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Social justice and medical leadership: what is preventing trainees in the East Midlands from accessing leadership training?
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  1. Rebecca Clegg,
  2. Jennifer Bowen
  1. Leadership and Management Programme, NHS England East Midlands, Leicester, UK
  1. Correspondence to Dr Rebecca Clegg, Leadership and Management Programme, NHS England East Midlands, Leicester, LE3 5DR, UK; rebecca.clegg3{at}nhs.net

Abstract

Introduction Health inequality is a problem worldwide, with life expectancy decreasing in parts of the UK. Social justice requires effective leaders. Doctors can engage with their patients to understand how social determinants of health affect them and use their leadership skills to create meaningful change.

The East Midlands Leadership and Management Programme (LMP), run by NHS England (NHSE) East Midlands, teaches trainees the grounding principles for effective leadership and management. Many trainees struggle to access the course; therefore, we created a survey to determine the barriers for access.

Methods The survey was sent to all applicable trainees in the East Midlands. 210 of 3000 trainees responded (7%). The questions were both qualitative, analysed using thematic analysis; and quantitative, which were descriptively analysed.

Results 90.5% of trainees said leadership training was somewhat or very important; however, only 52.4% had accessed training. The top barrier was not knowing what training was available (54.3%), followed by a lack of time or study leave (48.6%), and being unable to get a place on a course (46.7%). Concerningly, 3.8% thought leadership training to be of little or no importance.

Discussion Despite most trainees acknowledging the importance of leadership training, barriers to access exist. Of concern, some thought leadership training to be unimportant.

Leadership is vital for social justice and to enact positive changes within our communities. The LMP provides tools for doctors to help them achieve this. Our work documents the perceived barriers our trainees have to accessing leadership training, alongside proposals for change and further research.

  • medical leadership
  • trainees
  • clinical leadership

Data availability statement

Data are available on reasonable request. All data are anonymised and would be available for review on reasonable requests after discussion with the APD who is responsible for the programme.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • Leadership is vital for social justice, with doctors well positioned to help create positive change. Our research investigated the barriers trainees perceive in accessing leadership training.

WHAT THIS STUDY ADDS

  • Our research shows that not all trainees understand the importance of leadership and management training, or do not think it to be relevant to them. Alongside this, the common barriers to leadership training for respondents is discussed, which is likely applicable UK wide.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • Alongside recommendations to improve access to leadership and management training, further work around the area is proposed, such as assessing nationally why trainees do not believe leadership training to be important to them.

Introduction

Effective leadership is a requirement of all doctors, with good leadership resulting in improved patient care, staff morale and staff engagement.1 2 As medical education acknowledges the necessity of leadership from an early stage in medical training, it becomes increasingly important that junior doctors can access training opportunities to recognise, develop and apply their leadership skills. Despite the General Medical Council’s emphasis on leadership skills for medics of all grades,3 there does not appear to be more training opportunities.

In this paper, we discuss the importance of leadership for all doctors, including the need for doctors to recognise and implement social justice in their leadership roles. We also examine what trainees perceive the barriers to be for accessing leadership training, culminating in the actions taken to reduce these barriers and recommendations for further research.

Health inequality

Health is defined as ‘a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity’.4 A person’s health is intimately linked with the social determinants of health, influenced by social, economic and political factors including where a person is born and brought up, their education, income, access to healthcare and conditions for both work and leisure. Inequalities in healthcare stem from the unequal distribution of resources, power and money. Those in lower socioeconomic positions with reduced income and resources have a lower standard of health, and higher risks of premature death.5–7

Great disparities in health and life expectancy still exist in the UK, with life expectancy stalling for the past 10 years for the first time in over 100 years. Alongside this, life expectancy has fallen for those living in the most deprived neighbourhoods.5

The impact of COVID-19 has made inequalities in healthcare ever more apparent, with lower socioeconomic groups disproportionately suffering from both the direct effects of the disease, and indirectly through lockdowns leading to reduced healthcare contacts, opportunities to provide and receive informal care, and the ability to exercise.8

Those in the most deprived areas in the UK also spend a higher proportion of their already shorter lives living with poor health.6 The need to tackle healthcare inequalities has been recognised by policy-makers in the National Health Service (NHS), who included this as part of the NHS Constitution for England.9

Social justice and health equity are intricately linked. Social medicine and social justice, from which the idea of the social determinants of health developed, are not new concepts, with Virchow pioneering social medicine over 150 years ago when he hypothesised the social causes of disease.10–12

The concept of social justice is now widely taught at medical schools, forming one of the four pillars of medical ethics, as proposed by Beauchamp and Childress, alongside autonomy, beneficence and non-maleficence. Justice is often equated to fairness and can be considered the ‘moral obligation to act on the basis of fair adjudication between competing claims’.13 The focus in healthcare is often on distributive justice, the idea of fairly distributing resources, risks, benefits and costs associated with healthcare, in a way that is socially just within society.13–17

Previously, distributive justice focused on equality where all patients are treated the same. This actually disadvantages those with healthcare disparities who have a greater need for resources. It is now recognised that distributive justice should instead focus on health equity, allocating resources in such a way to eliminate disparities in health. Essentially, equity is social justice in the healthcare setting.13 18 19

This links to the theory of the inverse care law, where less time and money in healthcare is invested for those with the greatest need and the fewest resources, generally those in the lowest socioeconomic brackets.5 In the NHS Long Term Plan, there is a commitment to increase funding in areas with the highest levels of health inequality.6

Social inequality leads to financial as well as health implications, with an estimated £4.8 billion yearly spent on hospitalisation caused by social inequality in the NHS. One of the barriers to social justice is funding. NHS funding is determined by the government, with funding linked to governmental initiatives and priorities, rather than population need.20 Recently, there has been increased recognition of the importance of tackling health inequalities by the government. One of the key functions of newly introduced ‘Integrated Health Systems’, who determine healthcare funding locally, is to tackle health inequalities.6 21

Social inequality and health inequality are still major issues in healthcare, and areas that NHS leadership have recognised as important. Communities, especially those in the most deprived areas, need doctors to act as leaders and champion social justice, to drive long-term positive changes in healthcare.

Doctors as leaders

Doctors have the potential to exert change at a local, regional and national level. Medical professionals have connections with patients and communities, allowing them to understand the needs of these communities from those experiencing the issues, alongside connections with other healthcare providers in their area and beyond, sometimes also having links into government. Social advocacy, often linked with social justice, involves working with and for patients to improve resources and services, changing policies and procedures to benefit the community, and influencing healthcare delivery and the social determinants of health to ensure patients have the tools to thrive.22–24 Community facing specialties such as general practice and psychiatry will naturally have close links to their wider community, and can enact change through these relationships. However, it is within the power of all doctors to advocate for the social well-being of their patients.

Many styles of leadership exist. For enacting social justice, transformative leaders are often favoured. This can be defined as ‘ethical stewardship that integrates a commitment to values and outcomes, optimising the long-term interests of stakeholders and society’.25 This creates leaders who think laterally to overcome problems and are ‘change agents’ who actively search for, analyse and synthesise information to make informed decisions.26–28 As well as being innovators, transformative leaders have an ethical commitment to their patients, colleagues, organisations and the wider community. They focus on the needs of those around them, rather than their own, while questioning inequitable practices and trying to improve their communities. By returning to the principle of beneficence, the transformative leader can promote true social justice.25 29 30

To achieve social justice, we need effective leaders with the courage to continue pushing for changes that address the social determinants of health, reducing health inequity,31 32 while simultaneously empowering communities to take control of their health and well-being.33 34 The role of leaders not only lies with creating direction, but in identifying and training others to effectively lead and bring around changes.34

East Midlands Leadership and Management Programme

NHS England (NHSE) East Midlands runs a free Leadership and Management Programme (LMP) for post-foundation doctors in training of all specialties, with approximately 320 participants yearly. The course has run for several years, in several formats. Sessions are run by experienced faculty members.

The LMP is being reviewed post-COVID-19 to reinstate face-to-face teaching and increase the course capacity. The course now has three phases. The first phase teaches doctors the fundamental principles of leadership and management through e-learning and workshops. In phase 2, they implement the principles learnt by undertaking a quality improvement project, before the final phase, where more advanced leadership and management topics are covered in e-learning, culminating in a final workshop reflecting on what they have learnt, and their ongoing leadership journey. Trainees are assessed formatively throughout the programme, using reflections, participation in workshops and discussions with their supervisors and mentors. The course allows doctors to develop their leadership skills while in specialty training to prepare for consultancy and beyond.

We are also increasing the active learning done by participants during the course. Active learning uses teaching methods that move trainees away from passive learning, such as listening and rote learning, and encourages a deeper engagement with learning. Activities, such as talking, writing, or reflecting are undertaken to help trainees understand and create meaning from new concepts. This helps improve knowledge retention, critical thinking and problem solving, increasing engagement and encouraging a greater depth of knowledge.35 36

Given the importance of leadership to bring about social justice, it is crucial trainees have access to high-quality leadership training and understand the principles of social justice and social advocacy. These concepts will be included in the final phase of the LMP, with the content currently being developed.

Despite the importance of effective leadership training for doctors, from previous feedback we know that this is not always accessible, therefore we sought to understand why East Midlands trainees may not be able to access the leadership training available to them.

Methods

An online survey was sent to all East Midlands trainees post-foundation years, equating to roughly 3000 trainees. The survey was open for 3 weeks between September and October 2022. Alongside the initial email, one reminder email was sent. These emails were sent by the NHSE East Midlands administration team. To maintain anonymity and impartiality, the researchers had no direct contact with trainees, nor knew their email addresses. A total of 210 participants responded (7%).

The questions were both qualitative, in the form of free-text responses, and quantitative, in the form of 5-point Likert scales and closed questions. The qualitative data was analysed using theoretical thematic analysis. Qualitative responses were analysed and codes created for the information found that was relevant or particularly interesting in relation to the questions asked, and the overall research question. Using these codes, broader themes and subthemes were created. The quantitative data was descriptively analysed.

Results

Quantitative data

Of the 210 respondents, 55.2% were at registrar level (ST3+), with 44.3% of respondents at SHO level (CT/ST1-2), and 0.5% at associate specialist level. Participants represented nine specialties. 31.9% were GP trainees, 25.2% medicine trainees and 10% anaesthetic trainees. Other specialties represented included surgery, paediatrics, psychiatry, obstetrics and gynaecology, emergency medicine, and public health. 1.9% of participants did not specify their specialty.

90.5% of respondents agreed that leadership training was somewhat or very important, as shown in figure 1, with 93.6% needing to provide evidence of leadership training for their ARCP or appraisal.

Figure 1

Perceived importance of leadership and management training.

Despite this 47.6% had no formal leadership training, and 36.8% remained unaware of the available training. Furthermore, 49% of trainees reported that accessing leadership training was difficult or very difficult, with only 6% finding training easy to access, as shown in figure 2.

Figure 2

Accessibility of leadership and management training.

Of those who attended a course, only 10.6% rated their training experience as very good, while 27.6% felt their training had been poor or very poor.

Many barriers to leadership training were reported. The main issues surround the options for, time for and availability of training. The principal reason trainees felt unable to access training was not knowing what was available (54.3%), followed by an insufficient time within training, or lack of study leave to attend courses (48.6%), and being unable to get a place on a course (46.7%). All documented barriers are shown in figure 3.

Figure 3

Reported barriers to accessing leadership and management training.

3.8% thought leadership training was of little or no importance, especially common with medicine trainees. 24.3% of trainees highlighted they had other training priorities when answering why they had not accessed leadership training. This was mostly seen with anaesthetic/ICM trainees, with over 50% reporting other training priorities. 1.9% of trainees were discouraged from seeking leadership training by others, with 4.3% not seeking further training due to previous negative experiences of such courses. Anaesthetic/ICM trainees reported this most, with discouragement or negative experiences reported by 14.3% trainees.

Qualitative

Difficulty securing a place on a leadership course

This was the most common theme, with many participants commenting that courses filled up very quickly. Specifically looking at the LMP within this theme, places were very difficult to get due to limited course numbers, exacerbated by the short notice of courses affecting study leave approval. Comments from trainees included:

Limited sessions.

Limited spaces on regional course…. Courses should be run more frequently.

The course is difficult to access as slots get booked up very quickly. Also means I lose a lot of procedure training time as it’s run over several sessions on multiple dates.

The LMP is a useful course

Trainees who had attended found it useful, covering the areas they thought important to their training and helping them prepare for leadership during their career. Comments from trainees included:

The leadership and management courses offered by HEE were very good. The tutors took time to explore each group’s ideas and I learnt much through the discussions.

The course was very organised, informative, constructive and useful.

It was such an eye-opening course. It is also helpful in other spheres of life, not only in medical training.

The importance of leadership training

Many trainees commented on the importance of leadership training for their profession, and the need for effective training to provide the skills needed throughout their careers. Comments from trainees included:

I think it’s important to have leadership skills and these need developing and should therefore be encouraged to be a part of continuing study and training.

Leadership and management courses should be mandatory during each year of training; we never cease to be a leader and we keep growing as a leader. I feel with regular annual sessions these will eventually help in shaping good leaders and managers.

Formal leadership training is not important

A small proportion of trainees did not see the importance of formal leadership training, commenting that training on the job was more important, leadership courses were not fit for purpose, and courses did not change their clinical practice. This is included as a theme due to the importance of trainees not wanting to attend leadership courses. Comments from trainees included:

I have attended multiple leadership and management trainings in the past, many with negative experiences.

I did not learn anything substantial from the session.

Discussion

These results show many important aspects around perceptions of leadership training that will be discussed, alongside recommendations for changes to be taken now, and proposed future research to better understand the barriers to leadership training for medics.

Our results show that most trainees understand the importance of leadership in medicine and agree they require it for their training. Despite this, many do not access leadership training. The discrepancy between the acknowledged importance of leadership training and the numbers actually receiving training suggests barriers are more likely to be extrinsic, and thus can be influenced once identified.

Issues highlighted regarding the LMP are being addressed. For example, the main difficulty was securing a place on the course, therefore, we are increasing course numbers by 40% through changing the course structure and increasing faculty numbers. It is clear we could also advertise the course better, as many trainees were unaware the course existed. Although this may seem to put additional pressures on course numbers, the new structure where e-learning is completed first means large numbers of trainees can learn simultaneously and at their own pace, meaning people access the face-to-face sessions at different times. By expanding the faculty, we will increase the number of face-to-face sessions, helping increase course numbers further. Additionally, more work could be done locally, regionally, and nationally to highlight leadership training and opportunities available to junior doctors.

Being able to access leadership courses is an issue for many trainees, not just with the LMP. Many courses have small numbers, many charge a fee, and some have specific entry requirements that preclude many from attending. It is therefore clear that trainees need better access to local and regional high-quality training, most likely organised by their local deanery, without these barriers.

Trainees have limited study leave allowances, and there can be regional variations as to which courses are accepted for study leave allowances and budgets, depending on the specialty and local rules. Some trainees struggle balancing study leave for courses against training time lost. There needs to be clearer processes to ensure all trainees can access study leave for vital courses, such as leadership training. Possible changes include greater clarity from specialties on accepted courses for study leave, ensuring trainees have sufficient time to apply for study leave and a greater awareness of the importance of leadership training, rather than being viewed as detracting from training, or a tick box exercise.

Although most participants found the LMP useful, there were large variations in the perceived quality of the LMP and other courses attended. It is vital that the course curriculum is constructively aligned with trainee needs. Constructive alignment refers to aligning the learning objectives, learning activities and assessments, to ensure what is taught is relevant, and improve student engagement.37 38 Curricula should follow approved models and guidelines to ensure content is relevant. We have addressed this with the LMP curriculum redesign, constructively aligning all aspects and creating the curriculum using the Healthcare Leadership Model and the Medical Leadership Competency Framework.39 40

Areas of concern from the survey are the number of trainees who did not believe leadership to be an important area requiring formal training or did not see leadership as a priority. Trainees may already believe that they show adequate leadership skills and do not require further training, or they may perceive themselves to be in a role where leadership is not required. Also concerning is the number reporting low-quality teaching.

27.6% of trainees reported experiencing poor or very poor leadership teaching. It is unclear whether this relates to clinical experiences or leadership courses. All leadership courses should regularly review and improve based on feedback, and ensure their curriculum relates to the most recent guidance and best practice. We continually review the feedback on the LMP and identify areas for ongoing improvement to the course.

Trainees may not understand why leadership is important or may have misconceptions around what leadership involves. Educating trainees on how leadership fits into their role is vital to help them understand the benefits of attending leadership training. There appears to be some split based on specialty, with anaesthetic/ICM trainees more likely to report other training needs. They are also more likely to have negative experiences of leadership courses, and more concerningly are deterred from attending courses by their peers. Further work to assess why this is the case is required.

Conclusion

Leadership is vital in medicine, with skilled leaders being able to enact social change and improve the health and well-being of their patients who are negatively affected by the social determinants of health. Doctors must, therefore, receive effective leadership training early in their career, and understand the potential of what they can achieve for their patients and the communities they work with. The main purpose of medicine is to help others, with this need to help motivating many physicians. Trainees must understand the concepts of social advocacy and social justice to allow them to help their patients and the needs of the wider community.

The LMP in the East Midlands gives trainees the skills to start their leadership journey, encouraging them to grow as leaders throughout the process, developing the confidence and skills, alongside the knowledge required, to tackle social justice issues and minimise health inequality for their patients. Despite the importance of leadership training, there are several barriers to accessing this. Although several are specific to our programme, mostly due to capacity and administrative constraints, we have identified barriers that likely affect trainees nationwide.

It is clear that trainees would value better access to leadership training, and the ease of accessing high-quality training should be reviewed UK-wide, to ensure trainees can access this vital resource.

Recommendations

  1. Training schemes need to promote the importance of leadership training at a local level, helping trainees who may otherwise not engage understand the importance of leadership for their development.

  2. More leadership courses should be provided at a deanery level, with these courses constructively aligned and mapped to appropriate models and guidelines, to ensure trainees receive high-quality, useful training.

  3. Leadership training needs to include information on health inequality, the social determinants of health, and promote the concepts of distributive justice and social justice.

Further areas of research

  1. Determining why trainees do not believe leadership training is important, to develop effective strategies to educate trainees on the importance of leadership in their careers, and the impact they as leaders can have on their patients and communities.

  2. Understand what negative experiences trainees have had on leadership courses to assess if there are any patterns that could be addressed.

  3. Conducting similar research UK-wide to understand the views of trainees throughout the country.

Limitations

The limitations of our study include the relatively low response rate at 7%, and that it only surveyed trainees in the East Midlands. There may be differing views in other areas in the UK, dependant on available courses, resources and regional specialty teaching. Although participants from several specialties responded, some specialties had low levels of representation, such as public health, with some specialties not represented at all, such as radiology.

Data availability statement

Data are available on reasonable request. All data are anonymised and would be available for review on reasonable requests after discussion with the APD who is responsible for the programme.

Ethics statements

Patient consent for publication

Ethics approval

Ethical approval was granted by the Associate Dean working for NHSE East Midlands who oversees Leadership and Management development for East Midlands trainees. All responses were anonymous; consent was assumed by response to the survey.

References

Footnotes

  • Contributors The authors have worked together on updating the programme stated. JB created the survey described, reviewed by RC before sent to trainees. RC reviewed the results of the survey and subsequently wrote this article, with revisions and comments from JB. RC is responsible for the content as guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.