Clinical leadership: individual advancement, political authority, and a lack of direction?

The Review 'No amount of competencies, skills, authority, or inspiration will make leadership good if it leads us off a cliff. A moral compass is essential ...' 'Doctors and leadership: oil and water?' asked Richard Smith, before he became editor of the BMJ. 'Doctors have problems with leadership, both leading and being led,' he pointed out, quoting Leadership Professor Warren Bennis: 'leading doctors is like herding cats.' 1 Only a few years ago, the question of whether doctors should be doing more to lead the NHS was still open to debate. 2 Questions are no longer asked about whether doctors can or should do leadership. Since Ara Darzi's 2008 NHS Review emphasised the importance of 'leading change in the NHS' and 'fostering leadership for quality' 3 leadership has appeared with increasing prominence in medicine's clinical and political rhetoric. Competency frameworks and an industry of medical education have been constructed to support a standardised model of leadership. The Health and Social Care Act and discussions surrounding it have further influenced the concept and promotion of clinical leadership. However, questions persist about what leadership actually means in medicine. This essay suggests that the morality of leadership and the direction of progress have been overlooked. OLD-FASHIONED LEADERSHIP IN PATIENT CARE Clinical leadership once described the role of clinicians implementing hands-on change and improvement in clinical practice (for instance, implementation of hospital information projects, 6 management of stroke, 7 and interventions for specific patients 8). A 2005 BMJ editorial on the theme of patient safety, for example, asserted that 'basic errors in clinical care' arise from the insufficient contribution of experienced staff, insubstantial support of junior doctors, and 'inadequate time devoted to team-building': clinical leadership was advocated as the solution to these problems. 9 The theme was elaborated by correspondents who emphasised the value of teaching leadership and helping doctors 'understand the impact of their behaviour and actions on the team'. 10 Another letter-writer advised: 'What is required, however, is not the leadership beloved of politicians, where bullish confidence and decisiveness, often in the face of considerable opposition, are the order of the day. Rather, an atmosphere of trust in the clinical team is needed ...' 11 This discourse and its implied definition of clinical leadership (trust-engendering, team-building leadership-within-the-clinic) no longer pertains: the 'leadership beloved of politicians' prevails. An individualistic, hierarchical, and highly-politicised notion of clinical leadership has been created alongside proposals for reconstruction …