MY colleagues and I recently conducted a study looking at medical engagement in Australia and the UK. We found that Australian doctors feel much more engaged than their counterparts working in the UK. Medical engagement means doctors are fully involved in leading and designing the delivery of health services.

This research, in which a medical engagement questionnaire was sent to all medical staff working at 159 UK National Health Service Trusts and 18 health services organisations in Australia, is likely to be of great interest to regulators and training bodies in both countries.

The UK is facing a workforce crisis which has been called “DRexit” – doctor exit. This is a long term trend towards young doctors reducing their clinical workload, taking short term leave, or leaving medicine to pursue other activities. Our study found that many doctors now hold negative views about aspects of working in medicine including factors such as “loss of respect, lack of value and fragmented teamwork”.

Changes in working conditions in the UK, such as to pay and leave arrangements, “unsociable hours, increased workload, and the years of austerity” are also having a material impact on doctors.

In contrast, our research shows doctors in Australia feel valued and empowered, they have purpose and direction, and work in a collaborative culture.

As part of my research at the Centre for Health Leadership, I interview hundreds of doctors and talk to them about their experience. Intrinsically, they feel that leadership is core to their professional value and something inherent in the daily clinical practice.

However, Australia is at risk of developing its own form of “DRexit” unless we increase the involvement and participation of doctors in the leadership of health organisations. This interaction with management cannot be tokenistic.

We need to revisit rigid career structures, providing flexible working hours, offering peer support and safeguarding the right development opportunities.

It’s important to ensure that clinical staff are introduced to management or leadership concepts early in their educational development and then subsequently as their service career progresses. In Australia, current pathways for doctors into management and leadership roles are relatively ad hoc and poorly understood. Australia currently lags behind other countries in its attention to, and evidence base for, effective medical engagement.

In comparison, the UK regulator is advocating that doctors receive sustainable, appropriate and consistent support in their workplaces.

In Australia, the nation’s leading bodies concerned with the setting and maintaining of standards of practice and professionalism have yet to publish or endorse principles of medical leadership. As long as this remains the case, work to promote medical leadership at a jurisdictional level is likely to continue to be programmatic in nature. That is, doctors are enrolled into courses and development activity that is usually designed to address or “fix” a perceived problem, such as service redesign. Consequently, doctors will perceive leadership as something additional to their core clinical practice, rather than central to their professional identity.

While it is right and proper that funders and policymakers focus on the wellbeing of doctors, particularly junior doctors, they are too often ignoring their level of engagement, which relates to their commitment and wellness to work.

Despite the extensive writing available and work to engage them, there is a perception that doctors are unhappy or even alienated from the systems and organisations in which they work.

Health professionals need to not only be experts in their chosen clinical discipline but be competent professionals with leadership and management skills that enable them to be more actively involved in the planning, delivery and transformation of services for patients.

Incorporating leadership competencies into education and training for all clinical professions in Australia will help establish a stronger foundation for developing high level leadership capability across the health system.

Taking a systems approach forces designers and planners to go beyond the simple, unicausal, structural, and mechanical cause-and-effect view of problem-solving, which is limited and outdated. It also requires a commitment by health leaders to work across organisational and professional boundaries and silos, which traditionally separate clinicians, administrators, government bodies, users and other stakeholders.

The willingness of doctors to participate is very important as there is an urgent need for bodies such as the colleges, the Australian Medical Association, medical boards and the Australian Health Practitioner Regulation Agency (APHRA) to work together to include leadership in their professional and educational standards and related codes of practice.

Paul Long is Founding Director of the Centre for Health Leadership. He holds senior academic posts at the Clinical Excellence Commission Sydney and St Vincent’s Health Australia.

 

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.

9 thoughts on “Doctors need to lead and design health services

  1. anonymous says:

    Thank you Paul for your considered assessment of an important topic. It deserves the limelight.

    I have been in private practice for most of my working career. In that setting, the leadership is primarily in the hands of a system which values non-medical middle management, primarily nursing managers, DON’s, financial executives. The management direction is often top down, not denovo. Financial directives are important, after all the ‘bottom line’ is what ultimately will keep the wheels turning in a private business (I wouldn’t expect a business to run at neutral or a loss, otherwise why would they even consider opening up and employing staff). Often the decisions are made at a level outside of the doctors’ sphere of influence, by the owners/board of the group of hospitals rather than the doctors and we can modify that. Some hospitals are better at listening to doctors, and this probably is a cultural phenomenon unique to that hospital and speaks of the relationships between executive and doctors rather than a system.

    When doctors are given a chance to talk, very often it is ticked off as a membership of a particular committee within the hospital and the minutes will record the most vocal of speakers at the forum, rather than the most knowledgeable or unbiased.

    The agenda direction of the hospital management can be played off between one doctor or group of doctors and another, depending on the bias of those doctors and their alignment with the intentions of executive, so it is possible in a way to ‘buy’ the opinion of weaker minded doctors and use those to direct the hospital.

    there is so much more to this discussion.

    Medicine has been a very wonderful journey with lots of nooks and crannies. But it has been painful much of the way, it is stressful for me even now. I am as i get older more inclined to think more philosophically about the benefits of modern medicine, knowing that we are mainly meant to be benefiting the quality of life of our patients. Not sure if longevity is an answer either, with other issues creeping up like discussions about climate change and over population, inequality in access to health care. Until we serve as a country to ensure absolutely equal access to all, have we really ‘led’ anything in health care? If we haven’t been able to influence the world leaders to ensure a utopian access, have we really done anything worthwhile? or have we only served a privileged few (half the world lacks access to essential health services, see link below to the WHO article.

    https://www.who.int/news/item/13-12-2017-world-bank-and-who-half-the-world-lacks-access-to-essential-health-services-100-million-still-pushed-into-extreme-poverty-because-of-health-expenses

    then consider the access to vaccines in this Covid-19 pandemic. the inequity not only of health care, but of systems of government that ensure financial health which is a precursor to mental and physical health.

    We do not operate in a vacuum as doctors, and we are as doctors often the bigger fish in the small ponds we operate in, and this gives us some dignity, until you stand atop the nearest hill and look out to see there are other ponds and many that are bigger than yours.

    Sometimes, I wonder what it is I have really achieved at all other than to hold the hands of many patients and their families/loved ones. Perhaps that is what is wanted from us at all.

    Leadership is not for the faint harded, because the decisions can be made to benefit many with a single stroke, but not always. But this leadership is often requested of doctors when there is no remuneration for that valuable work. This means it is an add-on to the clinical work. It also means less time with your own family. I once was told as part of a function of a group of medicos by a senior leader of a private hospital group, that our sacrifices as doctors meant that our families were second in line to our attention, and this comes at a cost also.

    Nowadays, i nurture many hobbies and interests in preparation for a retirement that i yearn for, as I yearn for medical leadership much less.

  2. Gerry O'Callaghan says:

    Well done Paul for a considered and challenging paper and editorial. How engaged clinicians feel is directly related to their experience in the system which is highly variable. What has become abundantly clear is if clinicians aspire to a different experience and greater influence in how the system is designed, led and functions then practicing clinicians will have to make the difficult decision to devote time to pursuing this professional development pathway with the attendant requirements for learning new skills and capabilities. I accept that these pathways are not well developed and ongoing clinical practice is difficult to maintain. The various levels of the Australian health system remain very available to consultation and input from professional associations, colleges and unions and I hope we can avert the experience of other jurisdictions and maintain and build on what we have.

  3. Anonymous says:

    Doctors in Australia feel valued and empowered?
    Not by administrators or government. Emergency departments are inadequately staffed and under resourced and when inevitable poor outcomes arise as a consequence, medical staff are blamed. If we are less negative than our UK counterparts, it is because their system has already destroyed the profession; give Australia time, we’re getting there.

  4. Anonymous says:

    Nearing retirement age I have witnessed a marked decline in doctor work satisfaction and empowerment. Junior doctors have to suffer abuse for years to get onto a training scheme, then like their senior colleagues, they are still pushed around by administrators often with little knowledge , experience, intelligence or goodwill.

  5. Anonymous says:

    This is a topic that I feel particularly passionate about so, I apologize for the length of this e-mail.
    Perhaps those of us who are old enough to remember the halcyon days of medicine in Australia feel valued and empowered or, at least have had the privilege to have felt that until recently. I have been in specialist practice for almost forty years now and still see the practice of medicine as a privilege.
    However, I firmly believe the situation has become very different for our younger cohort. Despite significant waiting times for specialist medical care, particularly within the public system ( several years to see an ENT surgeon, 18 months or more to see a dermatologist etc etc) there is no increase in the number of training positions being made available. Instead young doctors are forced to spend years in non-training positions before (perhaps) getting a training job. All of this at a time in their life when they are actually trying to have a life. No wonder there is an increasing number of these extremely talented young people joining Australia’s Drexit of junior doctors.
    Shame on our specialist colleges for propagating this abuse of our junior colleagues. Shame on us, as members of those organisations for standing by and allowing this to continue despite plainly witnessing the psychological and sometimes, financial abuse of these junior colleagues.
    I believe it is time for an independent review of these self-interested, protectionist bodies and for government to stand up and have an input into the number of trainees required to provide a timely service to the whole community, not just the privileged, wealthy city dwellers.

  6. PETER BRADLEY says:

    “Doctors in Australia feel valued and empowered”

    WHO KNEW..?

  7. Anonymous says:

    Agree with Anon above. I would like to know where this proof is that doctors feel valued and empowered. certainly not the prevailing sentiment!

  8. Anonymous says:

    It is such a sad indictment on the nativity of the medical profession that they have let non-medical administrators and government bureaucracies take control over what used to be a trusted profession. Now the best we can hope for is to please the profiteers and government in the hope we can maintain some level of say in patient care.

  9. Anonymous says:

    “Doctors in Australia feel valued and empowered”
    LOL !!!

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