Clinician in Management (2005) 13: 111–14 # 2005 Radcliffe Publishing

Editorial

Clinical leadership: an oxymoron? Hilary Thomas MA PhD FRCR FRCP Medical Director, Royal Surrey County Hospital, Guildford, Surrey, and Professor of Oncology, University of Surrey, UK

The concepts and principles of leadership are generic. The characteristics of truly great leaders are the same whether they are doctors, politicians, chefs, teachers or chief executives. The ideas in this paper are drawn from my own experience and observations, my reading of the literature and an inspiring week spent at Harvard Business School on a course entitled ‘Strategic Planning for the Non-Profit Sector’. I have set out my template for the generic leader and the impact they can have on organisations. I will then consider how this might be relevant in medicine – whether you view yourself in a silo or delivering a firstclass service across organisational boundaries. One of my Damascene moments in recent years was the Harvard Business Review Paper, ‘Level 5 leadership: the triumph of humility and fierce resolve’ (Collins, 2001). Collins was interviewed in the second edition of In View, the journal produced by the NHS Institute for Innovation and Improvement ‘for senior leaders in the NHS’ (Dearlove, 2004). Collins operates a management research lab in Boulder, Colorado, and has published widely on leadership, particularly in relation to companies. In this landmark paper Collins studied 1435 Fortune 500 companies, to find that only 11 achieved and sustained greatness. The latter was defined by achieving stock returns at least three times those of the markets for 15 years after a major transition period. These 11 companies had one thing in common – a ‘Level 5’ leader in charge. Level 5 leaders exhibit the paradoxical combination of deep personal humility with intense professional will. This is a rare combination and defies our assumptions about what makes a great leader. I now understand that Collins’ paper is famous among the cognoscenti. It is written about the business world and cites examples of company chief executives in the context of what ‘catapults a company from really good to truly great’. However, in my view, the principles apply just as well to an acute hospital or a large GP practice as they do to a company. In the paper, Collins describes a number of Level 5 leaders, but perhaps the one who stands out is Darwin Smith, Chief Executive at the paper products manufacturer Kimberley Clarke from 1971 to 1991. He was a shy, awkward individual who was not comfortable in the

spotlight but showed iron will and complete determination in re-designing the firm’s core business, despite scepticism from Wall Street. As a result, Kimberley Clarke became the world leader in its industry, generating stock returns 4.1 times greater than that of the general market. Smith started life as the company’s in-house lawyer and was never convinced that the Board had made a wise choice in appointing him as CEO. However, he clearly led his company ‘from good to truly great’. This, in spite of the fact that very few students of business would even have heard of Darwin Smith. Level 5 describes the highest level in a hierarchy of executive capabilities identified during Collins’ research. Leaders at the other four levels can produce high degrees of success, but not sufficient to move their companies from mediocrity to sustained excellence. Level 5 leadership is not the only requirement for transforming a good company – other factors include getting the right people on the bus (and the wrong ones off the bus) and creating a culture of discipline. It is, however, an essential component of this transformation. Collins also points out that Level 5 leadership is counter-intuitive and counter-cultural. It would generally be assumed that ‘good to great’ companies require larger-than-life leaders. When Darwin Smith was asked in an interview to describe his management style, after a long and uncomfortable silence, he finally said, ‘eccentric’. As a result there were no flashy Wall Street Journal features about Darwin Smith. He grew up on an Indiana farm and put himself through night school at Indiana University by working through the day. He eventually earned admission to Harvard Law School. When he first took over Kimberley Clarke, he and his team concluded that the traditional core business of coated paper was doomed, but that the consumer paper products business had a greater future. He announced that Kimberley Clarke would sell its mills, including its namesake mill in Kimberley, Wisconsin, and invest in the consumer business with brands such as Huggies1 nappies and Kleenex1 tissues. Wall Street analysts downgraded the shares as a result but Smith never moved in his resolve. Twenty-five years later Kimberley Clarke had bought Scott Paper and beat Procter &

111

H Thomas

Gamble in six out of eight product categories. Reflecting upon his performance in retirement, Smith stated, ‘I never stopped trying to become qualified for the job’. Another example of a Level 5 leader cited by Collins is Abraham Lincoln, who ‘never let his ego get in the way of his ambition to create an enduring great nation’. So are great leaders created or born? There are a number of other factors that Collins cites as being important for Level 5 leaders. The disciplines required are to attend to people first and strategy second. Deal with the facts of your reality, keep absolute faith, and you will prevail. Level 5 leaders need the determination to keep pushing until they break through. They also need to adopt the hedgehog concept. This entails deciding what your organisation can be best at, thinking how its economics work best, and defining what ignites people’s passions. This is based on an essay by Isaiah Berlin, in which he described two approaches to thought and life using a simple parable. The fox knows a little about many things, but the hedgehog knows only one big thing very well. The fox is complex, the hedgehog simple, and the hedgehog wins. A simple hedgehog-like understanding of three intersecting circles, what a company can be the best at in the world, how its economics work best and what best ignites the passions of its people. When you get the hedgehog concept and become systematic and consistent with it, you can eliminate virtually anything else that does not fit in the three circles (see Box 1).

Box 1 The hedgehog concept What can your organisation be best at? How its economics work best What ignites people’s passions Eliminate everything else!

An important aspect of the behaviour of Level 5 leaders is that they are inherently humble. They look out of the window to apportion credit, but invariably in the mirror to assign responsibility, never citing bad luck or external factors when things go badly. In Collins’ study the executives who did not achieve Level 5 frequently looked out of the window to apportion blame, but preened themselves in the mirror when things went well. Level 4 leaders tend to have huge egos, which they can’t subjugate. One other important insight for me was a plenary lecture by the management guru Rosabeth Moss Kanter, towards the end of my Harvard week. Her recently published book entitled Confidence: how winning and losing streaks begin and end draws on numerous examples of success and failure from the world of sport (Moss Kanter, 2004). 112

Rosa Beth is a rather unusual individual. I understand that when asked to speak to a group of teenagers in a Boston School, she gave her entire talk in rap! Her book concentrates on how winning streaks and losing streaks become self-perpetuating. On 14 August 2003 the North East Power Grid in the US went down for two days. Most of the major American airlines had to cancel huge numbers of flights. American Airlines cancelled 200; North West Airlines cancelled 180 flights. However, this crisis became an opportunity for Continental Airlines. They cancelled fewer than 30 flights and were able to accommodate passengers from JFK who had intended to use other airlines. As a result they made $4 million on each of these days because they had an ability to shift their resources to the field. Over the previous few years, they had transformed themselves from a losing to a winning streak organisation. Moss Kanter states that when chief executives leave winning organisations, if they are really working, they will have built leaders in their wake in order to have a succession plan. Taking Level 5 leadership as a starting point for the clinical leader, we clearly face other significant challenges in the health service in forthcoming years. There has been significant investment in the NHS recently. Some of this has gone into higher pay and an increased number of staff. The NHS Confederation and Sir Derek Wanless would argue that much of this has been to compensate the chronic under-investment in the 1980s and 1990s (Wanless, 2002). Nevertheless, a service which is free at the point of delivery and based on taxation for funding will challenge parties of any colour, especially given the geometric growth in healthcare innovation and the increasing costs of interventions when investment can only grow arithmetically. A recent salient example has been the dramatic improvements in survival of women who are HER2 positive, and who receive Herceptin before the development of widespread disease. The cost of this nationally is likely to exceed the total budget for cytotoxic chemotherapy back in the mid-1990s. There will be other Herceptins, other landmark treatments and increasing numbers of patients for whom they are suitable. In order to afford this in the future we will need patients to engage with their health, and a greater focus on prevention, wellness and health promotion rather than our current medical interventional model. The NHS will need to be more flexible in its decision-making processes and able to respond to progress in a timely manner and by making very real choices about prioritisation. This healthy tension between competing goods – optimal treatment for the individual and healthcare, which provides the greatest health gain for the population – is a tightrope which doctors have to walk on a daily basis, especially in management roles. If we are fortunate enough to develop a fully engaged model of healthcare, then the clinical leaders

Clinical leadership: an oxymoron?

of the future will not only have to engage their own staff but also their patients (Wanless, 2002). Putting staff first and strategy second requires recognition of and reward for staff for their contributions. It takes time to meet and function well as a team, it requires useful and relevant feedback on performance and, ultimately, the culture of a successful organisation should motivate the individual to always look for ways to improve. Clearly there are different types of leader. The historic Churchillian leader, who inspires and has vision and charisma, is often described as a distant leader. In the NHS we need more nearby leaders who have particular interpersonal skills, are human and empathic. But whatever the type of leader, fundamental characteristics include honesty and integrity (see Box 2). Human systems are also much better at promoting vertical leadership mechanisms, but the need for a flexible, even subtle, NHS in the future will require greater investment in horizontal structures, such as networks. Vertical systems are hierarchical and usually transactional. They lead to a focus on buildings or silos. Horizontal systems, such as clinical networks, can be transformational. They tend to be more empowering and more likely to lead to a focus on services. With greater plurality and diversity of provision and an increasing focus on the importance of commissioning, a focus on the patient pathway rather than the building is going to be very important. In the words of WH Auden: ‘Let us honour if we can the horizontal man, though we value none but the vertical one’. (Daily Telegraph, 2005) Box 2 Characteristics of different types of leader Distant leaders Vision Charisma Inspiration

Nearby leaders Interpersonal skills Human Empathic

Honesty and integrity above all for all leaders

Beverley Alimo-Metcalfe has developed a model of transformational leadership which has been written about extensively. This is set apart from many models of leadership in not being focused on the US, or the leaders themselves, and not being based on distant leaders or the usual white male model, which is so widespread. For the work, she interviewed 150 men and women in the NHS and local government and over 60 doctors. From over 2000 constructs of leadership identified, she developed a questionnaire which was distributed to more than 600 organisations. There were responses from 2000 NHS organisations and 1400 in local government. The dimensions of the

‘best’ leaders are set out in Box 3, but included genuine concern for others, empowering others to lead, being flexible, approachable and accessible, as well as prepared to take risk, encouraging a challenge of the status quo and managing change sensitively and skilfully (Alimo-Metcalfe and Alban-Metcalfe, 2001).

Box 3 Dimensions of the Alimo-Metcalfe model .

Genuine concern for others

.

Inspirational communicator, networker, achiever

.

Empowers others to lead

.

Transparency, integrity

.

Accessible, approachable and flexible

.

Decisive, determined and prepared to take risk

.

Clarifies individual and team direction

.

Team orientated to sharing crises, problems and values; engages

.

Unites through a joint vision

.

Inspiring others

.

Encourages challenge of status quo

.

Supports a development culture

.

Analytical and creative thinker

.

Manages change sensitively and skilfully

Perhaps some of the important challenges requiring leadership skills in medical leaders are the tensions in the medical management model. Doctors with management roles are often regarded with suspicion by their peers and yet not seen as credible managers by their executive colleagues. A challenge for all of us in the health service is the endless cycle of structural change. For most doctors change is not a welcome way of life, and for the medical leader holding this together and averting the rise of cynicism can be difficult. Structural change may not disrupt medical careers as much as managerial ones (unless perhaps you are in public health!), but it does mean regularly having to forge new relationships. As medical leaders we need to foster change first and then an ability to change. As our ability to intervene and divert the health trajectory increases we must be careful to keep an eye on the big picture. The attraction of new technology and the ‘boys’ toys’ aspects of medicine, alongside the subliminal influence of the pharmaceutical industry, must remain counterbalanced by the more anodyne challenges of prevention, health promotion and self-care. The system may not be geared up to rise to the occasion and it will take real medical leadership to ensure that the health of the nation remains firmly in our sights. 113

H Thomas

To quote Sir Cyril Chantler (1999), former Dean of Guy’s and St Thomas’ Medical School and Chairman of the King’s Fund: Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous. The mythical authority of the doctor used to be essential for practice, now we need to be open and work in partnership with our colleagues in healthcare and with our patients. All of this requires an adaptability and receptivity to change which was perhaps less essential 20 or 30 years ago. Take the development of new provider services, the greater ability to intervene along an individual’s health trajectory, and the increasing need to consider prevention. For this to really work at the level of individuals, organisations (silos) or, better still, pathways of care, we need a real ability to engage clinicians as well as promoting and fostering the medical leaders of tomorrow. Cultivating clinical engagement requires a range of qualities – most of which are generic leadership skills. Of these, clearly trust is vital, which stems from honesty and credibility, along with communications skills and a wish to provide information and keep people in the loop, and allowing clinicians to own the problems and thereby proffer the solutions (see Box 4). This will need skilled bottom-up management, which enables the organisation to work cohesively, without the distraction of the ‘us and them’ mentality which is so rife in the NHS. Taken in the round, change is a constant challenge for the medical leader – but that is the easy bit; it’s sustainability that will ultimately transform what we do, and that takes far more time and skill. Whether the clinical leader is trying to inspire a group of disaffected doctors with a modernisation initiative

114

Box 4 Characteristics of a medical leader .

Trust – integrity and credibility

.

Communication

.

Information, involvement

.

Ownership of the issues

.

Bottom-up management skills

which requires their engagement, or helping the Board to understand the tensions of integrated governance, these leadership qualities are essential.

References Alimo-Metcalfe B and Alban-Metcalfe J (2001) The development of a new Transformational Leadership Questionnaire (TLQ). Journal of Occupational and Organizational Psychology 74: 1–27. Auden WH (date) reference to come from author. Chantler C (1999) The role and education of doctors in the delivery of healthcare. The Lancet 353: 1178–81. Collins J (2001) Level 5 leadership: the triumph of humility and fierce resolve. Harvard Business Review 79 (1): 66–76, 175. Daily Telegraph (2005) Auden’s Salute to the all rounder. Daily Telegraph 23 April. Dearlove D (2004) Explaining the numbers. In View, The Journal for Senior Leaders in the NHS 2: 9–11. Moss Kanter R (2004) Confidence: how winning and losing streaks begin and end. Crown Business: New York. Wanless D (2002) The Wanless Report: securing our future health. The Public Enquiry Unit, HM Treasury. Available at: www.hmtreasury.gov.uk/wanless (accessed 29/12/05).

Correspondence to: Professor Hilary Thomas, Royal Surrey County Hospital, Guildford, Surrey GU2 7XX, UK. Tel: +44 (0)1483 51122 ext 6823; fax: +44 (0)1483 406813; email: [email protected]