Do You Work in a 'Diva Subculture'?

Nicky Broyd

August 14, 2019

A new report from the General Medical Council (GMC) warns about problems with medical leadership subcultures that can affect patient care. 

The report, How doctors in senior leadership roles establish and maintain a positive patient-centred culture , highlights issues with 'notable clinical subcultures', including diva, insular, and patronage subcultures.

Meanwhile, healthcare leaders have another challenge to face as the latest Social Attitudes Survey looks at why some patients head to accident and emergency (A&E) departments rather than to their GP.

'Notable Clinical Subcultures'

The GMC leadership report comes from medical ethics consultant Suzanne Shale who identified a number of potentially harmful subcultures:

  • Diva subcultures, involving powerful, successful professionals who are often viewed as untouchable and not called to account for inappropriate behaviour. Colleagues may work around them to reduce their detrimental impact.

  • Factional subcultures, with endemic disagreements with teams organised around different 'sides'. Disagreements could be over approaches to treatment but the report also talks about factionalism arising from interpersonal conflict, intimate and family relationships, and arguments about private practice.

  • Patronage subcultures, which arise around high-status, well-connected influential leaders who staff depend on for developmental roles and who may then feel a sense of obligation towards.

  • Embattled subcultures, where high demand and inadequate resources leave staff feeling overwhelmed, leading to stress, anxiety, and burnout.

  • Insular subcultures, where units are isolated geographically or psychologically from the mainstream organisation, allowing professional practice or care standards to deviate from those expected.

Identifying Cultures

The GMC commissioned the report to better understand some of the challenges facing doctors and consultants as they step up into senior leadership positions.

Evidence was gathered through 27 in-depth interviews carried out in 2018 in the NHS in England and Scotland.

These included medical directors, GPs with commissioning or educational roles, and medically qualified chief executives. Around a third were women, and a fifth came from BAME (black, Asian, and minority ethnic) backgrounds.

One of the report's conclusions was: "It is apparent from the reflections of senior medical leaders that in some respects the most demanding but unsupported period of the medical leadership journey is in the first step beyond consultant (or equivalent) leadership, often as a clinical director. Many participants acknowledged that performance in these roles can be central to the experience of colleagues, but that they are undertaken by those who are still novice leaders and receiving limited developmental support.

"The nature of the trajectory from novice to expert medical leader is one which appears to be critical to health care organisations, but it seems to have been little explored in the literature.

"The evidence from this study suggests that as medical leaders mature they make an important shift of emphasis from a focus on achieving tasks, to a focus on enabling people. Given the different effects that both novice and expert medical leaders can have on colleagues, services and patients, an important question is whether and how this process of maturation may be supported and accelerated."

Do you work in a subculture like the ones the report describes? Please use the comments box to let us know about your experiences.

'No Born Leaders'

In a statement, report author Suzanne Shale said: "The evidence we already have suggests there is a clear association between constructive working cultures and measurably better outcomes for patients. Senior leaders are vital in developing those cultures, and many fulfil that role to a very high standard despite the pressures they face.

"But until now there has been limited research into how senior medical leaders view the culture they work in and meet the day to day challenge of building positive working environments. This study set out to capture their perspectives, and to convey their lived experience of attempting to nurture positive cultures in a wide range of healthcare structures and organisations."

GMC chair, Dame Clare Marx, said: "Positive workplace cultures are important in all sectors, but in healthcare they are especially crucial as they impact on patients as well as staff. Safe and high-quality care depends on a team working well, and that depends on them being led effectively.

"We cannot just assume that doctors in senior leadership roles will automatically be good leaders. Leading in healthcare isn’t easy. Leaders are developed, not born, and doctors who choose to take on these roles deserve to have all the necessary support and resources to help them succeed.

"This research is a really valuable contribution to an important issue, and should be required reading for people right across healthcare in the UK. There are many of us with roles to play assisting those in leadership positions, and I would encourage people to read and digest this report. This is the start, and there are more conversations to be had about the lessons we can all take from this work."

Social Attitudes

On the other side of the fence, patient insights into emergency care come from the British Social Attitudes Survey from The National Centre for Social Research. This used data from 3879 interviews with a representative, random sample of adults in Britain carried out between July and October 2018.

A major theme was the problem of getting timely appointments with a GP so patients go to A&E instead.

Among the findings:

  • People from deprived areas were more likely to think A&E doctors were more knowledgeable than GPs

  • Parents with children under 5 were less likely to have confidence in their GP but were also more likely to turn to the internet for health advice

  • Overall, 86% thought that too many people make unnecessary use of A&E, while 32% had actually used emergency departments. This was higher in parents with under-5s (54%)

Responding in statements, British Medical Association Deputy Chair, Dr David Wrigley, said: "These findings are disappointing but not surprising given that after years of cuts to NHS staff and services, patients know first-hand the frustration of longer waiting times for GP appointments, hospital appointments and inadequate social and community-based care."

Professor Helen Stokes-Lampard, chair of the Royal College of GPs said: "What this research highlights is that more public education is needed so that patients know where to turn when they become ill – and it gives useful insight into where this could be directed for the best possible impact."


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