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Is Clinical Credibility a Requirement for Medical Directors?

When Medical Directors worry about their credibility they appear to be concerned about their clinical credibility with medical colleagues. This is true in both the UK and USA - but should they worry? And if they are right to be concerned, how can the Medical Director of 2015 be expected to gain and maintain this credibility?

The NHS Confederation has attempted to better understand the role of the Medical Director in the UK . This publication followed two seminars and a series of in-depth interviews involving a range of Medical Directors and their deputies. Whilst it was clear that the role was disparate and sometimes ill-defined, there were some common themes. A growing number of these are defined in statute, such as the Responsible Officer role, but many of the elements best fit under the heading of ‘clinical leadership’ (the development of clinical strategy, maintenance of clinical standards, professional leadership and clinical advice to the board). It is easy to see from this simple list why Medical Directors are interested in their credibility, without which they would not be ‘believable’ to either clinical colleagues or indeed to non-clinicians.

If credibility is important to Medical Directors, what kind of credibility is required and how is it to be gained? There are some behavioural traits that are essential requirements for any believable, i.e. credible, leader including integrity, consistency and clarity of purpose. But we are interested in the specifics of the Medical Director, and for this purpose we must consider the role of clinical credibility. Medical colleagues and non-clinicians on the board have to believe that the Medical Director ‘knows what he or she is talking about’. The Medical Director must be able to understand and interpret clinical colleagues, to challenge arguments and recognise when self-interest is masquerading as patient focus. To exert the necessary amount of influence in these settings requires specifically clinical credibility.

By definition, Medical Directors will have worked in a clinical role before they are appointed, usually at a senior level and often for many years. At first, they will draw on this past experience and as a result clinical credibility will come very easily with peers. How this experience is regarded by members of different specialties and sectors (primary care versus secondary care for example) will vary. It may be that the first challenge to clinical credibility will come from a specialty or area of practice in which the nascent Medical Director has no, or little, experience. Whilst this simply offers ammunition to a disgruntled group of clinicians within, for example, an acute trust (“what does a physician know about anaesthesia anyway?”) it may also act as an insurmountable barrier to medical leaders transferring between sectors, some would argue that it should.1 If it is uncontroversial that every Medical Director should come into post with considerable clinical experience, just what constitutes the appropriate amount and level of experience is difficult to define. Even less evident is whether one type of experience offers the aspiring Medical Director an advantage over another. It will become more important to answer these questions as the career pathway for medical leaders becomes itself more defined in the future.

In a totally unscientific trawl of an NHS recruitment website, 3 out of 4 adverts were explicit or implicit in requiring continued clinical commitment from Medical Director appointees. Indeed, traditionally most Medical Director roles have been part-time in order to facilitate this clinical commitment. But the role has become more complex, time consuming and just downright hard work, making a part time approach less and less viable. At the same time the requirement to demonstrate continuing clinical competency has become more onerous. Will the Medical Director of 2015 be able to fulfil both a clinical and leadership role, and if they must, how can this be best supported?

The pace of medical change means that the speed at which clinical knowledge, and therefore, at least in part, clinical credibility declines, suggests that Medical Directors will have to maintain some patient-facing commitment in order to fulfil their clinical leadership function. The need to stop being a ‘hands on’ doctor completely is only probably necessary with the move on to a Chief Executive role. At that point the aspiring medical CEO will want to consider the average tenure of a chief executive in the NHS before finally giving up the option of a return to clinical practice! For the Medical Director however, the question will not be if but how to maintain some clinical practice.

What are the options and how much is enough? Of course, there is no single answer to the question of how much. The bare minimum for a GP, for instance, may be set by the requirements of the local performers’ list. For a technical speciality, there is likely to be a minimum number of procedures recommended in order to maintain competence. However, these requirements should be built into the job plan of the full-time Medical Director, with an acceptance that they are an integral part of the role, not just an optional extra. This means they can be set with the advice of the relevant Responsible Officer, who should be interested in ensuring that the job plan is acceptable for the purposes of revalidation. It also allows for some flexibility e.g. the cancellation of a clinical commitment, should this be necessary to support the trust board, without creating conflict between the board and a separate clinical employer.

Without a more structured approach, the Medical Director in 2015 will be forced to continue in a vain attempt to maintain clinical credibility whilst managing an ever expanding role as Medical Director, as do many of their colleagues in 2011. If we are to make this important role attractive to talented doctors in the future, we must address this issue, not duck it.
S Rawstorne 25.04.11

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