From white coat to grey suit: should more clinicians manage the NHS? – with Dr Stephen Swensen and Dr Dominique Allwood Episode 23 of the Health Foundation podcast

Episode 23|24 August 2022|40 mins

About 1 mins to read

In meeting the huge challenges facing the NHS, technology is often looked to as the great hope. Yet studies suggest good management is a more active ingredient for success.

Over the years numerous reports have called for more clinicians to manage the NHS, highlighting their deep knowledge of clinical care, and insight and credibility to make effective change.

Now, over a third of all NHS chief executives hold a clinical qualification and about a third of jobbing clinicians have part-time management roles too. But that’s still only a third, and getting trained in management is patchy and haphazard – a finding echoed in the recent Messenger Review of health and social care leadership.

How can we support more clinicians to manage the NHS, and learn from those who already do it well?

To discuss, our chief executive Dr Jennifer Dixon is joined by: 

  • Dr Stephen Swensen, Senior Fellow at the Institute for Healthcare Improvement. Stephen worked at the world-leading Mayo Clinic in Minnesota for three decades, overseeing the development of over 4,000 physicians and 200 leaders. 

  • Dr Dominique Allwood, Chief Medical Officer and Academic Health Science Network Deputy at UCLPartners, where her focus is on clinical engagement and management. Dominique is an experienced medical leader and an expert in quality improvement.

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Jennifer Dixon: In meeting the huge challenges ahead on the NHS, tech is looked to as the great hope. Yet studies suggest it is good management that is a more active ingredient for success. And studies also suggest that core business experts, that is clinicians, should be in charge. Why is that? They have deep knowledge of clinical care and the insight and cred to make effective change. I've lost count of the number of reports calling for more clinicians to manage the NHS. And now over a third of all NHS chief executives are clinical and about a third of job clinicians have part-time management roles too. But that's still only a third, despite the huge talent on the shop floor, getting trained in management is patchy and haphazard, nothing like the training to be a doctor or nurse. It's almost ‘do it yourself’ according to a recent survey we carried out at the Health Foundation. And this was a finding echoed in the recent wider review of NHS management and leadership by Gordon Messenger and Linda Pollard. We've got to do better than this and learn from those who do it well. So how? Well, with me today to discuss all this, I'm very pleased to welcome Dr. Steve Swensen, who for three decades had serves patients at the Mayo Clinic based in Minnesota. Among many other achievements, Steve oversaw the development of over 4,000 physicians and 200 key leaders at Mayo. He's also senior fellow of the Institute for Health Improvement. And Dr. Dominique Allwood, who is chief medical officer at UCL partners and deputy at the Academic Health Science Network there, her focus is on clinical engagement and management. She's worked in healthcare for 18 years in various leadership management and advisory roles. And Dom is also an expert in quality improvement. Welcome both. And I think the first obvious question is why would more clinicians managing health services be a good idea? What's the evidence here, Dom? 

Dominique Allwood: So I think there are a number of reasons why having clinicians skilled in management is an important part of their role in the health service. I remember starting my job as a junior doctor and not knowing anything about how the organisation was structured, how things were paid for, I don't think I talked about money for about the first 10 years of being a doctor. How the workforce comes in, how they stay in the organisation. So for a number of reasons, I think people having an understanding and some knowledge and skills in management is a good thing. Then there becomes a sort of pyramid and thinking about how people move up that into hierarchical positions in management. And I guess we can talk about different stages of career and training, but for particularly at the CEO level, I think we see a number of clinicians sitting in that CEO role, but many less doctors than nurses. I think that the great thing about having clinical leaders and managers is that they get to see the decision through a clinical lens, they have real credibility, empathy, authority to speak on behalf and with their clinical colleagues, there's often a lot of trust and people report being led and managed by clinicians, being clinicians themselves is really helpful, important. There are some flip sides to that, I don't know whether you want me to go into those Jennifer -  

Jennifer Dixon: Yeah, go on. 

Dominique Allwood: Well, I think really because you are a clinician, it doesn't automatically make you a good manager. Now nurses get a lot more exposure to this early on in their careers, they often manage a budget and people on their ward. Whereas I've mentioned doctors don't have that experience. But really just because you are a clinician, doesn't automatically give you the skillset and the knowledge about how to do management well. So I think there is a level of needing to have that development and training that comes with it. And we can't just assume that because people have good relational skills and they have empathy and they understand the core mission and purpose that is enough in management, both for clinicians, I think, and also non-clinicians in management too. 

Jennifer Dixon: I mean, just as a background there, and Steve might be interested in this, to say that the current chief executives who are clinically trained, 63% are nurses, 19% are doctors, 4% pharmacists and 11% is others, which I suspect is quite different in the US. So you are right, Dom, it's mostly in nursing rather than physicians. So back to Steve and the Mayo, why are clinicians managing such a good idea and what's the evidence there? 

Stephen Swensen: So, Mayo is a physician-led organisation. We started 160 years ago with William Worrall Mayo, who is an English man that immigrated to America, and his Scottish wife, Louise. So, we've had some practice of this for 160 years. When I look at this, I ask myself just this question about one of the best symphonic orchestras in the world, the London symphony orchestra. And could we imagine the best conductor for these musicians making fabulous music would be a professor who studied conducting and who studied music and who studied marketing for music, but never played the violin, would be the best conductor? And so, I started with that. So I think physicians by themselves, probably not, but physicians in a dyad or triad relationship with an MBA administrator and/or a nurse leader is I think the ideal combination for a mission-driven patient and community and family-focused organisation. So it starts with the staff, the musicians, the physicians, the nurses, you have credibility as a leader if you have actually played a violin or are still playing it, and you understand how an orchestra works from the inside, not from textbook. And if you look at the research in this, it looks like most of the physician or clinician leaders, including nurses and other professionals tend to focus more on the music, more on the care, more on the patient and family and less on the finances. But then focusing on quality and focusing in on staff engagement and focus on patient experience actually has a business case that ends up with helping the organisation get the margin, the need for success. So that's the big thinking that I look at without, there's actually some research that supports that, but that's how I would look at it, who nurses, doctors want for a leader. 

Jennifer Dixon: And so in Mayo, is it that it's just axiomatic, it's kind of bleeding obvious that to know the business, the frontline business, it's better to have those people in management or is it based on research evidence? 

Stephen Swensen: The research at Mayo was basically that it works for over a century with physicians that from the first day they come on staff are being developed as leaders, more than 5,000 physicians at Mayo, and then a very small percent of those end up in significant leadership roles, including leading the this what? $16bn not-for-profit organisation. It's hard to get good causal randomized controlled trials. But if you look at the top-rated hospitals in America, the most credible in respected assessment is this US News and World Reports honourable been around for decades since a very comprehensive look of safety experience in the organisation. 13 of the top 21 organisations in the country are led by physicians. And all of the top six are led by physicians. And then Goodall looked at, well, what about the quality? Well, that quality is 25% higher than those run by non-physicians, if you look at close to 6,000 some hospitals in America. And in the United Kingdom, you're probably aware of Castro and Richard Dunn's work, it's from 2008. But basically, they also found the same thing in the UK, is that there's a clear association between quality and to the extent which physicians contribute to the hospital management about 20% higher, financial, and clinical quality scores than those that had fewer clinician leaders. So, it's not just a CEO, it's clinician leadership and clinician leadership up through the ranks. 

Jennifer Dixon: And I did read something, you mentioned Amanda Goodall's work. There is something that one of her studies, which showed that it was clinicians who were really good clinicians, not any old clinician, if I can put it that way, with a background training in X or Y, but really good clinicians who made the best managers and made the most difference? Is that your experience, Steve and indeed Dom. 

Stephen Swenson: I would say absolutely. And part of how we select leaders at Mayo, the candidates are selected by the staff that they will be leading. So you are a paediatrician, you are a paediatrician. The paediatricians would say, these are the after face-to-face interviews of every paediatrician, these are the five men and women that we would like to lead us so that they're respected by their colleagues and then leaders from other departments in its integrated practice, make the final selection of who that paediatric chair will be. So they start with all the social capital they need to succeed and partly it's based on their competence, and certainly it's based on their emotional intelligence and the respect they have from their peers. 

Jennifer Dixon: So not self-promotion, which is quite interesting. And Dom, what is your experience of really respected clinicians in their fields being effective over anyone with a clinical training as it were? 

Dominique Allwood: Well, I think the thing that you would have probably the skill set that is the beneficial piece, it's the relational part of how you deliver your clinical care that helps you communicate well with colleagues and patients and having the good clinical acumen will make you respected. But I guess if the trade-off isn't there, because if you think about clinicians who are good clinicians, they've spent time working in their clinical practice, if they then layer on a management role into that, they spend less time being able to be clinicians. Then becomes a trade-off of those good clinicians, do they want to take that jump into spending less time with patients? And then I guess the tension becomes well, other people that are left, the ones who want to go into management roles, the right people who are skilled to do that. And when you stand around and look at people who are ready to take on a management role somewhat early on in their career, for example, ahead of specialty, so coming out and being a new consultant. Generally you find people who sort of want to take that role on are moving away traditionally from wanting to often be in their clinical time, or they can't juggle both because the job planning doesn't allow them. So there is a trade-off I think around potentially being a good clinician and being able to retain that in the UK-based system, I think it's very different in the US. But we have a very lean management structure here in the UK, we spend a small amount of our budget on administration and management. So it means that we don't have the dyad model that Steve talking about where you can double up all clinicians with a manager. And so there's a trade off on that clinician's time, because the more time they spend in their management role, getting good at that, I guess they're getting drawn away from their clinical practice. 

Jennifer Dixon: Yes. And of course there's an issue in the NHS of status of management, but we'll get onto that, I think. Dom, while you've got the floor, can you just chart for us a typical path for say a newly qualified doctor that they might take if they want to be a manager or they become a manager let's say, or a CEO in the NHS, is there a typical path or is it really do it yourself, which some of people are reporting? 

Dominique Allwood: I think it's a combination of both. So there is actually an undergraduate intercalated year that you can do, a one-year course in management while you are doing your medical training, that's quite different to a full MBA, but there is management for people in undergraduate clinical training. And then, once you come out into your postgraduate training, as part of the requirements for training, you do have to do some management. So people tend to go on a short course, run by organisations like the King's Fund, or do some kind of mini-MBA for medics the weekend at the RSM or something. But those are usually self-taught and self-funded. And then I guess once you qualify as a consultant, the route is somewhat typical, which is you tend to go into being ahead of specialty first, then up through clinical director route, into a medical director or CMO role before then a very small number at the top of that pyramid moving sideways or up into CEO or sideways into other medical management and leadership roles, either within the NHS or beyond. But I think I've made that sound like quite a linear and well circumscribed path. And I don't think it's in reality, there are lots of variations that happen along the way and the training that people get to do those roles is quite variable. But I guess that jump between head of specialty into clinical director, up through medical director and into CEO is probably the main route that medical managers take in the NHS. 

Jennifer Dixon: Yes. And the question there, which I'll go on to ask Steve in a minute is then what happens? How are these clinical consultants, if you like, who take that route brought on or supported and developed and what we're finding in some of our work, and also indeed the Gordon Messenger review is that it's pretty haphazard. Some trusts are obviously very organized, but few, but the rest is a largely bespoke self-oriented development. Is that your experience, Dom, that's more or less what you're saying, is that right? 

Dominque Allwood: Yeah, that is, I mean, I was a recipient on the Prepared to Lead program and I've done Darzi Fellowship and currently doing an MBA, it sounds like collect badges, which is probably not untypical for doctors in this space. But it's about, I think selecting the courses and programs that will help you do your role really well. And at trust level, some trusts do have sort of partnerships with the King's Fund or other business colleges to set up management programs for doctors at various stages of their training. But I guess there's no management way in the NHS for doctors. And it tends to be a sort of pick and choose what places you can find, the mentors and role models that suggest things and I guess the opportunity to fund those things as well, really. 

Jennifer Dixon: Yes. And you sort of go through the system and enclothe yourself and sort of external credentials that have been delivered by someone else outside of your main focus of work, if you see what I mean, main centre of work. So that's very interesting. So Steve, I'd be very interested in your response to that. And if you also can describe the typical path in the Mayo Clinic, I must preface by saying, I read the book that you recommended when I heard you speak last, it's by Leonard Berry and Kent Seltman on ‘Management Lessons from Mayo Clinic’, which is a very famous book. And it was eye watering, I have to say, this pathway and the care with which it's taken to develop these clinicians. So perhaps you can describe that for us. 

Stephen Swensen: Sure. It might be worth just a sentence or two about how we use a dyad. So leadership dyad, we look as the Mayo, it's a physician-led organisation and the physician’s partner with an administrator. The physicians, everyone, all the way up to the CEO still maintain a clinical practice and they act as leaders, they don't act as managers. The administrators with the MBAs and MHAs act as managers. And so the physicians, 95% of our physician leaders don't have an MBA or equivalent. But they have the basic understanding of finance and accounting and law and human resources and etc, quality improvement. But their role is to be a leader of all the clinicians and in that big picture. And that allows them to, with this partnership with administrators to still maintain a practice. So the 5,000 some physicians we have at Mayo, when we onboard them for three years, it includes everything from emotional intelligence assessment to simulation centre training for how they interact with other members, and it includes quality and some basics in those first three years before we have a permanent appointment. And then we have this pipeline, there're 5,000 some docs, we have 242 formal titled leadership positions for physicians that we monitor. And those include division department chairs, it includes the deans of education practice and research, all the way up to the CEO, 242 of those. And for each of those, we have a succession pool that we assess, and the succession pools are the talent, the doctors that could be the next chair of surgery, or they could be the next dean of education. And if for each of those succession pools, we have a scorecard that rates them for readiness, competence and ethnic diversity and gender diversity. So we look at that from all the way up. So the pipeline to get someone who could be a dean someday or a CEO someday, those men and women physicians, they develop over two to three decades before they get to that top level in the organisation. And so they know the culture, they get the social capital, and they have the competence. I'll talk about our leader index in this little bit, that's our primary measure of competence. And so that's how the pipeline works. And the pipeline keeps moving because we have term limits, no physician leader, we rotate our administrators also, but no physician leader can be in any given role from a chair to deanship to chief executive office for more than eight years, two four-year terms. And I was refreshing that. 

Jennifer Dixon: Yeah, that's incredible. So does that mean that the Mayo is just constantly scanning all the time, this talent pool and assessing. I mean, obviously you have moments where you have the scorecard is completed, and then you people move on. But it sounds like a very constant scanning constant work to assess these skills, is that right? 

Stephen Swensen: Yes, but most of the work is done by the incumbent leaders that's supported by the... So it's diffused. So the chair of paediatrics, her job is to run the department of paediatrics, to make sure patients have the best possible care and experience, etc etc. And her job is to make sure that there is talent that is ready now that we have a choice of to replace her when she either decides to go back to practice or she decides to be considered for a dean or the CEO or whatever. So it's a diffused responsibility, but we do monitor it centrally to make sure that the really key roles of those 242, that we have a good talent pool to choose from so we're not stuck with not having someone that could be our next dean. 

Jennifer Dixon: Yes. And just to press that. On the 242, so the system sort of almost, when I read the book, it was almost people were encouraged to apply, they were almost tapped on the shoulder, this is your turn now it. It wasn't so much self-promotion, they were pushed, obviously people had to want to do the job, but there seemed to be quite a lot of it's your duty, the system was asking individuals to do a particular job because they showed the requisite skills, is that right? 

Stephen Swensen: Yeah. So there's very little self-promotion in the culture because the leaders, these talent pools for the next chair of paediatrics or the chair of rheumatology, they are selected by the people that they will lead. So it's not like you can petition the dean or the CEO or the next level of leadership to say, I want this job because the candidate pool is chosen by the paediatricians or the surgeons or the rheumatologist. And then the leader from that pool is selected by leaders from other departments. So then you've got this combination of the staff saying, we like these leaders and the rest of the organisation saying, well, that person is chair of paediatrics, she could work with surgery, she could work with radiology, she could work with administrators, so that's the best choice for the organisation. 

Jennifer Dixon: Yeah. Dom, I'm sure you know all this, Dom, but I just wondered what your response is that is to that kind of approach compared to what you described? 

Dominique Allwood: So we in the UK have a very different system, which I guess is focused on those medical managers, doing both those roles together or juggling at least in some variation of that. And I think that you find that you might get at the head of specialty, that kind of unit level, maybe two to four hours a week to do that management role. So you can see why that doesn't feel very attractive to a clinician who has anywhere between 10 and 40 clinicians to manage direct reports to them and a service. Of course, they have an administrator working alongside them, but they may be working across a range of different specialties. So I guess there's a sort of sense within the NHS that sort of ‘Buggins's turn’, so everyone looks around and says, well, I hope it's not going to be me, and the last person left sort of ends up stepping in. So I'm characterising that a little bit. Of course there are attractive management roles within the NHS, but often they feel unattractive because the time is limited, I guess, as you progress up the hierarchy towards CEO level, it's not just specific to doctors, but the CEO term in the NHS is short and people have to do a lot of managing upwards and those jobs do not always feel attractive. And so if you combine that with, I guess, no systematic way of trying to identify talent, we're left with this sort of vacuum of the role seems really hard, and we don't have people lining up ready to do it, nor have they been encouraged or developed in advance of getting to that point. And so it does feel like we're often a sort of crisis mode of looking around and trying to beg and borrow people to get into those roles. And we have similarly a three-year term and at the end of that, people are scrambling around saying, where are we going to find the next person and try and tap your friend on the shoulder and say, do you think you can do it? You can see understandably how we've ended up in that position. I guess some of the issues around that, not least, are around diversity, how are we ensuring that we have a diverse people that go into those roles and how do we really prepare them? Well, I guess it's not just about the knowledge and the training program, but it's about skills and on the job support through things like coaching and mentoring. So it's often seen as sanctuous role, particularly that sort of new consultant level, I think. 

Jennifer Dixon: Can I just ask on that, Dom, contrast the NHS and Mayo, I mean, obviously huge differences, but are there some structural factors in the NHS that are making things more hostile here? For example, as Messenger said, and Pollard in their review, the need in our system to look upwards and deliver upwards. And also because of budgetary pressures, which are intense. And also because of the less money we spend on management per se, which is obvious in Britain compared to other countries like Germany, or indeed France, certainly in America, or do you think those structural factors that I'm describing are overblown and it's just an excuse and actually it's quite possible for Wolverhampton General or Sussex, whatever to design its own system? 

Dominique Allwood: I don't think they're over blown at all. You can't imagine the energy it takes to be managing all of the data measurement and politics that have to go sort of upwards into a national system. We gain a lot of benefit from having a universal healthcare system, but the flip side of that is a lot of feeding that industry that is there. And I think the difference that you see around the contrasting of the two systems is I guess that pressure to do that because we're very centralised. A lot of health systems around the world are facing workforce shortages, but if you've already got lack of resource, a lot of pressure on what to do with that resource, limited workforce, having to look upwards, looking, I guess, across and downwards towards your patients and your staff and thinking about what you are really there to do as a manager, to create good working environments, best care and value all around for your system, you're going to really struggle with all the constraints you're in that system. So I think are starting on a back foot with all of that. And COVID has hugely worse than that environment for people. So it's difficult context to manage at the moment in. 

Jennifer Dixon: Yes. So Steve, hearing that and us looking at Mayo. Mayo seems incredibly well endowed, you mentioned the budget there, was it $16bn organisation, that sounds very well endowed. You may not have the same budgetary pressures as we have. Do you think that's a big factor? Has Mayo ever been in financial difficulty and has that really skewed priorities away from what might be the value generation that you are describing and far more on managing the books? 

Stephen Swensen: So Mayo's not for profit, and the money that we run on for the practice is all generated from seeing patients. So we have the same constraints with different payer mixes that as the other 6,000 hospitals in America do, so that we're not taking anything from an endowment to subsidise the practice. Some of the philanthropy we get goes to our research and education programs, but the practice sustains itself, the reimbursement system we have in this country. When we're talking about the leadership piece here, another potential advantage of clinician leadership is the engagement of staff. So I think that one of the primary responsibilities of leaders in any organisation and especially in healthcare, is to engage the physicians, the nurses, the social workers, so that they've a pronoun test that comes out like this, this is my organisation, we can do this instead of talking about the leadership of the organisation as they and them and theirs. So if we have leaders whose primary goal, one of the primary goals is to engage their staff and focus on their wellbeing. Then the comradery, then the relationships with patients and families and other groups in the organisation are so much more positive and flow with more discretionary activity and less turnover and lower rates of burnout. And it's different if staff talks about leadership as they and them, and they feel like they're victims and they feel like they don't have agency. 

Jennifer Dixon: So just to put this rather too simply, if you can think for NHS itself, there seems to be, let's say two broad approaches, one is that the clinicians could go out and get lots of baubles, lots of credentials from external providers on management of this and that, just say. Diploma in this, MBA there and so on and so forth. But another one, which is what I think is very interesting about Mayo, is how the NHS itself grooms clinical people within a kind of, I don't know, framework to bring them through. And it sounds as if there's a bit more of the former and not as much of the latter at the moment, is that right? 

Dominique Allwood: Yes, I think that's true. I think there is a place for having some kind of centralised, probably framework or set of competencies that we want to see across people, but that can be locally determined and delivered. Because if you think about, particularly for these types of roles, the experiential learning and the skills and behaviours are really important, not just the knowledge and how you do that needs to be embedded into your local work. And so there are programs in other countries like in Australia, where they have their medical administrator model. And indeed many MBAs where people go away and do those full time, they're classroom based, but then they've got to come back and translate all of that into what it means to do the day job. And so I think having organisations taking some of that local view in the context and using that within their development is really important. Some just have commissioned local programs, but I think there's this tension isn't there and balance between ensuring there's some kind of standard common level and I guess systematic view of how we view management and what we want people to learn know and do, and how we are operating like that locally and ensure that people are embedding and supporting them to do that learning and development and putting it into practice. 

Jennifer Dixon: Yeah, there's one issue standardizing it, but there's another issue which I think is demonstrated by Mayo, it sounds, which is to integrate the development of clinical management within an operating model or a value framework that's operating within an organisation. And Steve, Mayo is very unusual, isn't it? It's held up as being highly unusual, not just being in the Minnesota fields. And now what is it, Florida and Arizona. But it's a very unique system where people stay for decades, such as yourself, in fact. The NHS is also where people stay for decades because we're a kind of almost monopoly provider. The question for me is how typical is ‘the Mayo way’ and other provider systems in the US as far as you know in terms of this rather homegrown grooming as I call it. 

Stephen Swensen: So I think you've characterised it well, but what I would say is that even though there may be only an 8, 10, 12 integrated group practices that were modelled after Mayo Clinic, including Cleveland Clinic and Ochsner and so on. There are actually hundreds and hundreds that have adopted critical success factors, not that we didn't create all these at Mayo, but we've integrated those into our leadership model. So the dyad model, the integrated group practice, the pure salary compensation model, the leader indirect assessment system. The annual staff survey for the last 40 years of staff on culture and leader behaviours and teamwork. All of those are elements of this integrated group practice leadership model that we adopted from the best for-profit public companies in the world, and we put them into this practice. So I think when you look at it that way, what we're doing is evidence based and it's maybe not so unique, what we do is unique, maybe we've put all those together into this fabric. 

Jennifer Dixon: Yeah, okay. That's useful to know. And just a couple of other, I suppose, two further questions before we round up. The first one, I guess, is that we've just had a rock thrown into our world, which is the pandemic. And I just wondered what the pandemic did. Did it fast track any useful changes in the NHS that you saw, Dom? And Steve, was Mayo more resilient to the pandemic as a result of the pandemic or did the pandemic show up cracks in your system that you needed to useful modify? Let's put it that way. So Dom, you first. 

Dominique Allwood: I think two things I noticed really through the pandemic, the first one was in my role as medical director at the Nightingale. And we had a lot of people who'd never had quality improvement experience, even having ever worked in healthcare before coming to these temporary field hospitals to come and work and support patients. And although we didn't have a huge number of patients being cared for through there, we had to make sure that we were trying to do the best job we could with the resources we had. And how do you look at quality and ensure quality improvement and learning reaches through all that? So one of the things we found was that everybody had the ability to learn and improve and change. And I think a lot of stuff about how we transformed care really came out during COVID. I guess what we found though, was that because the NHS runs at very high capacity on this very lean model of management, the ability to translate those changes that we have now into our business as usual, and to our care transformation as a result of all that learning is somewhat limited. So our management capacity to take that through is difficult. And I guess the second thing to say is if you ask most people in the organisation, they probably look at you quite blankly, I don't think people know or knew what that was. But I think what came out through during COVID was lots of people were using command management, this incident management way of working. And I think that gave a real structure to how organisations felt that their kind of different levels operated. It gave a rhythm to the work, there were huddles that happened from board to ward in regular fashion, data flowed up and down, decision making became very clear. And so if you think of those kinds of those core and traditional tenants of management about decision making and etc, you see that we actually have very strong management in some places doing that very well. And so I guess, how do we learn about having a management system, an operating system that we can use and draw on in everyday life that isn't just related to when we have critical incidents, there are great examples in the NHS of organisations doing that based often on the high-performing organisations from the US. But I think sort of understanding how having a management operating system running through your organisation and people being aware of that as a thing was really important. So I'd say those two things. 

Jennifer Dixon: Yes, maybe the pandemic emergencies sort of unified mission for everybody, whichever role they had in the hospital, maybe that was the issue, it's integrated in a way that normal times wouldn't. Steve? 

Stephen Swensen: The pandemic pushed and stretched every medical centre in the world in these really tough couple years, and I know we're not totally done with it yet. And I think what we saw at Mayo was it reinforced how important practicing clinician leadership is in an organisation where you've invested in social capital, the trust and interconnectedness of all of the members of the team. We have these annual staff surveys of 73,000 staff at all of our 23 hospitals and included in this annual staff survey that we've been doing since 1981, is 12 questions about your immediate direct report leader. And those 12 questions are basically about your leader's behaviour. Does she seek to understand? Does he express appreciation gratitude to the staff? Does your leader communicate transparently? Does your leader mentor and coach staff members looking for what you can be doing next year at the NHS, at Mayo Clinic? And is a leader of your immediate group inclusive of everyone regardless of gender or genome or phenome or religion or beliefs, whatever it is, does everybody feel welcome there? And these five leader behaviours we track now for close to two decades, there's a very, very strong relationship between those behaviours as assessed by the staff of their leader and between fulfilment, satisfaction, and professional burnout. And all those numbers go dramatically in the same direction. So there's total of 60 points that any given leader can get through the eyes of their staff. And for every point on that scale of 60, there's an 11% higher rate of staff fulfilment and a 7% lower rate of professional burnout for one point out of 60. So we manage to this, we select leaders for it, and it builds social capital and credibility among those leaders. And it's part of the secret sauce I'd say for engaging staff. 

Jennifer Dixon: Yes. Face validity to advancement, actually sort of crowdsourced if you like in a structured way. Sounds wonderful. So maybe the last question, it's a big one to end on. Given where we are in the NHS, and Steve you've come to this sort of newish, but what you've heard about the NHS, to maximize clinical talent in management. What do you think we should be doing next to try to improve things? If there were say three things that you think should be done to improve, given that it's a long-term agenda for sure. What would you expect to see? So maybe I'll start with Dom because you'll be closest to this. 

Dominique Allwood: I guess the first thing really is about valuing management and the role of clinicians in management. I think things are changing, but you still do hear people talk about going over to the dark side and this piece about are you here to be a clinician or a manager? Do you need to make that choice and actually valuing having clinical leaders in management positions is really important? And doing that through ways, including how we develop, how we reimburse, etc. I think another part of this is really important is we're now developing a much more system delivery approach to the NHS, no longer do people just work within organisations and teams in their own walls and boundaries, they are starting to work much more across systems. And I think we need to bring that a lot more into our training and development. And then on that note, number three probably then is about the multidisciplinary nature. So quite a lot of the programs I've kind of cited, the Faculty of Medical Leadership, the Darzi Fellows, etc, they were mainly aimed at doctors, I tended to do my management training earlier on with other doctors. Doctors don't just work, manage, and lead other doctors, they work in a system. And I think having that multidisciplinary management training but recognising that clinicians will need some different parts of that too to supplement their knowledge and skills is really important. So those would be my three. 

Jennifer Dixon: Wonderful, thank you. And Steve? 

Stephen Swensen: Well, thank you. The NHS is just this amazing, exemplary model of population healthcare in the world and is beautiful. And from a distance, I'd be intrigued by this moving forward with taking three trusts, three trusts that are willing and able to be innovative and taking those three trusts and plug and plain in developing this dyad model with practicing clinicians, a pipeline model that includes all of the major and of succession pools of clinician leaders for competence, readiness, and ethnic, gender diversity. Having the staff select their leaders, have leaders rotate measuring their competence leader index. And then showing a couple years down the road that the quality of care improves, the experience of patients and family improves. The operating margin improves, because of this partnership and integrated look at developing leaders make a difference for the wellbeing of their staff that make a difference for the wellbeing of patients. 

Jennifer Dixon: That's a very intriguing suggestion, thank you. I'll be definitely chewing on that there, Steve. And wanting to know a little bit more, again, about your model, and in particular, the staff survey that selects leaders, those 12 questions, I would be very interested. But I think that's a very interesting thought and certainly this homegrown within the organisation in which you work approach as opposed to the external centralised sort of model, I think is a really interesting one and shows great promise. I think that's a great place to end. So thanks very much to Dom and Steve for being such thoughtful guests on this topic, we must leave it there. We'll put some useful links in the show notes, including the Berry, Seltman book on managing the Mayo way. Well worth a read. We'll also add a link to Steve's book, he didn't mention on ‘12 Lessons to Avoid Clinician Burnout’, all very relevant post-pandemic and all proceeds from the sales of that book go to charity by the way. Next month, well, it's party conference season. And with a new prime minister installed, will policy suggestions from the parties be all confection and froth or will there be some hard signals about what to expect in the months ahead for health and care in these challenging conditions? Join us then. Meantime, stay well and bye for now. 

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