Clinical leadership training: an evaluation of theWelsh Fellowship programme

Purpose – UK fellowship schemes have been set up to address low-level engagement of doctors with leadership roles. Established in 2013, the Welsh Clinical Leadership Fellowship (WCLF) programme aims to recruit aspiring future clinical leaders and equip them with knowledge and skills to lead improvements in healthcare delivery. This paper aims to evaluate the 12-monthWCLF programme in its first two years of operation. Design/methodology/approach – Focused on the participants (n = 8), the authors explored expectations of the programme, reactions to academic components (provided byAcademiWales) and learning from workplace projects and other opportunities. The authors adopted a qualitative approach, collecting data from four focus groups, 20 individual face-to-face or telephone interviews with fellows and project supervisors and observation of AcademiWales training days. Findings – Although from diverse specialties and stages in training, all participants reported that the Fellowship met expectations. Fellows learned leadership theory, developing understanding of leadership and teamwork in complex organisations. Through workplace projects, they applied their knowledge, learning from both success and failure. The quality of communication with fellows distinguished the better supervisors and impacted on project success. Research limitations/implications – Small participant numbers limit generalisability. The authors did not evaluate longer-term impact. Practical implications – Doctors are required to be both clinically proficient and influence service delivery and improve patient care. The WCLF programme addresses both the need for leadership theory (through the Academi Wales training) and the application of learning through the performance of leadership roles in the projects. Originality/value – This work represents an evaluation of the only leadership programme in Wales, and outcomes have led to improvements.

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Background
The importance of developing medical leadership has been well documented (Griffiths, 1983;Darzi, 2008;Francis, 2013;Tweedie et al.,2017). Griffiths (1983) emphasised the importance of medical leadership within the National Health Service (NHS), and both Darzi (2008) and the Francis (2013) recognised that doctors and clinicians required much more support to become leaders of the future. Darzi (2008) argued that leadership had been "the neglected element of the reforms of recent years." More recently, the General Medical Council (GMC) (2012) concurred that leadership is a requirement of all doctors and essential for quality improvement and patient safety, stating that being "a good doctor means more than simply being a good clinician." Although historically, doctors have taken on leadership roles throughout their careers, their somewhat low level of engagement with leadership and management positions ha sbe enwe l ldo cu men te di nth el it e ra t ure ( Bohmer, 2012;Warren and Carnall, 2011). Taken together, these reports and papers recognise the need for doctors both to be educated in the theoretical background of leadership and fulfil leadership positions or roles. Leadership and management are terms related to each other. Notwithstanding the myriad definitions, Mullins (2010) described leadership as "essentially [...] a relationship through which one person influences the behaviour or actions of other people," and that management is "getting work done through the efforts of other people." Leadership is about relationships, and management refers to a set of processes (e.g. planning, budgeting, staffing, measuring performance and problem solving when results do not go to plan) that keep an organisation functioning. In terms of leadership, as service demands increase, some have argued that there is a need for doctors to move from being "transactional" leaders (Weber, 1947)to"transformational" leaders (Burns, 1978;Sonsale and Bharamgoudar, 2017;Gillam and Siriwardena, 2013). Transactional leadership is a style of leadership where rewards and punishments are used as a basis for motivating followers; it recognises that everyone affects something or is affected by something (Sameroff, 2009). Transformational leadership is a style in which leaders use charisma and enthusiasm to inspire followers; they broaden the interests of employees to look beyond self-interest for the good of the group (Bass, 1990). However, no one style of leadership suits all environments, and leadership programmes recognise the value in leaders having a repertoire of approaches to use in different circumstances.
Leadership development programmes have been initiated by a number of medical education and training organisations, for example, the Institute of Healthcare Improvement in Massachusetts (Provost et al., 2006). The NHS London Leadership Academy offers bespoke "Darzi" Fellowships designed to meet the organisational and evolving health care needs of the NHS in London. The Fellowships are facilitated by a number of educational establishments, including the University of Leeds and London South Bank University. In Wales, the Welsh Clinical Leadership Fellowship (WCLF) programme was initiated, managed and funded by the Wales Deanery in 2013, with academic input provided by Academi Wales and accredited through the University of Wales Trinity St David's. As part of Welsh Government, Academi Wales had an established leadership programme for senior clinicians, and the Wales Deanery were able to negotiate fellows joining this programme. The WCLF programme, tailored to the Welsh health system, builds on the successful NHS Darzi Fellowship Programme (Stoll et al., 2010) and is informed by the Medical Leadership Competency Framework domains (Academy of Medical Royal Colleges and NHS Institute for Innovation and Improvement, 2010). The aim of the programme is to recruit aspiring future clinical leaders and equip them to build and lead improvements in healthcare delivery (Box 1).

LHS
The programme is designed to develop fellows' capacity to effect service improvement and leadership. It is open to full-time or less than full-time medical or dental core higher specialist trainees, regardless of specialty or training grade, who are planning greater involvement in clinical leadership and health service management as part of their role on completion of specialty training and who are able to take a year out of training. Selection is by application and competitive interview. The 12-month Fellowship comprises three components: theoretical background of management and leadership provided by Academi Wales (Table I); a project proposed by and based within a host organisation, under supervision; and a package of additional training comprising joint induction with other UK leadership fellows, a course at the Massachusetts Institute of Technology and the Institute for Healthcare Improvement. Action learning sets (ALSs), informed by the Kolb (1984) learning cycle, are a scheduled part of the Academi Wales programme and include needs-led activities and skills-based sessions on critical thinking and influencing. During the year, fellows are located in the host organisation where they undertake their project and are released to attend the training events as they occur. Fellows are also allowed to work clinically up to 20 per cent of the time. This was included to enable trainees to keep clinical skills up-to-date and ameliorate a loss of income arising from a change in their banding; Box 1. NHS Wales Medical Leadership programme aims Support the achievement of organisational objectives through effective management and leadership of people and resources Support the delivery of service innovation Increase self-awareness and understanding of personal impact on situations with strategies for improved effectiveness income reduction has been identified as a deterrent to participation in such schemes (Brown et al., 2012). Academic accreditation (postgraduate certificate in Professional Practice -Clinical Leadership) is awarded on completion of at least 80 per cent attendance at workshops and action learning and an associated assignment. Through a mixture of theoretical sessions and hands-on activities, participants are given the opportunity to put learning into action and test their skills in unfamiliar situations. In addition, three coaching/mentoring sessions were available whereby fellows could access a coach of their choice through "Coaching Wales". Fellows were also required to complete one 360°Healthcare Leadership Model online appraisal and receive a 360°face-to-face feedback session during the year.
In this paper, we report findings from our evaluation of the first two years of the WCLF programme, following Cohorts 1 and 2 (2013/2014 and 2014/2015). Formative in nature, the aim of the evaluation was to understand what worked and why and explore whether the purposes of the Fellowship had been achieved. The focus was on the fellows and two primary elements: their experience of the training and the workplace and project experience.

Method
The first two years of the Fellowship programme attracted four fellows in each cohort, ranging from specialty training (ST) grade 1 to 7. Summary information on the participants, their host organisations and projects is given in Table II. Their specialty background did not determine which project they undertook. Thus, for example, an anaesthetic trainee might undertake a project based in paediatrics.
At the commencement of their 12-month programme, participants completed a proforma outlining the reasons why they were taking part in the Fellowship and how they would judge if the experience had been a success. Main data collection comprised individual telephone interviews with fellows using a semi-structured interview schedule; face-to-face focus groups with fellows; observation of training; and one-to-one semi-structured telephone interviews with workplace project supervisors (see Table III). All were audio-recorded, transcribed verbatim and anonymised for reporting purposes. In reporting, each fellow was given a pseudonym. In Cohort 1, we named participants Maddox, Kirsty, Bryn and Gwen, and in Cohort 2, Morgan, Francis, Cerys and Emlyn. In presenting quotations, the notation

LHS
indicates the cohort (C1 from 2013 or C2 from 2014) and mode of data collection (FG:focus group; tel int: telephone interview). During interviews and focus groups, fellows provided accounts of individual experiences and insights into their expectations of the programme, benefits and barriers to the projects, academic training and supervision. In interviews, the supervisors offered their views on the Fellowship scheme, their fellows and their role as a supervisor. A Framework Analysis method (Richie and Spencer, 1993) was adopted with framework themes shaped by the Kirkpatrick (1979Kirkpatrick ( , 1998) evaluation framework -reaction, learning, behaviour, results -and informed by themes from the Darzi evaluation (Stoll et al.,2 0 1 0 ). Responses from the individual fellows were mapped to the themes, and sub-themes were identified.
Ethical approval was granted by the School of Postgraduate Medical and Dental Education Research Ethics Committee at Cardiff University.

Participants' motives and expectations
Reasons for applying for the Fellowship were distilled from the initial proforma and themed under three main headings: to develop knowledge and skills in leadership and management (n = 6); influence/implement change and improve outcomes (n = 6); and develop knowledge of NHS management structure and leadership (n = 5). Other reasons given included aspiration for a career in NHS management; a qualification in leadership; and preparation for the challenges of being a consultant.
Using the optional clinical time All fellows made some use of the optional 20 per cent of time for clinical work. Two fellows chose to work the day-a-week in their clinical practice to maintain clinical skills and for financial reasons. One fellow worked between 10 and 20 per cent. Another fellow took up the 20 per cent but worked flexibly so as not to miss any opportunities during the year. The four other fellows undertook locums to maintain skills, boost income or simply because they missed clinical work. Three fellows who undertook locums were from different specialties, and of the two fellows whose background was in a surgical specialty, only one took up the 20 per cent clinical time to maintain skills. There was no clear pattern between fellows' training specialty and using the clinical time to maintain clinical skills.
Learning from the training The joint induction with other UK fellows was, in general, regarded as a positive experience. Fellows attended sessions on leadership, teamwork and self-awareness and the structure of the NHS. The focus was on the English NHS, which was "a bit frustrating at the start with them telling us so much about England" (Cerys), but an understanding of the English NHS Although diverse in specialty, years of training and experience, the individuals from each cohort bonded and worked well together during the Fellowship year. Peer support and the relationship with fellows in their cohort was particularly valuable and supervisors noted this camaraderie. Meeting up at Academi Wales days afforded them the opportunity to discuss how their projects were progressing. However, delivery of the Academi Wales training was variable. Maddox was unsure whether "it was delivered in the right way for me to really hugely engage in it." However, several external speakers were highly praised for delivery and engagement, and both the practical skills such as project planning and "personal stuff", such as Belbin (2010) roles, were regarded as valuable. Overall, the residential experience was well received. It provided an opportunity to understand the ethos of ALSs, team building and trust. Feedback on team working by lodge staff and talking through the experience with Academi Wales facilitators was perceived as a good mix.
Morgan described the residential course as "really good fun". Being part of a group, learning from others' experiences and thinking in different ways, was particularly valued. Although four coaching sessions were funded as part of the WCLF programme, not all fellows took up the offer either through lack of awareness or because they felt they already had enough access to a coaching-type input from regular meetings with supervisors, medical director, mentor or other fellows. Those who did take up coaching found the sessions useful. Two fellows (Cohort 1) had spread the sessions over the transition back into clinical work when the Fellowship ended.
Overall, the Academi Wales programme was seen as providing a well-balanced mix of theory of leadership and management, project planning, ALSs, residential course and included some excellent external speakers.
Learning from the workplace and projects What was learned. An understanding of organisational structures was important, in particular, the interplay between the NHS, government, third sector and other agencies, and working on health board-wide and strategic projects enhanced this understanding. Fellows were able to step back from their day-to-day jobs and see the health system from a different perspective. Both cohorts had spent time with members of Welsh Government, which had enhanced their knowledge of how politics impacts on the health service.
Cerys considered fellows fortunate to be based in heath boards, providing opportunities to: Understand how a Health Board works, who everybody is and how to realistically influence change where you're going to be working. (CerysC2, FG1) The diverse workplace experiences provided fellows with opportunities to hone their skills in team working. Working within a team environment had been of great benefit to Francis, who admitted to being more of a solo player than a team player. She had been able to step back from concentrating on individual or groups of patients and see things from the LHS executive perspective. Maddox compared team working in a medical setting, which he characterised as "self-promoting" and "competitive" to that within the host organisation: Whereas in (host organisation) it's more to do with real teamwork where you don't have the odd person who shines [...] less to do with personal accolade at the end and more to do with a job done. (MaddoxC1, tel int) Special mention was made of the ALS, which fellows found valuable. Of particular interest to Kirsty was observing how senior colleagues dealt with stressful situations and how they revealed their own need for support. Gwen remarked: Everyone, no matter where you are in terms of your career, they're all having the same problems basically. (GwenC1, tel int) How it was learnt. Key ways in which fellows reported learning about strategies of leadership was through observation of and connection with a variety of individuals both within and outside the host organisation. Shadowing of high ranking and influential people such as medical and clinical directors, chief executives, finance personnel and quality improvement officers provided an opportunity to understand how different parts of an organisation interact. Fellows reported that this had been a rewarding experience and enhanced their ability to think more strategically: Just having the experience to see how other people work is useful. (MaddoxC1, tel int)

His supervisor concurred:
He's learned quite a lot about the behaviours required of senior leadership [...] I think it has been a very rich experience for him. (Supervisor, MaddoxC1, tel int) Bryn described his supervisor as "the model supervisor", the type of person one would want in the role in future. However, not all were so fortunate. For example, Kirsty rarely met with her supervisor and assigned mentor.
Fellows were able to attend, present and chair meetings within and outside the host organisations, providing them with opportunities to practise their presentation skills, learn tactics, observe strategies leaders use to get the best out of various "characters" and enhance knowledge of organisational structures. Cerys had presented at an executive board meeting to the chief executive and "angry consultants" (FG2). From this, she had learned "not be afraid of such people, they are human", which had bolstered her confidence.
Fellows undertook the academic component of the programme alongside senior leaders within the health service; it was a rare but useful experience and provided further networking and learning opportunities.
The away team building thing was really, really good, but I think it's also the networks that we're making with the other senior leaders on the course (KirstyC1, tel int) Fellows faced a number of challenges during the WCLF programme. It was common to struggle to define their role within the project, and projects did not unfold as initially planned. Fellows whose projects were affected by fiscal challenges and practitioner disengagement worked to identify smaller, service improvement projects that did not require additional funding but still provided learning opportunities. Rather than being a negative experience, fellows learnt valuable skills (creativity, flexibility and negotiating) when things did not run according to plan. One supervisor remarked that fellows "encountered the usual frustrations of trying to effect change in a leviathan-like organisation." (Supervisor,KirstyC1,tel int Useful learning opportunities could also result from negative outcomes, as summed up by Gwen: I think maybe the things that I have learnt most from have been the things that, to be honest, haven't worked. (GwenC1, tel int) Some senior clinicians have cynically described trainees aspiring to leadership and management roles as "moving to the dark side" (Hayden, 2017). A few of the fellows reported that they had encountered such an attitude and had to justify why they had undertaken the Fellowship. Bryn had been told by one senior that "We don't normally get involved with stuff like that", which he thought was a very negative statement to make to someone who actually wanted to get involved in Leadership.

Factors affecting learning from the workplace
The host organisations determined what learning opportunities were available to the fellows, and the attitude of the fellows themselves impacted on how they capitalised on these experiences. Adopting a proactive, self-directed and flexible approach to a project enabled fellows to carve a niche for themselves within established, or sizeable, longitudinal projects. At the first focus group, Emlyn stated that his project was "very defined, but massive" and felt that he needed to find something within the project that was more clearly focussed: I need to find a bit within that that's much more clearly defined where I can say 'OK this is my end point. This is how I'm going to measure it', which at the moment I can't. (EmlynC2,FG1) However, at the final telephone interview, he reported that he was pleased to have seen it through to an end point and had done what he set out to do. Initially, fellows were challenged by working in a very different, less structured and more autonomous way. Morgan stated that he had made diary notes at the outset of the Fellowship to help him see what he had achieved each day. Starting a new job, meeting new people, putting oneself "out there" (Emlyn) and making presentations and working independently had been stressful, and the transition to the Fellowship was "somewhat overwhelming" (Emlyn). However, being part of a team, where some tasks were delegated to and led by other individuals, had helped. Initially, Francis also expressed feeling "a bit uncomfortable" with her role within the project but reported being well supported by staff and project board members. Over time, fellows successfully adapted to changes in working practice.
Fellows in both cohorts experienced varied levels of organisational support. Wellsupported fellows worked in organisations whose co-workers had been informed about the Fellowship; where they were introduced at meetings and to key people within the organisation; and where projects were prioritised. This impacted on the speed with which fellows could progress their projects and develop an understanding of the organisation.
The relationship between fellow and supervisor was an important factor in how both fellows and projects developed throughout the year. Although meetings tended not to be formalised, supervisors thought it was important to know when to support a fellow and when to step back, allowing fellows to develop leadership skills. However, there were LHS differences in the perception of what constituted supervision. Kirsty rarely met with her supervisor, and Gwen also noted lack of engagement with her supervisor: Two-and-a-half months, whatever it is, down the line [...]I 've been to one meeting with (Supervisor). S/he just won't engage with it all. (GwenC1, FG1) In contrast, her supervisor reported having met her several times and had communicated via "emails, texts and phone calls". S/he continued: When she needs help or something, or [...] support from me, I'm always there for her [...] she finds where I am and comes to see me if something needs to be done on that day. (Supervisor, tel int) Clearly, in this case, the nature of the supervisory role was interpreted differently by fellow and supervisor.
Themes from fellows' responses to the Fellowship were mapped to Kirkpatrick's (1994) four-level training evaluation model and are given in Table IV.
It should be noted that Levels 3 and 4 are difficult to measure effectively from fellows' responses within the Fellowship year. A longitudinal evaluation study is planned.

Study limitations and strengths
The focus of the evaluation was on the fellows, their experience of the training and the workplace and project experience. Methodological weaknesses of studies of leadership research in health care have been highlighted in the literature (Brady Germain and Cummings, 2010;Wong et al., 2013), and it is noted that similar to the study undertaken by Agius et al. (2015), the two cohorts in this study were small in number (n = 8 in total), which limits the generalisability of outcomes. We also note that this evaluation focussed only on the experience of the programme during the year and did not include any longer-term impact. Having said that, a strength of the study is the inclusion of two cohorts of fellows and perspectives from both the participants and their workplace project supervisors. However, numbers were too small to make comparisons between the two cohorts.
A strength of the evaluation was its formative nature. As a result of the evaluation, the Wales Deanery refined the criteria for projects and provided further guidance for developing potential Fellowship project proposals and clarified the role of supervisor. Issues raised by ongoing review of their programme, but in recognition that their leadership programme was designed for senior medical staff, not just fellows. Developing medical leaders. Within the workplace, doctors have wide-ranging responsibilities for management and leadership, for example, helping to develop and improve services, planning, using and managing resources and working in multidisciplinary teams, which impact on the quality of services and patient care. The complex and continually evolving nature of the healthcare system, affected by policy and politics, has given rise to a change in the competencies required of those in leadership roles (Ayeleke et al., 2016). These developments indicate the importance of leadership training. The WCLF programme addresses both the need for education in leadership (through the Academic Wales training) and opportunities to put learning into practice (the performance of leadership roles through the projects). Further, observing senior colleagues in leadership roles provided fellows with an insight into leadership jobs in action.
The WCLF programme encouraged fellows to acquire leadership skills early in their careers, to provide them with the leadership tools to navigate an evolving Welsh health system and to identify opportunities for change and improvement. Although fellows did not have a very clear idea of what to expect at the outset of the Fellowship year, nonetheless, in our study interviews, they stated that their expectations of developing leadership and management skills had been met, and they felt suitably equipped with the skills to be future leaders in the NHS. In particular, the theoretical background of team working and Belbin (2010) roles gave fellows an understanding of collaboration within the workplace. Projects offered fellows opportunities to network and work with seniors and managers within a NHS or non-NHS setting and benefit from the leadership expertise, style and experience to which they were exposed. Through the projects, fellows were able to gain an insight into leadership and management including an understanding of strategy, how politics influences it and how to effect change. They also learnt how funding impacts on decisions and how project outcomes could impact on service. This concurs with Agius et al.'s (2015) view that developing such skills is essential within the NHS setting and that leadership training needs to provide "handson experience of everyday issues and real-life solutions".
Although the host organisations benefitted from having someone focussed on progressing the project, as reported by fellows' supervisors, it was too early to quantify the impact of the Fellowship on service improvement. Workplace-based projects were specifically geared towards service improvement, but successful outcomes were not always feasible within the 12-month time-frame. There was some difference in opinion as to whether it was better to have specific projects with clear end points, or broader projects where a niche could be found to suit a fellow's particular strengths. Even where projects were at the initial stage of a larger piece of work, fellows were still able to benefit from the leadership experience.
After the Fellowship year, fellows returned to training and we do not have data on whether they transferred the skills they had learned into their clinical practice. Others (Nicol, 2011) have found that competencies gained during such Fellowships, "may not result in immediate tangible outcomes" but may "result in more informed and prepared individuals to undertake clinical leadership and innovative practice in the future." In this context, it is notable that Fellows undertook the programme at markedly different stages in their training and it is legitimate to ask if trainees are better suited to the leadership programme at one point in their career rather than another. Our data offer no firm conclusions. It seems that all LHS fellows, whatever grade, developed their learning and grew in leadership confidence. Rather than suggesting any hard-and-fast rule, it seems to be a successful approach to leave it open to the individual to determine when in their training it is appropriate to undertake the Fellowship. However, in advocating this, trainees in earlier stages of training should think through what leadership opportunities might be accessible to them on their return to training.
What makes a good leadership programme? The study provides an indication of features of a good leadership training programme. A good programme includes a flexible approach to the projects and opportunities to be involved with activities outside the main projects, such as attending meetings and conferences. A well-balanced academic programme is one that provides the theory of leadership and opportunity to apply learning in the workplace during and post-Fellowship. High-quality organisational support and supervision is important to the success of a programme. Although the Wales Deanery had organised sessions on supervision, there was a lack of clarity about what was expected of both supervisors and fellows. This has since been made explicit at the outset of the programme. Well-supported fellows worked in organisations where their projects had been prioritised. This impacted on the speed with which they could progress and develop knowledge of the organisation.

Conclusion
The Fellowship programme gave trainees the opportunity of working in a very different, less structured and more autonomous way, which had a significant impact or "mind shift" (Stoll et al., 2010) for both cohorts. Taking a year out of their specialty training to concentrate on leadership development was highly valued by the fellows. The programme provided fellows with the opportunity to develop not only their theoretical knowledge of leadership which they applied to a workplace-based project but also to develop personal attributes and non-clinical skills required in the increasingly complex NHS organisation. Further research is needed in studying the longer-term impact of the Fellowship.