In 2015 Kaiser Permanente wants to be the “best place to start and grow your family.” Leading this vision is a doctor. With over nine million members, spread across eight regions and six states, Kaiser is one of the US’s largest health management organisations, but inevitable tensions exist across its three separate entities. This requires leadership; a great deal of which comes from the medical profession.
Why does doctor leadership work in the US?
Doctors in the US do enjoy a respect – bordering on obsequiousness – that we have lost in the UK. Indeed, in the dog-eat-dog world of San Francisco’s aggressive housing market I think our status as a ’doctor couple’ is what got us a rental house.
The high opinion held of doctors means that it may be easier for them to assume a position of leadership in the US, but it’s equally as possible for them to lose the respect of their team; particularly if a doctor thinks leadership equals orders. What in the UK we call a multi-disciplinary management plan for a patient is still called ‘doctor’s orders’ in the US, which also says something of the cultural differences that exist.
There are other factors at work in the US that empower doctors as leaders, like hospital ratings that are based on a raft of well-defined clinical outcomes, such as the rate of elective delivery before 39 weeks of pregnancy. This system of measurement is set up so that clinicians have to be involved in order to enact change.
A good example of these clinical measurements is the US’s response to over-diagnosis and over-treatment. Here, a mixture of national measurement based on clinical outcomes by the Joint Commission and patient campaigns, like Choosing Wisely, work to change what care is delivered. The pressure from various groups makes clinical leadership, by practitioners who have a deep understanding of clinical guidance, increasingly important.
What about the UK?
NHS England says that it “give(s) pride of place to clinical leaders”. There are also really encouraging signs that more junior doctors and newer Consultants want to lead and have the skills to lead. For example, Damian Roland’s blog is a great example of a clinical leader at work in the UK.
Kate Wilson, however, explained eloquently the difficulties in attracting doctors into leadership. Some of those difficulties include a perceived lack of shared goals and a sense of going from annual appraisal to annual appraisal, rather than taking a longer term vision for personal and organisational improvement, which can lead to an ‘us and them’ culture.
What could the UK learn from the US?
I have been surprised by the lack of pride in the US’s healthcare system by a number of people I’ve met so far this year. You might not be surprised – but that might be before you’ve seen some of the best bits of the US system. Physician leadership and engagement is a real strength, from which we could learn a great deal. So too, is the embedded nature of hospital rating and measurement systems that make clinical involvement integral to improvements that clinicians and management both want to see changed.
Kaiser has been a stable and successful force in US healthcare for many years but it is large and therefore sometimes slower to react. There are smaller and more nimble competitors out there, which will almost certainly make things uncomfortable for large organisations. However, stability and a commitment to the long term is important, as this engenders trust – trust between managers and doctors, trust between doctors who lead other doctors and organisations and those who don’t.
There is also an understanding of the many (sometimes competing) facets of improving someone’s health and an ability to communicate that to patients and everyone working in an organisation. It seems that organisations that invest in physician leadership are more likely to succeed.
It’s not that doctors as leaders in healthcare is a panacea – I know that doctors bring their own problems to leadership – but it is noteworthy that healthcare organisations in the US truly value physicians in leadership roles and are not afraid to support their doctors when they step away from the consulting room.
Dr Ted Adams was Harkness Fellow in Health Care Policy and Practice based at Kaiser Permanente in the San Francisco Bay Area in California in 2014-15.
Adams T (2015) ‘What can we learn from clinical leadership in the US?’. Nuffield Trust comment, 3February 2015. https://www.nuffieldtrust.org.uk/news-item/what-can-we-learn-from-clinical-leadership-in-the-us