Nigel Edwards, Policy Director, NHS Confederation

As we made clear in our report 'Dealing with the Downturn', the NHS faces its greatest ever challenge. Health service funding will be squeezed severely from 2011 onwards, and we will have to make some really tough decisions in order to keep the NHS going in its current form as delivering free at the point of delivery on the basis of need.

One of the main ways we set out for meeting this challenge is to improve quality and redesign clinical services. This needs to happen in large enough scale to make real gains. Senior clinical staff will therefore be vital in driving this through. Strong evidence exists to show that organisations with clinicians engaged in the leadership of trusts deliver higher quality care and are able to respond to change more effectively.

Although thrown into sharp relief by spending pressures, our report 'Developing NHS leadership: the role of the trust medical director' highlights the fact that the challenge of better clinical engagement pre-dates the financial crisis. The NHS is unusual in comparison with other health systems in that it has traditionally had a very low number of clinicians taking up senior leadership roles.

There have, however, been some positive moves recently, such as in Lord Darzi's Next Stage Review, which stresses the role of clinicians – especially doctors – in delivering his vision for the NHS. Meanwhile, the NHS Institute has produced research on engaging doctors in leadership and worked with the Academy of Royal Colleges on a significant programme to define and build leadership into medical education. We also have the Chief Executive of the NHS David Nicholson who has also expressed a desire to see a doctor on the shortlist for all newly vacant posts.

We are keen to help with all this work and NHS Confederation Chief Executive Steve Barnett sits on the National Leadership Council, which was one of the recommendations of Lord Darzi's review. It is clear that we need to make more of the skills and insights that clinicians can offer the NHS.

Our report on medical directors is based on two seminars with NHS Medical Director Sir Bruce Keogh and in-depth interviews with current clinical directors. One of the first problems we identified about the role of medical director is that it is not very well or consistently defined. It is hard to sell the importance of a role to people – let alone highly trained clinicians – when the definition of the job is unclear. Our participants set out the functions of the role as: drawing up and implementing clinical strategy, leading on clinical standards, providing clinical advice to boards and acting as a bridge between the board and clinicians, aligning the organisation with clinical staff and working with other external organisations (such as PCTs and SHAs). Other roles such as clinical governance, education and revalidation are also often included within a medical director's remit.

The next issue is that there is no real career path into and out of the role of medical director. Most medical directors rise from departmental roles out of a wish to make a difference to their organisation, and the preparation for the role is somewhat haphazard. As one clinical director put it: 'You really have to create these things for yourself, talk to people and manage your career yourself.'

Enhanced training in the basics of management and how organisations work would help, as would appropriate administration to back up their work. The real opportunities to formalise the role and allow people to learn and improve, however, will come from mentoring programmes, project management and improvement roles, secondments to other organisations, and professionally organised learning groups or regular meetings with colleagues to share learning.

Even with a proper definition of what the role entails and support for people to grow into and develop their work, there still remains the issue of attracting people to the role in the first place. Most of our respondents said that the type of people who would make good medical directors are not always those who put themselves forward for the role. They were also keen to encourage junior doctors to see the value of getting involved in management. There were concerns that junior doctors only tend to see the negative sides of the job and have little exposure to the benefits, such as the opportunity to shape organisational strategy, improve patient care at a macro level and, as one respondent put it, 'influence things in a totally different way'.

Although the work is different and interesting, many doctors continue their clinical practice. This is partly about maintaining credibility among those who they manage, but it is also important as a route back into clinical practice should a director decide to move on.

The issue of career progression is important here. As mentioned earlier, the NHS does poorly in encouraging its pool of medical talent into organisational leadership. It is reasonable to assume that the role of medical director would be the first place you would look for future clinical leaders. Our respondents, however, were not enthusiastic about moving into chief executive roles. They cited a range of reasons, including the extra risk that chief executives take on in their jobs – not least the fact that the average period in post is two years. The nature of leadership roles is explored at length in another of our reports – 'Reforming leadership development…again' – and it is clear that there are cultural issues around the role of chief executive that need to be addressed. One of our interviews for the leadership development paper described the environment around chief executives as 'brutal' and 'arbitrary'.

Defining the role of medical director, and then supporting and encouraging clinicians in that role, is going to be very important. Nevertheless, as we rightly seek to make the most of one of the most highly skilled and able parts of the NHS workforce, it is clear that if we are to offer career opportunities that go right to the top of the NHS, we will need to address these issues – both through the culture of the NHS, and the relationships between central control and local leadership.