As a non-clinician, sometimes still practicing health economist and former CEO of two large national health not-for-profits, I would observe that what Canada needs more than ever before is to encourage more nurses, physicians and other clinicians to take on senior leadership positions. Here’s why. Here are the caveats. What do you think?
Canada is tough on its health leaders. As a former senior public servant of many years, I worry, and we all should worry, about why it is that worthy individuals are increasingly loath to throw their hat into the ring for senior leadership positions. It has been documented that the median shelf life of most senior officials running our $192 billion health care system has dropped from 7.4 years (decade of 1975-1985) to just 1.4 years (1995-2005). In the association world, we know that the tenure is longer in senior executive positions (average of 7 years), but is also in decline.
Part of this leadership challenge is a hangover effect from the decade of the 1990s; as Canada, first at the provincial level (anyone else remember the 1991 Banff declaration resulting in over 15 percent reductions in nursing and medical school enrollments?) and then with the spring 1995 federal budget took a broad axe to the resources of the system. De-layering was the option of choice. Mid-level leadership positions were restructured away. Physicians, nurses and others in the system were also seen by policy-makers as cost centres rather than service centres or value centres as seen by patients. Indeed, we have witnessed a “hollowing out” of the ranks of future leaders that is only now, as we baby boomers begin to move on, resulting in questions around where have all the (clinical) leaders gone?
The follow-up research pertinent to the declining shelf life in senior health leadership positions suggests a few other explanations for the possible reticence of high potential, high performing individuals to take on senior level jobs. Thirty senior public servants were asked, through key informant interviews, the reasons behind this downward trend. The first reason given by interviewees was the growing disjuncture or gap between authorities and accountabilities. In the current, regionalized environment, much of the managerial authority has been decentralized to health authorities.
With the exception of physician remuneration and drug benefits, virtually all other health care spending is now under the auspices of “arms length” regional boards. Accordingly, all the small “p” policy decisions are now beyond the reach of senior public servants. At the same time, the big “P” policy decisions have largely been wrested from Ministers of Health and given over to Premiers or First Ministers, looking for advice increasingly from departments of Intergovernmental Affairs. Anybody remember the series of First Ministers’ Health Meeting of the last decade culminating with the so-called “fix for a generation” accord off September 2004? And, get ready. It is all about to begin again. So, in short, while Ministers, Deputy Ministers and Assistant Deputy Ministers are still held accountable in the court of public opinion, the authority for significant policy setting and implementation resides elsewhere. This is what some might call the “stress of distress” of being a senior public servant these days.
Turning to the senior jobs in the administration of our health and health care system, casual empiricism suggests that more clinicians do seem to be taking on the big jobs. I would observe, and reinforce the point, that those that are doing so successfully view leadership as a discipline that needs to be well studied and better understood. And, having taken the time to study the discipline of leadership, successful health leaders must then take their leadership toolbox and carefully apply it to the unique, increasingly complex circumstance that is health and health care. Health care is not like the market for CD players or, indeed, like any other public interest pursuits (e.g. education). We have moved, as my colleague Geoff Rowlands at the HealthCare Leaders Association of BC is fond of pointing out, from a health system of corner stores to conglomerates (e.g. $11 billion Alberta Health Services budget).
The good news is that a “community of practice” of health leadership is beginning to emerge in Canada and be taken seriously. For example, the “Canadian College of Health Services Executives” has recently changed its name to “Canadian College of Health Leaders”. The Canadian Health Leadership Network has come together to mobilize the growing energy and enthusiasm at the College and across some 30 Network Partner organizations to address the leadership gap. All have embraced or formally adopted a new pan-Canadian standard framework called the LEADS in a Caring Environment capabilities framework. In this framework, knowledge and experience in health and health care are positively weighted over the lifecycle of leadership.
The bad news is there are still serious cultural impediments for clinicians moving from the surgical suite to the “C-suite.” All too often clinicians are seen as going to the “dark side” when they move into leadership positions. In my experience as a non-clinician CEO of a professional association, I often witnessed how moving from the ranks of care providers to policy setters is still accompanied by this sense of loss: loss of professional capacity; loss of prestige; loss of personal and professional support networks; loss of community engagement/respect; and, in some cases, a significant loss of income. Again, the good news is that organizations are mobilizing to provide new support systems and the leadership training required to enable clinicians to overcome some of the cultural hurdles (e.g. Canadian Society of Physician Executives and Academy of Canadian Executive Nurses).
More can and must be done to allow clinicians (and non-clinicians) who are passionately committed to a better Canadian health system to acquire the leadership skills necessary to realize their full leadership potential. In the end, to paraphrase the leadership gurus Kouzes and Posner, all leaders are made, not born: It’s what you do with your leadership potential that counts!
Founding Executive Director
Canadian Health Leadership Network (CHLNet)
December 15, 2010