have advanced communication skills

14% I can admit when I’ve made a mistake

10% I can show humility

10% I am able to compromise

0 20 40 60 80 100
% of respondents

Behaviours and qualities / What makes a top medical director? 13/

 Using qualities and skills to create an
improvement culture
Research suggests that doctors have the most influence when it comes to implementing
operational changes that can lead to improved performance

In Engaging Doctors, Can doctors influence organisational Such engagement is relatively new for many healthcare trusts
performance? 10 the authors suggests failures in care are often and needs constant reinforcement and support so that trusts do
blamed on inadequate medical leadership, poor communication, not simply slip back into their old ways. It is here that the medical
disempowerment of staff and patients and a disconnection director can really help to drive improvements and culture change,
between doctors and managers. Without doctors, attempts at by gaining the respect of the staff and ensuring they are actively
radical, large-scale change are doomed to fail. Lord Darzi’s 2008 involved in any transformation.
review of the health system in England, High Quality Care for All 11,
makes the case for clinicians, particularly doctors, being more Simon Holmes is medical director at Portsmouth Hospitals NHS
engaged in leading service improvement. Trust. He says: “I think that people now recognise that the best
changes are clinically led because you won’t make any changes
Being able to engage others in service development means without clinical buy-in. In this hospital we set up a development
relying on finely tuned communications skills and being able to program for young consultants, which goes on for about six
inspire staff, whether this is by displaying integrity, honesty and months. The program develops young consultants in management
openness or by showing compassion. However, the results of the techniques, and gives them more knowledge on management
joint HSJ Hunter Healthcare Survey show that medical directors roles.”
still have some way to go to understand their impact in this
respect. Just 18 per cent of respondents said that they believed The Faculty of Medical Leadership Management has stressed
spending time networking and influencing external contacts to the importance of good communications skills when it comes to
drive change was an important management approach for their creating a culture of improvement. It calls on medical directors to
job. This may be because it is perceived as a one-way process be true leaders and show the leadership that patients deserve, the
and rather than expecting doctors to step up, the senior executive organisation needs and the profession expects. “Communicate,
team should be providing opportunities for doctors to play this communicate, communicate. Never underestimate the power of
important role in engagement. talking to people.”

Writing in the HSJ, the King’s Fund’s Vijaya Nath and John Clark Dr Peter Maskell says it is vital to be as responsive as possible.
say: “Medical engagement should be about changing the culture He says: “You need to make it obvious why you make decisions
of a practice, department, service, hospital or system, so that and communicate as much as possible.” Dr Maskell does this by
doctors are actively involved in management and leadership, and meeting teams regularly, writing a blog and going to departmental
executives genuinely encourage doctors to lead improvement meetings whenever he can. He feels that in some ways medical
initiatives. Essentially, it is about getting doctors to become more directors are so bogged down dealing with internal firefighting
like shareholders than stakeholders.” that they don’t have time for the bigger picture. He says: “Bring it
back to the patient and make it clinically focused, it’s as simple as
This, in turn, means they are also on a sound footing at that. If you put the patient first and actually mean it then people
management level and not just seen as a staff representative on will take it.”
the board, as suggested by some of the medical directors we
interviewed. Far from leadership and the improvement of health Good communication skills are useful in many respects, but
care being led just from the top and the trust board, the Medical particularly when it comes to ensuring the board is aware of poor
Leadership Competency Framework indicates that doctors need performance issues without creating a stir or a panic. This can be
to become more actively involved in the planning, delivery and a two-way challenge, with medical directors often being the first
transformation of health services as a normal part of their role in port of call when the board has a specific concern. Being able
today’s healthcare. to interpret data and explain them in a way that is meaningful is
therefore important. This is not always straightforward because it

Using qualities and skills to create an improvement culture /

What makes a top medical director? 14/
means exercising judgement in areas where the medical director
may not have expertise, but they still have to gain the confidence
of the board and the consultant body.
The Medical Leadership
Competency Framework
Cultural legacy
The Medical Leadership Competency Framework (see box) aims The Medical Leadership Competency Framework was
to ensure doctors become more involved in the planning, delivery jointly developed by the Academy of Medical Royal
and transformation of health services as a normal part of their Colleges and the former NHS Institute for Innovation
role. The aim of the framework is to change the culture of medical and Improvement, in conjunction with a wide range of
engagement and influence the next generation of doctors to view stakeholders. It describes the leadership competences
engagement and leadership as part of their working lives. that doctors need to become more actively involved in
the planning, delivery and transformation of healthcare
In common with this, the medical directors we spoke to hope to services.
leave a culture of improvement within the NHS. This means that
well as ensuring they leave a legacy of safe and improved patient While the primary focus for doctors is on their professional
care, they want to see doctors speaking about working for a given practice, all doctors work in systems and within
organisation, retaining a sense of pride in where they work and organisations. It is vitally important that doctors have a
the role they have there. Dr Philip Mitchell wants to leave his direct and far-reaching impact on patient experience and
organisation in a better state than he found it as one that is open outcomes. Doctors have a legal duty broader than any
to learning. other health professional and therefore have an intrinsic
leadership role within healthcare services. They have a
Through this cultural transformation we should see doctors more responsibility to contribute to the effective running of the
engaged in the running of their organisations and therefore organisation in which they work and to its future direction.
enabled to innovate and deliver the highest quality of care The development of leadership competence needs to be
possible. Dr Steve Evans says that as well as leaving behind an integral part of a doctor’s training and learning. The
something that is tangible and measurable, he would like to framework is intended as an aid and driver for this and to
see a culture that will allow this to carry on. He says: “I want to enable a doctor in the NHS to be a practitioner, a partner
leave behind a system with plenty of clinical engagement, getting and a leader.
doctors involved – it is really important that this continues.”

Dr David Fearnley is medical director at Mersey Care NHS

Trust. He leads on innovation work and has tried to build global
partnerships on innovation. He wants to bring in clinicians on
exciting programmes and to give people opportunities to do
something different. He is keen to leave this as a legacy and is
would like it to be carried on after he leaves.

I would like to lead by

example. I would like to
encourage people to follow
and build on the things I’ve
built up. I want someone to
succeed me and advance
my progress
Dr David Fearnley, medical director, Mersey Care
NHS Trust

Using qualities and skills to create an improvement culture /

What makes a top medical director? 15/
 Engaging staff in the strategic vision

The key to being a successful medical director and being able to drive change lies in
building successful relationships with staff

Research has found clear links between performance and good Coming in to an organisation as an externally appointed candidate
medical engagement. Poorly performing trusts report significantly can present some significant engagement challenges. Dr Celia
lower levels of engagement. Skinner observes that coming into any trust is not a blank slate
and there is often a series of difficult decisions required, including
The Kings Fund has found that the most important determinant sackings and other organisational reshuffles that are always
of an organisation’s culture is current and future leadership.12 unpopular – these decisions rarely leave anyone feeling engaged.
A collective leadership is crucial and everyone must take Added to this, the expectations of the board about what needs to
responsibility for the future of the organisation. Staff engagement be done can often be at odds with what a medical director wants
is critical to this and can be established with high levels of debate, to do.
discussion and dialogue to ensure that everyone understands and
can commit to improving healthcare. The Kings Fund has also Most of the medical directors we spoke with mentioned that
found growing evidence to show that there is a direct correlation credibility with clinical colleagues was underpinned by visibility
between medical engagement and clinical performance.13 and being accessible and approachable. Dr Tony Berendt echoes
this point, pointing out that you can’t achieve assurance through
The amount of effort needed to engage with medical colleagues reports and audits but through “physical presence and trust”.
and other staff will vary between trusts and often depends on
whether the director is an internal or external appointment and Dr Christine Blanshard at Salisbury seeks to improve engagement
also on the size of the trust. within her team through combined walkabouts with the chief
nurse in particular, demonstrating both a unified executive team
Being visible and available for staff are two very important areas and also an approachable model for leadership. Initiatives like this
to the directors we spoke to, yet if the director’s trust operates are mirrored by other medical directors we spoke to, each arguing
over several different sites, this poses a bigger challenge than for that communicating and engaging with staff was more effective
a medical director in a smaller, single-site trust. for establishing credible leadership over a clinical practice.

For a medical director who has been externally appointed, there is However, this physical visibility is not always possible, particularly
extra work to do to gain the trust of staff. Dr John Lowes at Torbay in larger organisations. Dr Celia Skinner reflects on her experience
and South Devon says: “Some of my colleagues would view as deputy medical director at Barts Health NHS Trust. She
someone coming from the outside with a high level of suspicion. says: “How can you really display effective, visible leadership
Consultants generally see professional medical leaders as a across seven sites?” Dr Andrew Catto, believes the only way to
necessary evil.” establish credible leadership across multiple sites is to delegate
responsibility to others effectively. “You don’t know what you don’t
He says an externally appointed medical director will need to rely know and you need to be comfortable with the unknown and trust
on a different skillset, needing to be more charismatic in order to the team,” he says.
attract and encourage followers without prior relationships. But
while internal candidates may not necessarily need to win people The most important element of delegating leadership is the
over, it is easier to develop collaborative leadership. The flipside sharing of values. A medical director can be equally as visible
of that, however, is that you have come out of the consultant body through the establishment of a collective set of values as they can
and it will be seen that you owe an allegiance to that body. through their physical presence.

Engaging staff in the strategic vision/ What makes a top medical director? 16/
One of the principal concerns throughout our interviews was the compassionate they contribute to a drift in culture that produces
impact of negative culture across NHS organisations in recent the disheartening results in the NHS staff survey.
years, leading to problems with staff engagement and creating Workload can be a limiting factor when it comes to fulfilling
more risks of harm. Many of the medical directors we spoke to the duties of the medical director, especially in terms of staff
insist the system – in its present incarnation – is restrictive with engagement. In the HSJ Hunter Healthcare survey, 62 per cent of
regard to the development of doctors. This system-wide malaise medical directors found workload to be a negative aspect of the
has, as Dr Conrad Wareham notes, caused a weariness within job. The endless list of items that require attention takes away from
organisations whereby the staff retreat from engagement and the time to commit to the wider networks and engaging staff.
are more liable to resist possible changes. To tackle this, he
argues, requires great persistence and resilience to reassure the Engaging the clinical workforce can also be hampered by dealing
workforce and get them on side. with difficult and sensitive cases and maintaining sufficient
engagement with junior colleagues to be in position to nurture the
According to the latest NHS Staff Survey, levels of staff next generation of leaders. This engagement is often made more
engagement have increased, but it’s not all good news – 41 per difficult as some clinicians struggle to see the bigger picture. Dr
cent would still not recommend their trust as a good place to Robert Talbot observes how delivering high-quality care needs
work and 57 per cent say they are unable to meet the conflicting the clinicians to be engaged in quality governance. Some medical
demands on them at work. Bullying is also still a factor, with directors have tried other ways to engage staff, such as getting
13 per cent of staff feeling that they have been bullied by their the more junior clinicians involved in serious incident reviews to
managers this year, while only 56 per cent say they feel that they give them greater insight into the wider challenges.
have been able to contribute to improvements at their trust.

Professor Michael West, head of thought leadership at The

Kings Fund, says in his blog: “Leaders play a powerful role
in shaping cultures and when their behaviour is less than Case study - Heart of England
NHS Foundation Trust
This compassionate style Dr Andrew Catto sees getting clinicians and staff onside
as crucial – and also one of the biggest challenges. At the
of leadership is required at Heart of England NHS Foundation Trust he ran a “Back to
every level of the system. Bullying the Floor” initiative, with executives spending some time
doing the jobs of porters and domestics. Although there
at senior levels, as we know, can were concerns that staff would think it was just a stunt,
the project was successful. By getting back to the floor,
be replicated up to five levels down executives got a sense of the procedures that staff had to
follow and also the standards of training.
in organisations. So compassion
Staff listening events also took place for medical staff. No
will similarly be replicated if it is doctors turned up to the first one and it was difficult to
established as the dominant style of get them engaged, but gradually the word spread and the
second event attracted around 130 of them. The events
interaction. Of course there are tough covered what they liked and didn’t like about working at
the trust and what they would do differently if they were in
situations to face alongside financial charge.

pressures, but then all the more He has also put a medical leadership programme in place.

reason for listening, understanding,

empathising and taking intelligent
action to help at every level”
Professor Michael West, head of thought leadership,
The Kings Fund

Engaging staff in the strategic vision/ What makes a top medical director? 17/
 Supporting the next generation of medical
directors
While the leadership culture is gradually changing within NHS trusts and clinicians are
coming to the fore as managers, it is still apparent that there is not enough support for,
or clear definition of, the role of medical director to encourage the next generation to
take up the challenge

Medical directors are often expected to take on a management director she had doubts about her legitimacy. She says: “It took
role without the necessary tools, such as proper management me a while to realise that there wasn’t someone saying you can
training, to do the job effectively and with confidence. Being and you can’t, and that I could just get on with things. I was
a good clinician doesn’t necessarily mean you will be a great constantly wondering if I was allowed to. Giving myself permission
manager. to do that was an important step forward for me.”

Doctors moving into leadership need to be given the same Monitor 8 suggests that those in the post of medical director
development opportunities and management training as their come to it to drive improvement to services and patient care on a
management counterparts – for example, around self-awareness, larger scale and to ensure a stronger clinical voice on the board
communicating with and leading with others, understanding across organisations and in local health economies. But for some,
their impact on others, working within teams and understanding building that stronger voice can pose a challenge, when even the
systems and processes in the context of the NHS. corporate or management language of the board poses a barrier.
Miss Jane Wilson, medical director of Kingston Hospital NHS
Many of the medical directors we spoke to describe an initial Foundation Trust, says there is a lot of management language
lack of confidence when taking on the role, as well as difficulty where you can understand the word but not necessarily the
in knowing how to resolve conflict. Despite the role of medical context, which can be an obstacle.
director being a pivotal one for every trust – ensuring engagement
between staff and the board to create a culture of improvement Dr Julie Hankin at Nottingham says: “More support should be
– the majority describe their experience as having learned on the given to prepare people for the post. How do you constructively
job. In terms of training, Dr Clive Meux says he didn’t really have challenge each other as executives while maintaining the feeling
any coaching and, although he had a range of mentors, there was that you’re still a team?” Her own experience was that it wasn’t
no leadership training so he “picked it up as he went along”. immediately obvious how to do that.

Some medical directors did have mentors or coaches, but According to the NHS Confederation14 new approaches are
many felt isolated, unsure how they were supposed to carry needed to ensure that the role of medical director becomes
out their job. Others felt they needed lessons in teamwork or a viable career. It suggests that if doctors are to be attracted
how to challenge board members successfully. HR issues too to senior management roles, more effort should be made to
involve specific protocols and guidelines, so the help of relevant communicate the positive aspects of the role to junior doctors
professionals is needed. – for example, highlighting to junior doctors that becoming
a medical director would give them the opportunity to shape
Dr Des Holden at Surrey and Sussex Healthcare NHS Trust says organisational strategy and improve patient care.
most aspects of the role are pretty intuitive, apart from those
relating to HR. He says: “I had difficulty with some HR issues While the job can be stressful with a high workload, medical
because lots of HR processes didn’t appear to be intuitive. You directors believe that they can and do make a difference to
need to make sure you have access to a good HR director. HR patient care. So why is it so difficult to encourage junior doctors
problems are the hardest to get right. They are the most energy on to the board? Dr Christopher Burton, medical director at North
sapping and challenging, and can last years.” Bristol NHS Trust, believes the problem lies within the system.

One medical director says that while she knew her competencies Dr Philip Mitchell believes that in order to have effective
as a clinician, when it came to taking up the role of medical recruitment you need to build the right jobs for talented people

Supporting the next generation of medical directors /

What makes a top medical director? 18/
 We need to encourage people to do the job. Doctors
have protected jobs for life. I hear this conversation
and an anxiety that medical directors have. Being a
doctor at senior level doesn’t give you skillsets to be a
director of a large company
Dr Christopher Burton, medical director, North Bristol NHS Trust

Supporting the next generation of medical directors /

What makes a top Medical Director? 19/
to flourish in, with effective coaching – not just for the executive According to Monitor the role of medical director is critical to
team but for people in all different levels of leadership. His delivery of a revamped, effective and responsive healthcare
community hospital is in a rural area and he says there is no and will gain more importance in the years ahead. It suggests
significant pool of candidates because of the low number of that those entering the role will need increasing support and
doctors. “Currently there is no obvious framework for support into development as it continues to change.
the medical director role. We need effective deputisation but this
needs time dedicated to development and will detract from key This need for support has not been entirely ignored and it seems
clinical time.” measures are being put in place in many trusts now to ensure
medical directors no longer feel alone or isolated in their post.
The NHS Confederation has found that the role of the medical Many of the interviewees spoke of nurturing and mentoring
director is extensive and in some cases could be too much for one clinicians to ensure they are there to provide support and ready to
person. It suggests that the level of support provided is crucial to take over in the role.
determining effectiveness, including everything from high-level
support from other managers and associate directors to basic One medical director says: “I am interested in nurturing clinical
back-office and admin support. However, little has changed since colleagues because I’m struck by the fact that at the trust where
the NHS Confederation published its findings in 2009. I work in, three of my predecessors were external. It makes me
worry that we’re not developing medical directors in our own
The findings of the HSJ Hunter Healthcare survey back up the organisation. I do think there are people within the organisation
assertion made by these medical directors about the lack of who need the development to become our leaders of the future.”
support. While 59 per cent of medical directors surveyed say they She says the trust has introduced active recruitment for medical
felt supported by colleagues and the wider system, 14 per cent directors whereas previously they were simply appointed.
feel they get no support at all.
Dr Clive Meux also says that his trust focuses on nurturing
leadership with succession planning with a deputy. “You need to
Compared with many other put effort and energy into that deputy as they will be appointed
your successor. I have someone younger than me who I have
executives, you don’t have a mentored and who wants to be chief executive. We have
huge team working for you. The chief appointed three associate clinical directors and clinical associate
medical directors alongside associate medical directors. It helps
operating officer, director of nursing with succession and if they want to step up.”

and HR all have big teams, whereas Dr Robert Talbot says that while there was no coaching or
mentoring for him in the early days, the trust now looks out
I have four part-time associate for people who are potential leaders and sends all clinical
directors onto the organised Kings Fund training programme. Dr
directors. Producing the work for Andrew Catto thinks it is vital that doctors secure management
the board is difficult and it’s really qualifications at an early stage, which so far isn’t covered in
normal training.
hard to feed the beast. Ideally, I need
At his trust Dr Andrew Catto has put in place a medical leadership
more people reporting to me programme and has set up a collaboration with Warwick Business
School. Currently there are 140 staff on the course, not just junior
Dr John Lowes, medical director, Torbay and South Devon NHS doctors but also more senior leaders, including himself. He has
Foundation Trust also expanded his leadership team and currently has three deputy
medical directors and five associate medical directors. He says: “It

Supporting the next generation of medical directors /

What makes a top medical director? 20/
is a big medical leadership structure but it needs to be in such a The underlying message is that medical directors are creating
large trust. There is plenty of deputisation.” opportunities to engage clinicians and get them involved in
innovation and change. The challenge in this regard is creating
But there are those who feel that, although change is being made, a space for leadership training into the job portfolios while
it’s not happening quickly enough and more needs to be done. balancing out an already-stretched roster. The challenge for the
Dr Celia Skinner feels a more systematic approach is needed. medical director is to ensure the organisation can fulfil its duty of
She says: “We need a process and a job description. There isn’t care to the patients while keeping an eye on future care delivery
enough management in the curriculum for SPR training and there by investing time and resources on the next generation of clinical
is pretty much none in undergraduate training. Given there is leaders.
likely to be a leadership involved in these roles it is important that
training starts early, which it currently doesn’t.” It is no surprise that given the pressures of the job in terms of
workload and ensuring patient safety, some medical directors feel
Dr Umesh Prabhu believes proper leadership skills are vital and their only legacy could be to get out unharmed or to make sure
wishes he had had more advice and training before taking on the that the organisation didn’t hit the buffers on their watch. Part
medical director role. He would have liked to have more support in of the legacy also looks towards future appointments. Dr Umesh
how to be a team worker and inspire others. He now offers eight- Prabhu wants to see greater focus on more qualitative skills
day training courses for his staff. more than purely technical abilities. This process would be more
effective in bringing in clinicians who are more in line with the
He says: “Fundamentally we appoint leaders because they come values of the organisation overall but also to offer a better means
forward but we need to support leadership training and feedback. of identifying future leaders. As Dr Prabhu says: “The best leaders
We also need better role models – at the moment people look don’t always want to be leaders.”
up and think ‘I’m not like that’. The cultural barrier needs to be
overcome and we need to break down that medical-management
divide.”

He adds: “We are appointing for technical skills not for values and
leadership skills. Consultants who are leaders often don’t want to
be leaders. There aren’t enough medical directors being nurtured
into their role.”

It has been suggested that the UK can become an exemplar in

medical leadership and development, with international research
showing that few countries have made more progress than the
UK. However, Dr Conrad Wareham says he found a vast difference
in the approach to leadership training during a four-year stint in
Australia.

As medical director of a network of hospitals in Adelaide, he

was provided with a leadership training programme by the Royal
College of Medical Administrators. He says: “In Australia there is
a specialist register for those who enrolled in the Royal College
of Medical Administrators. I had a college-appointed mentor and
a personal mentor and both were quite truly inspirational in me
developing my style of delivery.”

Supporting the next generation of medical directors /

What makes a top medical director? 21/
 Conclusion

Our interviews and the results of the

HSJ Hunter Healthcare survey have
sought to establish what makes a top
medical director. We have found that
the role is unlike any other within the
NHS and varies from one organisation to
another. However, that hasn’t prevented
us from finding common qualities,
behaviours and skills exhibited by the
best medical directors

We know that qualities such as personal resilience, integrity,

honesty, openness and the ability to communicate effectively
are all important, but it is how these different ingredients are
brought together by successful medical directors that makes the
difference.

Top medical directors are able to engage staff, the board and
patients by taking them on an improvement journey that more
often than not leads to a cultural change within the organisation.
This improvement culture is sustainable and reaches every layer
of the organisation.

However, we also know that even the best medical directors need
support and that the next generation needs to be encouraged and
nurtured. Medical directors have told us about the mistakes of the
past, which have included a lack of support and being appointed
simply because they are considered bright.

There is plenty we can do to support our medical directors. We

have to create a situation where the roles are considered credible
career routes with a future that is inspiring enough to attract new
talent. The role is too critical for the future of the NHS for this call
to be ignored any longer.

Conclusion / What makes a top medical director? 22/

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Trust Public Inquiry. F rancis R, 2013 2014

2/ Report of the Morecambe Bay Investigation. Kirkup, B, 9/ Building and Strengthening Leadership – Leading with
2015 Compassion. NHS England, 2014

3/ 
The Changing Roles of Medical Directors. Kratz, S, 10/ 
Engaging doctors. Can doctors influence organisational
American College of Physician Executives, 2007 performance? Enhancing engagement in medical
leadership. Hamilton, P, Spurgeon, P et al, 2008
4/ 
The seven habits of emerging medical leaders. Warren,
O and Stanton, E, 2012 11/ High Quality Care for All. Darzi, A. 2008

5/ Faculty of Medical Leadership and Management: 12/ 

Developing collective leadership for health care. The
Transitions – Medical Director, 2012 King’s Fund, 2014

6/ 
Medical Leadership Competency Framework. Academy 13/  edical engagement – a journey not an event. The
M
of Royal Medical Colleges and NHS Institute for King’s Fund, 2014
Improvement and Innovation, 2010
14/ The Future of Leadership: the role of the trust medical
7/ Leadership and Management Standards for Medical director. NHS Confederation, 2009
Professionals. Faculty of Medical Leadership and
Management, 2015

References / What makes a top medical director? 23/

WHAT MAKES A TOP MEDICAL DIRECTOR?
/ 2016

PART OF HUNTER HEALTHCARE’S INSIGHT FOR SENIOR NHS LEADERS SERIES 2016