Exploring the role of senior medical leadership in mental health providers in England

Background

The medical director is an essential role in delivering integrated services in partnership with a variety of sectors such as social care, independent and voluntary providers in complex systems. It is an important position offering an essential clinical voice to the organisation’s board of directors, alongside others such as the director of nursing. Within this, they provide oversight, direction, insight and accountability around safety, quality, strategic direction and a range of other areas within their agreed portfolio.

Medical directors are also operating in changing and developing external landscapes, including the embedding of integrated care systems (ICSs) and provider collaboratives, all of which are at different levels of maturity with all operating under significant financial pressures and rising demand. Medical directors working in mental health organisations have challenging and complex roles, with significant internal and external organisational pressures. While progress has been made, these medical directors continue to be impacted by the landscape of mental health services due to conditions including:

• a lack of party of esteem, commonly measured by the following:

— excess mortality: with adults living with severe mental illness – such as bipolar disorder and schizophrenia – having a life expectancy 15 to 20 years lower than the general population

— the burden of disease: with estimates historically putting mental health at around a quarter of the disease burden and only 13 per cent of the NHS budget

— a growing treatment gap: while one in six people aged 16+ having experienced symptoms of a common mental health problem, such as depression or anxiety, and more people are in contact with mental health services than ever before, there are still over one million people on a waiting list to access mental health services and an estimated 8 million people with mental health needs not in contact with NHS mental health services.

• historic underfunding in comparison to other sectors, for example spending on mental health services declined from 14 per cent of the NHS budget in 2008 to just 9 per cent of the budget by 2021
• stigma against people with mental health conditions
• lack of investment in the mental health estate, which is some of the oldest in the NHS, with 18 per cent constructed before the NHS was formed and multiple sites classified as ‘not functionally suitable’ especially for therapeutic interventions critical for treatment and recovery outcomes
• workforce vacancies impacting service delivery and potential for expansion.

The mental health sector also has a unique legal framework and statutory requirements in applying the Mental Health Act – of which medical leaders require deep understanding and knowledge.

The role of medical director in a mental health provider therefore presents specific challenges and requires focused attention to ensure they are supported to be effective leaders. They need to be equipped to design and deliver a structure within the workforce which embeds leadership skills and attributes which will be essential in safeguarding the future of high-quality mental health services.

As part of the Mental Health Medical Director’s Forum (hosted by the NHS Confederation’s Mental Health Network) in England, members sought for the first time to capture a national picture of the medical directorate and medical leadership across the English mental health system to identify strengths, areas for improvements and how together they could achieve the most impact in their roles, structures and organisations. By understanding this, we aimed to establish if there is additional support medical directors may need so they and their directorates can operate effectively across their organisation and systems. Further, we looked at whether there is additional support needed when considering what comes next after being a medical director. This report explores what is already in place to support medical leadership in organisations, and what more would be helpful.

Methodology

In early 2024, a survey including qualitative and quantitative measures was sent to all members (60) of the Mental Health Medical Directors Forum to complete anonymously. This group consists of medical directors working across statutory, independent and voluntary organisations in England providing mental health services. Four focus groups were held in early 2024 for the same participants to explore the themes of the survey in more detail. A validation meeting to review the findings and update with any recent additions took place in April 2024, with six medical directors in attendance. Forty-two (70 per cent) medical directors in the forum responded to the survey, and 23 (38 per cent) medical directors took part in a focus group. Ninety-eight per cent of survey respondents were psychiatrists. Respondents worked full time (93 per cent) or part time (7 per cent). The type of organisation, region and years of experience as a medical director or chief medical officer are shown in the charts below.

Key findings

Role of the medical director

The role of the medical director is crucial in providing safe, high-quality services and improving outcomes for patients. Medical directors shared that this was done through amplifying the voice of clinicians across all levels of the organisation and facilitating their involvement in shaping and running services. The position enables broader impact, particularly in achieving better patient outcomes, improving the work and lives of psychiatrists and enhancing staff productivity. Succession planning and supporting trainees are seen as rewarding aspects of the role, as is using their clinical knowledge and experience to influence and have impact at board level. In many cases, the medical director is the only practicing clinician on the board. Medical directors shared that creating a collaborative approach requires patience but is ultimately the most effective way to improve services and makes the role more rewarding.

The medical director is a key board member. They do more than lend a clinical voice, but advocate for the patient at the organisation’s highest level and are crucial to improving the quality and value of care. A medical director plays a vital role in shaping their organisation’s culture and strategic vision and communicating this to staff on the front line.

Faculty of Medical Leadership and Management, NHS Improvement (2017), The Medical Director’s Role: A Guide for Aspiring Medical Leaders

Adapting, evolving and delivering

The role of medical director or chief medical officer (which are commonly used interchangeably) has continued to adapt and evolve as the health and care landscape around it changes. This is both within their organisation – with evolving service models and mergers between mental health and community trusts – and externally as ICSs become the established mechanism of commissioning and delivering services across 42 regions in England.

The areas which remain at the top of the medical director’s agenda include:

Other functions of medical directors across organisations in England include:

The external roles and responsibilities of medical directors are also growing,
within an increasing need for collaboration, relationship building and integration
through ICSs, both within the integrated care board (ICB), integrated care
partnership (ICP) and provider collaboratives. Many medical directors are part of
more than one ICS.

Common areas of external roles and responsibility include:

Clinical work as a medical director

The time commitment and type of medical director role varies significantly between respondents, with the majority indicating they undertook one day a week carrying out clinical work. Some who spend more time undertaking clinical work are from a provider collaborative or independent sector organisation, although not exclusively. The arrangement seems bespoke and personalised, and is supported by the board and chief executive of their organisation. The majority who still undertake clinical work find it adds positive value to their role as medical director, although it can be challenging to balance all commitments.

Benefits of undertaking clinical work

Having a practicing clinician on the board ensures they stay connected with current medical practices, make informed and empathetic decisions, and maintain their skills. The respondents shared that the role is enjoyable and feel it enhances their credibility among colleagues, fostering a strong connection between the front line and the board. It also positively impacts the wider workforce’s perception, reinforcing the clinician’s understanding of day-to-day issues and maintaining a position as part of the medical workforce and team.

Challenges of undertaking clinical work

Undertaking clinical work as a medical director involves the challenge of balancing dual roles, which one medical director described as like “riding two horses and the risk of falling between them both.” It requires careful management of protected time for clinical duties while also handling corporate responsibilities.

An underpinning principle of getting these benefits was having protected time and getting the right support in place from board colleagues who value and respect that aspect of the role. There was also a reflection that a different type of clinical activity may be needed than their area of expertise, as this could provide more flexibility to undertake both the clinical role and medical director role. For example, some medical directors undertook roles with more structured clinics to help manage workload and time rather than managing part of the inpatient area or having a catchment area to cover.

Building leadership of senior medical workforce

Building a senior medical workforce with leadership as a core skill and strength was seen as critical in supporting individuals to thrive at work and feel equipped to consider future roles in senior medical leadership positions. It was also seen as an area that needed support. Ideas shared which would enable this approach included the following.

Structuring to provide senior leadership opportunities. The structure of the medical directorate, including senior leadership positions, is necessary to providing both effective decision-making and leadership opportunities for aspiring clinicians. Leadership structures must be robust and clear to ensure clear lines of communication and accountability. Alongside this, they should be structured so medical professionals can progress through the organisation when they have developed skills and experience.

Investment required, both time and money. Medical directors identified the need for leadership development and training to be invested in, through both investment of money and time allocated for the range of formal and informal opportunities (see below ‘Formal and informal leadership opportunities’ below). Financial investment has proved challenging, with one medical director sharing they have been unable to provide any additional investment in this area since 2006. Using financial levers to the best of their ability, for example having more direct control over the medical workforce budget and using apprenticeship levies, were identified as potential good practice organisations can explore.

Supporting diversity in the medical workforce. Medical directors were asked to consider their directorate in terms of diversity. Based on their perception of their department at the time, which included medical and non-medical staff, respondents presented a generally positive picture around the diversity of people from different races and gender across their directorate. Less was known about areas such as sexual identity and disability within the workforce, and further exploration should be done by medical directors using staff survey data to understand the makeup of their directorate and their experience within the workplace. More exploration could be beneficial nationally, regionally and locally to ensure everyone is supported to thrive at work and consider leadership positions within the medical workforce.

Wider landscape and support. Essential for the above to achieve its intentions, there needs to be a wider landscape within organisations and structures which ensure people are ready to go for leadership opportunities when they arise. This would include effective job planning, business support and structures and having a specific medical workforce team. Alongside this, having an organisational development lead for the medical workforce was identified as beneficial, alongside an organisational-wide approach to leadership development which clinical staff can take part in. This organisational, multidiscipline approach to leadership development, alongside more bespoke targeted support for medical staff, creates a multitude of opportunities for learning and development.

Embedding triangulate leadership. Clinical leadership is multi professional, and working alongside colleagues in nursing and operations directorates in a triangulate leadership model can allow for better decision-making and for learning between each other. This type of model was also identified as a way to jointly bring in other professions from allied health professionals to digital leaders.

Formal and informal leadership opportunities. There needs to be a wide range of leadership opportunities and support structures in place, including both formal and informal opportunities. An example of a formal opportunities included using the apprenticeship levy to fund courses such as an executive masters in medical leadership. This course enabled participants to work on practical management and leadership challenges they have in their roles, and shows the medical workforce that the organisation is willing to invest in them and their future career. Another opportunity identified as a positive way of developing leadership skills was to engage in committees and projects with the Royal College of Psychiatrists.

Peer support, coaching and mentoring. Medical directors identified peer support, coaching and mentoring as effective ways for the medical workforce to develop management and leadership skills. One medical director shared an example of breaking down silos and bringing together deputy medical directors and clinical directors as a peer group, which provided mutual support and opportunities to develop together. 

Support medical workforce to look outwards. The role of medical director increasingly needs an outward facing approach, including partnership-working horizontally across other service providers and more widely within systems. Supporting the medical workforce to look outwards in their roles – for example building relationships across the health and care system, such as with acute, community and primary care – can help produce well-rounded leaders ready to progress to more senior colleagues. An example shared by a medical director included setting up action learning sets between medical leaders within different trusts. This included 20 consultants and SAS doctors joining from across mental health, acute, community and primary care providers.

Medical director career progression

The medical director is an important role within a mental health provider organisation, bringing a clinical perspective alongside leadership skills to engage and lead as part of a board of directors. As shown, many medical directors continue to dedicate time to undertake clinical work, and the time spent as a medical director varies considerably. The role has shown to open up a wide range of career possibilities when an individual is ready to move on from the role. The most common career steps include:

The ‘other’ category includes academic roles, taking a career break or being unsure on next steps due to being only in the first year of their medical director role.

Professional development opportunities which had been identified by medical directors as helpful to both build skills within their own role while preparing for future roles (especially if looking to progress to a chief executive, systems, regional or national role) included:

• Board development training: to support knowledge of finance literacy and skills needed for a board member. This is provided by a range of organisations from NHS England to membership bodies and consultancies. It was recognised that becoming part of a board can be a significant step from other roles, and continuing to develop in this area can be valuable.
• Joining formal and informal groups with peers and others who do the job, both internally and externally, where there is trust to discuss dilemmas and challenges in confidence.
• Engaging in formal coaching or mentoring, and having someone to be able to bounce ideas off and think through challenges.
• Undertaking courses and building expertise in areas complementary or adjacent to the medical director role such as on population health, public health or reducing health inequalities.

Areas where medical directors felt there could be additional support included:

• Helping individuals understand what roles are available and what they are like, for example roles regionally, nationally or within systems. Often engagement with these individuals would be on areas of work rather than as part of professional development, which changes the focus of the conversation.
• Training and support on managing and leading in difficult environments, managing conflict in the workplace and compassionate leadership. The area of management and leadership is evolving, and the styles and approaches in these areas can shape a medical director’s success in an existing or future role.
• Opportunities to learn, engage, shadow and role share with individuals in different settings, for example mental health and acute trust medical directors in an ICS footprint. With more services and organisations integrating in a variety of ways, more collaboration, learning and relationship building would be valuable.
• A development programme focused on technical skills working with wider-organisational colleagues, for example across estates and finance to inspiring the organisation to want a strong clinical vision. This recognises that leadership is more than just technical skills.

Conclusion

Medical leadership remains critical to providing safe, effective mental health services which meet the needs of patients and citizens. Supporting mental health medical directors to be the most effective leaders, and supporting them to design and deliver a structure within the medical directorate which embeds leadership skills and attributes, will be essential in safeguarding the future of high-quality mental health services.

This report has highlighted the need for a renewed focus on how we support medical directors working in mental health settings in their role and support their career progression. This is alongside how they in turn can support and develop the wider medical directorate to develop senior leadership skills to deliver high-quality care that is safe and have positive patient experiences within their organisations and services. To support this, we have set out a range of recommendations and proposed next steps to help meet these aims. 

More support for medical leaders in the first few months and years when beginning their roles. Action Learning Set style spaces to provide space for more peer-to-peer support between medical directors could be beneficial, recognising the wide range of responsibilities, pressures and priorities within their roles. It would also be worth exploring Action Learning Sets which involve other members of the board such as the finance director, director of nursing, operations director and human resources director given the essential role of collaboration and partnership in delivering high quality services.

A range of support and activities for medical director’s career development. Building on what medical directors have identified is beneficial, organisations, systems and national bodies can do more to support the career development of medial directors. This can be through prioritising time for them to complete courses such as healthcare leadership masters or through connecting them with people in roles such as chief executives or system leaders to understand further what these are like on a day-to day-basis. This would not just be beneficial in supporting medical directors, it would help embed a clinical vision across organisations, strengthening services and improving outcomes for patients.

More focus and prioritisation of developing medical leadership skills. The development of leadership skills should be embedded in all levels of medical training and medical roles, to support the medical workforce to be effective leaders at all levels and stages of their career. This can be through sharing good practice of existing models, and what makes these work in practice, for medical directors to apply and improve. This could also be through dedicated investment and support in training medical leaders, and creating a golden thread from undergraduate degree through to medical director of the leadership competency and skills needed at all levels of medical leadership.

Developing a flexible leadership framework for medical leadership roles. This could include a competency framework for the type of expectations for attributes, skills and expertise at different levels of medical leadership and example job descriptions for medical directors, deputy medical directors, associate medical directors, clinical directors and clinical leads.

Further exploration of how to support people ensuring diversity across the medical workforce. Exploring alongside staff surveys and data collected by organisations, more targeted programmes and support would be beneficial to support medical directors to support everyone within their organisation to thrive.

Further focus within the National Mental Health Medical Director’s Forum, hosted by the NHS Confederation, on areas identified. Building key topics into future medical directors forum meetings will be critical to ensuring medical directors themselves are driving this agenda. This could include topics such as developing an effective medical directorate structure, building medical director leadership and exploring and supporting diversity in the workplace.

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