6 How do doctors on boards influence performance? The case of NHS trusts

Introduction Healthcare organisations around the world are under increasing pressure to improve their productivity and quality of care, while achieving financial viability. In response, policy makers have argued for greater investment to support the development of clinical leadership at all levels. There is now a significant body of evidence demonstrating the positive impact of the increased participation of doctors on hospital boards on outcomes such as quality ratings, patient satisfaction and improved decision making. This positive impact is attributed to the knowledge that doctors have of the healthcare 'core-business', strong communication skills and their greater credibility. Secure in their profession, doctors may be willing to adopt more risky strategies, while always advocating for the patients. However, less is known about the relationships and dynamics created between the doctors (if more than one present on the board), executives and non-executives, as well as between the doctors and the chief nurse. Aims and objectives of the research project or activity Focusing on NHS provider organisations, this paper seeks to explore why senior medical leadership makes a difference to outcomes. Specifically, it reports on a study investigating the role of senior medical leaders in change management, to identify their unique leadership skills, behaviours and values, both in the context of the board of directors as well as in the wider organizational environment. The study also examined the relationships between doctors on boards, between each other (when more than one, executive or non-executive, is on the board), and between the medical director and the chief nurse. The aim here was, to understand if these relationships have a specific impact on governance and organisational outcomes. Method or approach Because of the exploratory nature of the study, essentially a scoping project, a qualitative methodology was adopted. Following two pilot interviews, a questionnaire was developed and refined. Twelve semi-structured interviews of physician executive directors from 11 different organizations were then conducted. The study used a maximum variation sampling method, by including doctors with none, one, or more than one additional doctors serving on the same board (executive or non-executive). The sample included NHS organizations that varied on several dimensions: acute/mental health, bed capacity, number of employees, Care Quality Commissioning ratings. A reflexive thematic analysis was chosen to allow for flexible and evolving coding. Transcripts for the first 6 interviews were checked and corrected, followed by initial coding and theme generation to refine research questions. These steps were repeated for the last 6 interviews. Finally, codes and themes were mapped, reviewed and finalised prior to defining, naming and recording the themes. Findings This study revealed that doctors are very efficient in the process of change management, through good operational knowledge, innovative ideas, and ability to identify and overcome many common barriers to change. It found that doctors in senior leadership roles tend to invest in personal relationships, they trust the people around them while helping them develop, and could think and act strategically. Doctors on boards displayed a mixture of the traditionally described leadership styles and behaviours and they lead based on the circumstances, the abilities of the people around them and the organizational culture. These approaches were combined with innovation, investment on relationships and learning, as suggested by complexity leadership frameworks. Additionally, the found evidence that some senior doctors on boards created coalitions that consist of three members in total: themselves, the chief nurse plus one more doctor board member (either executive or non-executive). The members of these coalitions were more likely to support each other towards either board reassurance or prioritisation. Lastly, the study identified several weaknesses of non-clinical board members, such as unrealistic expectations about change and intolerance to ambiguity. Here, the contribution of senior medical leaders was essential to achieve a more balanced approach towards organizational governance. Key messages This paper adds to the evidence base relating to the unique leadership skills, values and behaviours of doctors in senior leadership positions, which can be invaluable for healthcare organizations seeking to balance multiple goals of efficiency, high quality patient care and financial sustainability. It also uncovers the dynamic relationships between doctors on the board, who support, encourage, and advise each other, and form coalitions. A better understanding of the mechanisms and the processes behind the positive overall impact of increased physician representation in senior leadership positions is essential for evidence-based policymaking. Crucially it highlights a minimum requirement for doctor representation on boards, which is more than just the mandatory medical director role.