Clinical Leadership, District Hospitals and Rural Health

Clinical Leadership, District Hospitals and Rural Health

This publication “Strengthening Clinical Leadership In Hospitals – A Review of the International and South African Literature ” (2013) by Jane Doherty is a must-read for anyone who has a stake in strengthening local leadership for better health care.

Policy brief (download link above for full publication):

The debate around public hospital management reform in South Africa tends to focus on the extent to which authority should be decentralised to the senior management team and how to strengthen general management processes. These interventions are seen as key to improving hospital performance.

However, the international literature emphasizes that, in the hospital setting, decision-making that directly affects the quality of care largely occurs at lower levels of the management hierarchy. Equally importantly, it is largely clinicians, and not general managers, who make these decisions.

For this and related reasons, decentralised clinical leadership may be a good strategy for achieving the level of quality (and efficiency) that is required to ready public hospitals for National Health Insurance.

Clinical leadership is the transformational leadership provided by practising clinicians who drive improvements in the quality of care through innovation, either through formal participation in clinical governance activities or through informal role modelling and mentorship.

One of the most common mechanisms for strengthening clinical leadership is the creation of clinical directorates headed by a clinician who is usually supported by a general manager. The clinical director oversees clinical processes and also puts in place appropriate management systems so that he/she can manage the budget, human resources and procurement effectively.

Clinical leaders can be any type of health professional, although they are most commonly doctors and nurses. Importantly, they continue their clinical work on a part-time basis: this is what allows them to keep patient care at the heart of management, understand what is needed to protect the quality of care and retain the respect of the clinicians and other staff that they lead.

Successful examples of clinical leadership are based on open and inclusive communication as well as collaborative leadership styles that rely on influence and mediation (sometimes called “influence-ship”) rather than “command and control”. They allow clinical input into decision-making at all levels, facilitate clinical leaders’ understanding of the strategic direction of the health service and reconcile professional aspirations with resource availability.

The few local studies on this topic suggest that the concept of clinical leadership as it is expressed in the international literature – as central to clinical governance and improving hospital performance – may be productive for the transformation of South African public sector hospitals, many of which are experiencing a management crisis.

Further debate and research is required to understand how the local context may affect the relevance and implementation of the clinical leadership concept. Particular questions to explore in future work on the role of clinicians in leadership in South Africa are:

1. Can other clinicians fulfil the same clinical leadership roles as doctors?

2. Do clinical leaders need to be practising clinicians?

3. Do clinical leaders need to be the head of a management team to effect change?

4. Do clinicians have the skills to be leaders and managers?

5. Will clinician leadership lead to “medical dominance”?

6. What is the role of the professional health care manager in relation to clinical leaders?

7. Can the private for-profit sector provide lessons for improved clinical leadership?

Finally, clinicians already play a pivotal role in sustaining hospital services in South Africa. This is especially so in poorly-resourced areas: thus, in rural district hospitals, clinicians shoulder enormous responsibility, not just for managing the care of individual patients, but also developing staff and services at primary and hospital level, and contributing to wider decision-making around health care priorities and resource allocation.

This may make the district hospital a good candidate for exploring mechanisms to harness the leadership potential of clinicians.