Improving the performance of health services: the role of clinical leadership.

VIEWPOINT Reform of health-care systems in the past decade has been driven by ideas such as public/private partnerships, managed competition, managed care, and integrated care. These abstractions betray the grand nature of ambitions harboured by reformers. Faced with funding pressures on the one hand, and failures of service delivery on the other, policymakers have entertained radical solutions in the hope they will lead to improvements in health-system performance. In practice, reform has generally fallen short of both rhetoric and expectations, leading to reappraisal of the strategies pursued and a search for new policies. The failure of radical solutions stems in part from their limited effect on clinical practice. Improvement of the performance of health care depends first and foremost on making a difference to the experience of patients and service users, which in turn hinges on changing the day-today decisions of doctors, nurses, and other staff. Reforms based on ideas like managed competition and integrated care might have some effect on clinical decisions, but in professional organisations like hospitals and primary-care practices, many effects on decision-making exist. In these organisations, policies initiated by health-care reformers have to compete for attention with established ways of working and other imperatives, which may result in a gap between policy intent on the one hand and delivery on the other. A key feature of professional organisations, as Henry Mintzberg noted over 20 years ago, 1 is that professionals have a large degree of control. As a result, the ability of managers, politicians, and others to influence decision-making is more constrained and contingent than in other organisations. Thus, ways have to be found of generating change bottom-up, not just top-down, especially by engaging professionals in the reform process. This includes recognition of the importance of collegial mechanisms in professional organisations and the role that leaders from professional backgrounds themselves can have in bringing about change. Mintzberg's insights into the nature of professional organisations have been reinforced by studies of the effect of quality-improvement initiatives in health-care organisations in several countries, and we now draw on findings of these studies to explore the challenges entailed in improvement of performance. Accepting that influences on clinical practice are many and varied, 2 no one approach to improvement of performance is likely to be sufficient. incentives. 3 In many of these interventions, clinicians need the time and space to review established practices, and to introduce new and more effective …