The diagnosis was clear: if we want to do all we can to improve the nation's health, doctors and other clinical professionals should be more involved in the management of the UK's health services. But while Chris Ham, chief executive of the King's Fund, remarked recently that clinical leadership had moved from the "dark side to centre stage", there is still much to do.
The UK has one of the lowest proportions of clinically qualified managers of any health system – 58% compared to 74% in the US and a startling 93% in Sweden. This is surprising given that persuading doctors to become more involved in management has been an explicit policy goal in this country since the Griffiths report came out in 1983. Nearly 20 years later, the NHS Next Stage Review commissioned by Lord Darzi said: "Leadership has been the neglected element of the reforms of recent years. That has to change."
This has led to attempts to create a mixed economy of clinical and non-clinical senior managers in the NHS, with doctors on the shortlist for all future chief executive appointments. The medical profession itself supports change, requiring that all undergraduate and postgraduate courses incorporate a new medical leadership competency framework'. Meanwhile, the Royal College of Physicians has said the time has come to acknowledge the "corporate responsibility" of doctors and foster "complementary skills of leadership and 'followership' at all levels".
Also clear is that clinical leadership can pay dividends. This is suggested by new research from Leeds University Business School. We looked at the boards of English NHS acute trusts between 2005-06 and 2008-09 and found trusts with a high proportion of doctors on their boards were also those that performed best.
The average size of trust boards was 12.45 directors in 2008-09, the largest having 17. Overall, clinicians accounted for just over 26% of director (executive and non-executive) posts in English trusts in 2008-09, and 23% of those trusts had a clinician as their chief executive.
We wanted to know what difference the presence of clinicians on these trust boards really made to their performance. Using publicly-available information, including data from the Healthcare Commission and the annual national patient survey, we tested whether there was a relationship between having more clinicians on the board and better quality outcomes.
As part of the study, we tried to rule out other factors that might influence hospital performance, such as hospital size, status, number of admissions, length of stay, percentage of bed occupancy, number of staff and the average age of patients. We also looked into whether high performance levels were explaining the presence of clinicians on boards, rather than the other way around.
Our results were startling. Trusts that achieved the highest ratings were those that on average had the highest shares of clinicians (27%) on their boards. This was especially true with regard to doctors. Indeed, we found that increasing the proportion of doctors on boards by only 10% made it 10% more likely that a hospital trust would achieve a maximum performance rating of four.
We then looked at hospital standardised mortality ratio (HSMR) statistics and found that lower patient mortality rates were recorded in hospital trusts that had a higher proportion of doctors on their boards. We also tested what the patients themselves thought, and once again, hospital trusts with a greater ratio of medical professionals were those that achieved higher satisfaction scores from their patients.
The focus of our research was on clinical leadership roles at the most senior levels and not on what happens lower down within organisations. Our results also don't explain why having more doctors involved in executive boards makes such a difference. One can hypothesise that this will have much to do with their expertise and credibility, helping to improve both the content of decisions and the likelihood they will be implemented – although more research is clearly needed.
But our study makes it possible for the first time to quantify the benefits for patients and taxpayers of having greater medical involvement in management. If anything, one might say that previous claims about the contribution of clinical leadership may have been understated. Even a modest increase in the number of doctors on boards can have marked consequences for performance, including patient wellbeing and satisfaction. Nearly 30 years on, the case remains as strong as ever.
Professor Ian Kirkpatrick is professor of work and organisation and Dr Gianluca Veronesi is a lecturer in accounting and finance. Both at Leeds University Business School
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