The promise of shared leadership in primary care

Raj Nair is a GP Trainer and Associate Dean NHSE at Albion St Group Practice, Rotherhithe, London.

Since the inception of the NHS, GPs have run practices as independent contractors through a partnership model. Most practices run on a hierarchical partnership model of leadership by GP partners, though fewer GPs are choosing to become partners. There are many reasons for this, including not only added workload and financial instability, but also the added responsibility in decision making for the business.

One potential solution to the increasing pressure and quality demanded from general practice is good leadership. The link between leadership and quality, with a strong emphasis on medical leaders, is generally accepted and argued to be critical for effectiveness.

Shared leadership

Ever changing organisations, increased workload, and complex tasks have led to unrealistic expectations of a single traditional hierarchical leader.¹ More recently, shared leadership (SL) has gained interest. The Medical Leadership Competency Framework emphasises the distribution of leadership across the medical team.² West et al argue that a collective approach to leadership is key to delivering quality patient care, with a policy shift from hierarchical leadership (HL) to greater SL.³

Fletcher and Käufer describe three stages of learning in SL: staying within bounds of expectation, reflective practice to alter views based on others’ perspectives, and losing individual focus for the co-creation of ideas.⁴

A universal problem with SL research is how individual studies define it, making comparison and drawing overall conclusions harder to interpret.⁵ SL is one of many forms of plural leadership; others include distributed, collaborative, collective, and co-leadership. The various definitions of each, often dependent on the context of the organisation, can make the identification of definitional boundaries of SL, and its impact, hard to identify. This can question the findings of SL research and whether they could be due to different forms of leadership. I define SL in a more universal way, as a stance where decisions are made by diverse designated leaders through discussion and exploration with multiple team members, whereas HL is where leaders make decisions on their own.

In 2006, I joined my practice where all the GPs (and a nurse practitioner) were equal partners. However, as the list size grew and clinicians increasingly did more part-time work, we found that we had 11 partners and started to employ some salaried GPs. Despite this move, decision making and finding a convenient time for us all to meet was difficult. So, we switched to having a more HL model with an executive team (consisting of two partners, the practice and office managers) to make day-to-day decisions. This seemed more responsive to the fast-paced decision-making demands of the COVID-19 pandemic. There is further evidence of HL being of benefit during emergencies.⁶ However, not all partners felt they were aware or could influence decisions; so, in 2022 we reverted to a more SL model of a weekly meeting for all partners to make day-to-day decisions with the practice managers.

Nyenswah et al describe a similar experience during the Ebola epidemic of 2014–2015 in West Africa and how management of the epidemic was initially hampered by HL, with difficulties over coordination and communication with a central command structure. There was a shift to more distributed leadership, focusing on engaging stakeholders and communicating well; however, after the crisis, HL methods remained.

SL has been argued to improve outcomes,⁸ staff empowerment,⁹ and satisfaction.¹⁰ Salas-Vallina et al interviewed 42 Spanish heads of medical units and found that SL improved team performance during COVID-19, as there was a collective knowledge structure and enhanced planning. There were also improved relationships between staff, which led to better social support.¹¹ Ulrich and Kear argue that SL may be critical for improving safety and quality in health care, in part due to the multidisciplinary nature of the workforce.¹²

However, Aufegger et al conducted a systematic review of SL in acute healthcare teams and concluded that, although relevant to practice, there was no conclusive evidence base for it.¹³ This may be due to the inhibiting hierarchical structure of the NHS. Künzle et al found that, in high-performing teams in anaesthesia, both nurses and doctors fostered SL, though doctors displayed higher levels of leadership behaviour.¹⁴ Indeed, Liberman et al found that psychiatrists saw their role as the main leader in a team. Furthermore, Willcocks suggests the use of SL in multidisciplinary cancer care, facilitated by collaborative multidisciplinary team (MDT) working and an organisational culture of supporting innovation.¹⁶

Diversity and shared leadership

Konu and Viitanen researched SL among middle managers in medicine and found that SL was more common among female managers without a medical background and less common in smaller medical specialties.¹⁷ Kukenberger and D’Innocenzo argue that gender diversity can have a negative impact on SL, particularly in low cooperative environments, but that this would improve with positive effects of functional diversity.¹⁸ Idelji-Tehrani and Al-Jawad researched an NHS department enacting SL and argue that SL is a feminine model with traditional gender stereotypes reinforced.¹⁹ This may prove challenging to institute in the prevailing masculine model of leadership within the NHS.²⁰

Developing shared leadership

Carson et al found that team environment (communication and active participation in decision making), task complexity, having a shared purpose, voice and social support, the life cycle of a team, and external coaching were positive predicators of SL.²¹ Adequate resources, including finances and time, could cultivate SL.

SL, though, can threaten traditional hierarchal models and resistance to it can lead to difficulties in implementation.²² The hierarchical structure of a GP practice prohibiting SL fits with research suggesting that SL depends on culture²³ and team environment.²⁴ However, it is also dependent on transparent definition and allocation of roles,²⁵ autonomy, task complexity, feedback, and skill variety.²⁶ Self-managed teams, with flatter organisational structures, promote the need for leadership to come from within the team.²⁷ However, a GP partnership does not have flat hierarchies with doctors acting as both employers and leaders.

Practical application

A high partner-to-salaried ratio may release partners to focus on running the business and lead to more profit, while allowing salaried clinicians to focus purely on clinical workload, without having the responsibility of running the practice. This may be helpful in larger practices who would otherwise have a large number of partners in an SL model. However, there are areas of middle ground, as GP partnership may not be the only form of leadership in practices. For example, we have delegated some defined, boundaried paid partner-type work and decision making to our salaried staff to share the workload, develop their leadership skills, and allow them to experience some partnership responsibilities without having to fully commit. This also leads to potential succession planning within a partnership as well as growing a more diverse skill mix.

With the potential dismantling of the GP partnership model and the drive for a multiprofessional workforce in primary care, is this the right time to look at SL as a facilitator of positive change? Specifically, to not only improve patient outcomes but also retain engaged staff in primary care. Colleagues, across the MDT, in primary care may find the prospect of joining a partnership more attractive if they feel a practice has a more inclusive culture of SL. Furthermore, SL may appeal to not only those wishing to influence decision making more, but also those who may feel over-burdened by being a sole leader in an HL model of practice. Research specifically looking at SL within NHS GP practices is warranted to explore this further.

References

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Featured photo by Dylan Gillis on Unsplash.