Mel Moss and Claire Tanner, 2013. CAT as a model for development of leadership skills. Reformulation, Winter, p.11,12,13,14.
Mel Moss writes:
Clinical leadership and management skills are identified as a core part of the training and curriculum for medical higher specialist training as set out by the Royal College of Psychiatrists’ curriculum (2012:91-94). A large part of higher trainees’ role within the NHS is occupied with the interface between the organisation and the clinical workspace. The Curriculum emphasises the need to ‘demonstrate an understanding of the differing approaches and styles of leadership’ (2012:91). As a former senior medical manager, the emphasis on learning and development was with regards to my own personal skills and experience using tools such as the Myers-Briggs Personality Inventory (Briggs-Myers and Briggs, 1995)) and Action Learning Sets (McGill, 1993). These approaches focused on my own character and a practical response to a ‘problem’ rather than a systemic interaction exploring the function of the service and teams. As part of my role as a trainer of junior psychiatrists I am expected to teach them about Leadership but have no formal training in this field myself. Therefore during my sessions with my higher trainee (within one year of appointment as a Consultant) we used the model of CAT to explore styles of leadership and their implications.
From the date of their first appointment it is expected that a Consultant Psychiatrist will take a clinical leadership and management role within the services. This position is unusual in that even at the most senior grades there is an expectation that clinical and managerial duties co-exist (this is in contrast to many of the other professional care roles who move away from direct client work as they approach executive board level). A new consultant is thus expected to provide leadership within a team and to serve as an interface between the team and the organisation particularly with regard to quality indicators for clinical care and helping to resolve conflicts regarding the ‘needs of the individual patient and the service’ (RCPsych 2009 College Report 154, p34). With the advent of revalidation of medical practitioners it is imperative that all doctors demonstrate this focus on quality of care in terms of their own practice but also ‘promote excellence in service delivery’ (Laurence Mynors-Wallis 2012, p5).
Each higher trainee psychiatrist is attached to one Consultant per year during the three years of higher training. The Consultant has special responsibility for their educational and personal development during this year of their training. This includes development of management and leadership skills which the consultant may (or may not) have had practical experience of but may have had little training in themselves. There are tools available for the trainee to explore individually on the internet and in this case the trainee (CT) had completed e-learning modules (LeAD) based around the Leadership Framework (NHS Leadership Academy, 2013) but there remained a gap between these theoretical tools and their application in day to day practice. Therefore as part of our weekly supervision sessions we explored different models of consultant practice in relation to the multidisciplinary team both in terms of our own direct experience and in relation to serious incident inquiries. During these reviews we explored different frameworks for analysing Consultant behaviour and its impact on the core functioning of the multidisciplinary team and wider service. CAT was used as a model for illustrating this, allowing us to show both the target procedures, (i.e. aims of the Consultant role) and the reciprocal roles established between the Consultant and multidisciplinary team.
CAT is an integrative therapy with an emphasis on collaborative working between client and therapist. The theoretical background contains elements of object relations theory (Ryle, 1975) and this model is also applied by the Tavistock with regards to their training and models of multidisciplinary working. The Tavistock models have parallels with the increasing interest in CAT as a group based therapy (Hepple, 2013). Therefore there is an association between the theoretical principles of CAT and models of examining group processes and multidisciplinary teams. CAT approaches have previously been used as tools for formulation and resolution within a dysfunctional service within a general hospital (Walsh, 1996) and this identified key reciprocal roles between the managers and clinical staff. Reciprocal roles within the NHS management structures have also been elucidated by Welch (2012) which gives a framework for modelling interactions between managers and clinicians.
For the case studies we chose different styles of consultant behaviour namely the overinvolved and autocratic versus the disengaged. The autocratic style was exemplified by the Normansfield Report (Committee of Inquiry into Normansfield Hospital, 1978) in which the Consultant became increasingly intrusive and domineering with the result that relations with the clinical team became increasingly fraught. This ultimately led to a general strike in a learning disability hospital in which the needs of the patients were completely neglected. The staff had the option to either passively submit to the demands of the Consultant or rebel leading to the strike, neither of these outcomes were responses to the needs of the patients but rather reactions to the provocation of the Consultant. In this instance the focus of the staff group changes from a duty to provide care into a need to manage the behaviour of a senior colleague by either acquiescence or resistance.
More recent inquiries such as Winterbourne View (Department of Health, 2012) and Staffordshire (Francis, 2013) have identified a different problem with Consultant behaviour in the task orientated disengagement from the wider service. Whereas the Normansfield Inquiry and the later Ashworth Hospital Report (Fallon et al, 1999) described the roles and duties of Consultant psychiatrists in detail, later developments such as New Ways of Working (CISP/NIMHE, CWP, RCPsych, 2005) have sought to reduce pressure on consultants by limiting their responsibility for actions of other team members and these later reports identify consultants disengaged from the management of services and failing to advise non-clinical managers. In the Staffordshire Report (Francis, 2013) there was a failing to inform managers of the impacts of service changes and draw attention to poor standards of care, whilst at Winterbourne View (Department of Health, 2012) it is notable that the Consultants were not mentioned in a report highlighting the abuse of vulnerable patients. Disengagement of consultants leaves managers without senior clinical guidance and other professionals without access to their skills and knowledge. It is an instance where the authority implicit in the Consultant role is essential as the position allows ready access to communication both with the multidisciplinary team and the senior management structure of the organisation.
Having identified extreme positions with these cases we looked for a more balanced intermediate position. We considered whether a consultant could be clinically authoritarian and not monitor standards or vice versa, but it was felt less likely that an individual would be overzealous in one area and laissez faire in the other (and this did not accord with our direct experience). From this we drew a third diagram illustrating the ideal position. This is not purely a description of the Consultant but also their behaviour in relation to the multidisciplinary team. The ability to reflect on events and errors is essential to improving standards and the honesty required to acknowledge one’s own shortcomings is a necessary part of inspiring confidence and trust in others. In this we have been lucky to work with a robust and challenging team who are enthusiastic about patient care and supportive to each other: debriefings have been shared events and frank exchanges and day to day clinical practice involves shared learning and decision making.
Claire Tanner writes:
Developing management and leadership skills are an essential part of my training and will be a key skill in my future working life as a Consultant. With this in mind I have accessed the training resources available (LeAD and Royal College of Psychiatrists, 2012) and taken opportunities to attend the Executive Board meeting of the Trust, meet senior managers and represent my colleagues on the Local Negotiating Committee, as the Trusts higher trainee representative, a role which involves interacting with Trust management. However there remained a discrepancy between what I have learnt academically and what I have experienced first hand. It is difficult to identify the components of good quality leadership when things are going well. Using the inquiry reports as case studies Dr Moss and I were able to pick out interaction patterns at times of crisis. I am not experienced in the use of CAT but the diagrams we drew gave me insight into how my attitudes would impact upon the behaviour of others and what approaches are most useful to avoid escalation of a situation.
The use of reciprocal roles also helped to illustrate point not covered in the leadership curriculum, namely that the Consultant is not only in a leadership role over others (self to other relationship) but is led by two other groups. Firstly consultants are lead by more senior colleagues who are giving direction to service changes and secondly by certain members of the clinical team who inevitably have more skills and experience in certain areas (Other to Self Relationships). There is also a large element of self-management and leadership (Self to Self Relationship) necessary to maintain professional practice and standards. Ultimately I have learnt that being an effective leader is not about just about assuming a leadership position but also recognising times when I should be being lead rather than leading. It is also important to make sure that the processes resulting from this are safe and supportive for my patients.
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