Leadership, management and administration

• The fundamental purpose of clinical leadership is to improve health outcomes and quality of care for your patients, so it is an essential part of being a doctor.
• Your own personal characteristics and skills determine your ability as a leader and team manager and have a direct influence on the care your patients receive.
• Leading and managing improvement in healthcare systems is just as important as, and complementary to, acting on behalf of an individual patient. Effective primary care requires the co-ordination and commitment of a multiprofessional team working in partnership with patients.
• Leadership is everyone’s responsibility and there is a wealth of evidence to show that a well-led organisation is a safer environment to work in and to receive care.
• GPs are responsible in taking on a growing range of leadership and management roles in the NHS, from running a practice through to leading primary care networks, GP federations and ‘commissioners’ groups.

Good leadership practice has a direct impact on safe and effective patient care. The culture established by the leaders of a healthcare organisation is essential to enable a team that is able to work together to achieve the best outcomes for all patient populations. Being able to share knowledge within teams and the wider community (education, mentoring or change management) is a central principle of shared leadership.

The General Medical Council (GMC) Generic professional capabilities framework (2017) includes the domain of ‘Capabilities in leadership and team working’. This requires doctors in training to demonstrate that they can lead and work effectively in teams by:

• demonstrating an understanding of why leadership and team working is important in their role as a clinician
• showing awareness of their leadership responsibilities as a clinician and why effective clinical leadership is central to safe and effective care
• demonstrating an understanding of a range of leadership principles, approaches and techniques and applying them in practice
• demonstrating appropriate leadership behaviour and an ability to adapt their leadership behaviour to improve engagement and outcomes
• appreciating their leadership style and its impact on others
• actively participating and contributing to the work and success of a team (appropriate followership)
• thinking critically about decision-making, reflecting on decision-making processes, and explaining those decisions to others in an honest and transparent way
• supervising, challenging, influencing, appraising and mentoring colleagues and peers to enhance performance and to support development
• critically appraising performance of colleagues, peers and systems and escalating concerns
• promoting and effectively participating in multidisciplinary and interprofessional team working
• appreciating the roles of all members of the multidisciplinary team
• promoting a just and fair, open and transparent culture
• promoting a culture of learning and academic and professional critical enquiry.

The UK population is changing with new and ever-increasing capability to treat and manage illnesses that previously caused great disability or death. At the same time, people are living longer, with increasing levels of comorbidity and long-term conditions and limited resources within the NHS. Emerging from the Covid pandemic has already created further pressure on these finite resources and this is likely to be a significant consideration in the coming years. GPs shape and adapt to the future plans for the NHS, understanding how each part of the health service is working to deliver the planned outcomes.

Leading in healthcare post pandemic will require GPs to model new ways of working to better integrate services and teams delivering and co-ordinating care.

As a GP you have a wider social responsibility to use healthcare and environmental resources economically and sustainably. In addition to their business and employer responsibilities in local practices, GPs also perform a growing range of leadership and management roles in other NHS organisations.

Leadership frameworks and models

There are a range of leadership frameworks and models available to help GPs engage in change processes. These processes are key to GPs performing in their role as leaders and supporting others’ leadership development. They also provide structure and method for leadership activities to enable safe and effective patient care.

In engaging with change processes, patients and staff will look to GPs to influence and help determine the future direction of services. In leading and managing change there is a need for you as a GP to understand yourself and how you can work effectively with your teams and others and take people with you. This means contributing to the wellbeing of yourself, your colleagues and your patients through good management of all those involved in the provision of care and through the design of robust systems that encourage good care and effective, sustainable and environmentally sensitive use of resources.

Many GPs take on the additional challenge and responsibility of running their own practice, acting as the employer of a team of administrative and clinical staff and taking on financial responsibility for their business. This requires GPs to develop a wider range of business and management capabilities than doctors in most other medical specialties.

Common leadership and management areas in general practice

There should be a working knowledge of the following topics. Although this is not an exhaustive list, it includes:

• equality and diversity, including disability registration, rights and access and discrimination law, considering all protected characteristics outlined in national legislation relating to equality
• probity, such as gifts, conflicts of interest, financial probity and the effect of payment by results
• NHS complaints procedure and principles, litigation and medical negligence, raising and acting on concerns about patient safety and freedom to speak up
• identifying and addressing poor practitioner performance
• welfare of colleagues, such as health and conduct.

National regulations, contractual and legal frameworks

• Medical indemnity applied to primary and secondary care, including medical negligence
• Other acts of parliament and regulations relevant to medical practice, including (but not limited to):
  • controlled drug regulations including registering, prescribing, storing and destruction
  • data protection, including the Caldicott Principles, the General Data Protection Regulation (GDPR), record-keeping, legal basis and consent models for information sharing, lost records, privacy and fair processing notices, sharing electronic records, storing and destroying medical records
  • health and safety at work regulations relevant to general practice, including infection control, vaccine storage, decontamination and spillage (Control of Substances Hazardous to Health (COSHH) Regulations), safe practice and methods in the working environment relating to biological, chemical, physical or psychological hazards that conform to health and safety legislation
  • NHS prescription regulations
  • Performers Lists, regulatory board regulations and GMC guidance regarding fitness to practice.

Administration

Administration is an important part of general practice. What follows are examples of key administrative roles. This is not an exhaustive list but includes:

• death and cremation certificates, including regulations on completing certificates, when to refer to the coroner or procurator fiscal
• general administration of do not attempt cardiopulmonary resuscitation
• (DNACPR) forms, including safekeeping in the community and appropriate review of these
• insurance reports, including for life insurance, critical illness insurance (personal medical attendant reports) and travel insurance
• notification of infectious diseases
• power of attorney paperwork
• private certificates and medicals, including principles such as disclosure of information, for example, firearms, insurance cancellation, probation, adoption, critical Illness cover, fitness to fly or travel, fitness to drive
• registration, including visual impairment and disability
• relevant benefits and allowances, including end-of-life and maternity support
• relevant regulations under mental capacity and mental health acts
• statements of fitness to work certificates and related sickness regulations, including principles of returning to work.

Practice management and business matters

You should have a working knowledge of:

• contract requirements such as clinical outcome frameworks and enhanced services
• external assessment and inspections (for example, by the Care Quality Commission (CQC), training inspections, the Care Inspectorate)
• federations and GP networks
• financial aspects of a medical practice
• the Freedom of Information (FOI) Act and information governance, including Caldicott Guardians, management of data, confidentiality
• information technology to facilitate clinical and business practice
• key issues of being self-employed, including partnerships and locum work
• key issues of employing or being employed
• legal and contractual frameworks for provision of primary care services in all four nations
• patient participation groups
• patient registration and eligibility for NHS care
• patient access to medical records
• pensions
• practice development plans and strategy, including contributing to development of safe systems
• principles of commissioning
• principles of employment regulation, including appointment, discrimination, redundancy and dismissal, and occupational health for staff, including immunisation, ill health and infectious disease
• provision of additional services (such as dispensing medication, travel clinics)
• record-keeping, including clear, accurate, legible and contemporaneous record-keeping and amending records
• staff development, training, and appraisal
• UK health priorities and regional and local variations
• workload issues and major incident planning, and the role of the GP.

Work-based learning

Undertaking a leadership activity provides an opportunity for GP registrars to provide evidence linking to leadership and teamwork. This will provide a deeper level of integration within the organisation, benefits for the practice, for example system changes leading to greater efficiency, and benefits for patients relating to improvements in patient safety.

Doctors will enter GP training with a range of experience in leadership and it is important for them to consider, in conjunction with their clinical and educational supervisor, how to develop these skills over the course of their GP training and beyond. It is important that an environment is created to encourage leadership activities, facilitating the process and providing opportunities and support, with an openness to feedback.

Suggested activities might include:

• chairing meetings
• running an educational session
• designing clinical protocols or pathways of care
• producing information and resources for patients such as webpages or leaflets.

Quality improvement projects

The GMC expects all doctors to take part in systems of quality improvement. Quality improvement projects should be led by GP registrars, supported by their educational supervisor, and include working as a team with other members of the practice to create a sustainable change.

The topic for a ‘mini-QIP’ could be a process or system, clinical care issue or educational initiative that ultimately has an impact on the safety of patients.

It can be harder to carry out quality improvements in secondary care in a short timescale due to the larger scale and complexity of the organisation – but it is possible to become involved with how changes are introduced. If you have the opportunity to speak to or shadow someone introducing a project you can learn from observing how service changes can be carried out even in a large organisation.

Self-directed learning and formal learning

You can find an eLearning module(s) relevant to this topic guide at elearning for healthcare.

Learning with colleagues

Leadership and quality improvement are always best learned with others from as wide a clinical background as possible. It is essential to get used to seeing how others (patients, clinical and managerial colleagues) see the problem to be able to find a solution. Obtaining feedback as you learn is essential, as is the ability to give supportive and constructive feedback to others.

Applied Knowledge Test (AKT)

• Statutory legislation such as information governance and confidentiality
• Responding to patient safety concerns
• Data interpretation related to systems and improvement of practice

Simulated Consultation Assessment (SCA)

• A patient who is a receptionist in the practice requests sick leave because she is being bullied by the practice manager
• A patient newly diagnosed with essential hypertension asks why the drug he has been prescribed is not recommended as the first-line choice in the current guidelines
• A new district nurse asks advice on the management of an uncomplicated sore throat in a housebound patient with a previous stroke

Workplace-based Assessment (WPBA)

• A Quality Improvement Project (QIP) looking at the number of salbutamol inhalers prescribed to adults and reviewing patients who may need additional treatment
• A learning log on leading the afternoon session on the vocational training scheme (VTS) course
• Attending a course on leadership skills for the future GP
• Completing a Leadership Multi-Source Feedback (MSF) to gain colleague feedback on personal leadership behaviours