Introduction There is growing evidence that doctors may make for superior executive managers compared to their non-medically trained counterparts according to financial and staff performance, and patient outcomes. This is reflected as 66% of the top 100 global hospitals are doctor-led. However, only 10% of NHS Trusts are currently doctor-managed. Examining this disparity revealed several barriers preventing doctors’ entry into such roles, including the lack of a defined pathway and job insecurity. We focussed on the sparsely researched area of the effect of doctors’ perceptions on their intentions to become managers. Our research identifies doctors’ perceptions of healthcare leadership across all levels of medical training and sheds light on the complex dynamics driving their perceptions. Ultimately, we aimed to create interventions to enable more potential doctor-managers to enter leadership roles. This was performed through semi-structured interviews with secondary care doctors at various stages in their training and professional development.

Aims and objectives of the research project or activity We conducted a literature review aiming to understand reasons as to how and why perceptions influence doctors entering managerial roles. Our subsequent research focussed on the transition of doctors to doctor-manager roles within secondary care in the NHS, emphasising doctors’ perceptions surrounding this shift. Our aim was to explore the attitudes of doctors towards doctor-managers and how they influence, if at all, their own transitions.

Thus, the main research question addressed doctors’ perceptions of NHS Trust Executives at all levels of medical training, examining the factors influencing these views, and their role as potential barriers or facilitators to managerial positions. This was with the aim of:

• Understanding what the perceptions are

• Understanding how such perceptions affect doctors entering managerial roles in the NHS

• Identifying the drivers behind these perceptions

• Identifying differences across levels training in such perceptions

• Creating and trialling interventions to address drivers of perceptions

Method or approach Our research employed a three-stage methodology, involving sample selection, semi-structured interviews (SSIs) and thematic analysis.

The decision to use 29 SSIs, spanning all levels of medical training, stemmed from limited prior research on perceptions hindering doctors from entering managerial roles, allowing flexibility to explore new insights whilst maintaining a structured framework. Snowball sampling was utilised for participant recruitment, to effectively target senior executives in a specialised population. Diverse initial informants mitigated community bias. Interviews, conducted virtually, incorporated open and closed questions, fostering a free-flowing conversation for deeper insights. Pilot interviews informed iterative question refinement.

Thematic analysis, employing Braun and Clarke’s process, revealed perceptions and drivers. These perceptions and drivers were then analysed and compared to existing literature to derive novel insights. (The study contributes to understanding doctors’ career pathways and provides practical insights for addressing managerial role perceptions in the medical profession.)

Findings From our data, we were able to identify interesting and novel findings.

Notably, doctors’ perceptions of executives tend to be based upon the actions of middle-management, attributing their negative outcomes to executives.

Our findings highlight the differing scope of doctors’ and executives’ roles as a natural cause of conflict and negative perceptions. Whilst both groups self-report synonymous goals of providing quality care for patients, doctors focus on individual patient care, while executives prioritise population health within a resource-constrained environment.

Importantly, we note perception drivers not under the direct influence of executives (Doctor-driven-drivers, NHS-context) predominantly form negative perceptions. Thus, in the absence of early-executive action, negative perceptions naturally form.

Doctors’ altruistic motivations lead to scepticism when colleagues transition into executive roles, likely rooted in an engagement gap, with doctors perceiving such moves to be incentivised by self-interest rather than a genuine desire to benefit patients.

Our study reveals a correlation between doctor seniority and perceptions. More junior doctors often exhibit indifferent or negative perceptions, while senior doctors often hold stronger negative perceptions, potentially explained by increased interaction with middle-management. Conversely, heads of departments develop more positive perceptions, possibly attributed to increased interaction with executives, reciprocated relationships and respect earned through seniority.

Key messages Thematic analysis of our SSIs derived key takeaways. Fundamentally, junior doctors either lack knowledge about NHS management and are indifferent, or reflect the (mostly) negative views of passing conversations. Consequently, the prospect of doctor-leadership, unless an innate desire, is a far cry for most junior doctors. Interestingly, however, doctors are most malleable in the junior stages of their careers. This comes in stark contrast to senior doctors, whose attitudes towards management are increasingly polarising and concrete.

Therefore, doctors would benefit most from education about medical leadership whilst at medical school, as evidenced by our survey completed by students from numerous UK medical schools. Our FMLM-powered healthcare leadership conference at Imperial College demonstrated the benefits of educating and inspiring the next generation of healthcare leaders. Attendees reported increasing interest in taking up such roles after hearing the journeys of current doctor-managers and the work of FMLM in shaping future leaders.