How can leadership theories and change management models be applied in establishing sector wide network reporting service in regional Sussex Hospitals?Introduction:Radiology is an important service and plays a central role in the diagnosis and monitoring a wide range of diseases. Imaging with now more complex modalities such as CT and MRI plays a significant and central role in the current clinical care resulting in rising demand to an extremely high level. This along with the unsuccessful recruitment to radiology consultant posts in UK has resulted in extreme delays in reporting, particularly in cancer and other serious conditions; which has severe adverse affect on the quality of care provided to patients ( Dalton review, 2014)1.Amongst the 31 audited EU countries, UK was found to have the third lowest number of radiologists per population2. The UK has 7.5 clinical radiologists as opposed to the EU average of 12.7 per hundred thousand patients2. It is reported that the NHS spend 88 million for the reporting radiology back logs. This amount is the equivalent of paying 1,028 full time consultants2. The emergence of Picture Archiving and Communications Systems (PACS), which enables the instant availability of images and transmission to specialist centres have led to an increase in remote reporting( teleradiology ) to combat the gaps within consultant vacancies; resulting in reducing the patient care provided by local radiology service3. Remote reporting also has a huge impact on training opportunities and duplication of work as clinicians prefer local opinions. Also, lack of access to previous imaging and clinical information can lead to repetition of tests3. Such short term measures leads to individual trusts not interested in investing in recruiting more radiologists3.In order to overcome this crisis, instead of proving service to a few hundred thousand the existent radiology should work jointly in the form of networks to serve a few millions. The staff and the equipment will still be managed by the local hospital and only the reporting of acquired image will be part of the network. An example of this would be a central IT hub is connected to PACS which is in turn amalgamated between few hospitals depending on the available economy 3.The hub manager would execute a set of rules which would help transfer images to the relevant location3. These rules are agreed by the network group. Some of the intended benefits include3:1) If special expertise is required due to increasing complexity of the scans, it can be delegated to appropriate subspecialty trained consultant across the region especially at time of annual leave. Thus not delaying management decision in patient care3.2) Scans will be available readily for MDM discussion from regional hospitals instead of requesting them from other hospitals or needing to log into their PACS systems during the meeting; hence saving a significant amount of time.3) By this method of network collaboration, the up and downs of smaller services in reporting can be alleviated.This proposal is based on the new care models of setting up acute care collaboration (ACC) vanguards, a shared vision of Five Year forward (2014) and NHS central to provide high quality care, smooth patient flow, to meet the demands of the changing population and to save money by creating a single hub where there is standardisation of protocols and process, sharing systems and consolidation of services6. This transformational change is not easy and engagement of all parts of the systems involved in new models of care development and delivery is prudent for its success6. Also, in order to achieve sustainable improvement in the long term, fundamental changes are needed in the way this service is delivered, which involves staff working in different ways6. Considerable attention needs to be given to informing, up-skilling staff and supporting them to adapt how they are working5. Effective and strong leadership is critical for any new change5. In order to deliver and achieve expected goals, the old model of ‘heroic leadership’ must be adapted to that of a shared leadership within organisations where concept of understanding plays an important significant part 7.‘There can be no effective management without leadership– because the organisation will not know what it is meant to be doing. And without good administration, management can be rendered futile. The three are interdependent’4. Application of leadership theories and change management models to case study:In the East midlands, a new system of reporting was required to address the imbalance between the existing radiologist reporting capacity and the ever-growing demand for reporting. In 2015 a new reporting system was piloted. This was the EMRAD vanguard8 and its aim was to form creative solutions for the above crisis by harnessing technology invoking an open leadership culture that encourages innovation and change. It looked at trailing new ways of working which were heavily based on transformational and transactional leadership8. This in turn would lead to quicker reporting, better use of current resources, reduced outsourcing expenditure and a culture change in the working pattern of radiologists. The first pilot 8included 6 neuroradiologists who had workstations set up in their own homes for a period of three months. This meant they could look at images from home in an out of hours setting. Clearly defined and aligned objectives was set as part of their contracts allowing them to work on CT, MRI, and X-rays for all patients across East Midlands. The activity from this pilot was constantly monitored by EMRAD support team8. Metrics were measured for productivity and to reassure that the reward working did not have an adverse effect on the radiologist day role. Based on this successful first pilot the learning, innovation and team working skills were then applied at Northampton general and Sherwood hospitals8. Effective team working meant that 1 whole member of staff could be generated by 6 staff adopting the above method of working. This in turn led to a significant reduction in the backlog of the amount of radiology reports waiting to be reported8.Strong leadership along with clear objective support and effective team working have led to the EMRAD reporting being done at rate more efficient than that set by royal college of radiologists. This well led team work is estimated to have saved trusts three million per year. It also has been possible as the results of this project to have been undertaken by NHS staff than being contracted outside the NHS.The other benefit from this project is the value of the radiologist to be able to have worked from home. Some of the issues during the role of this system have included stability of the system and agreeing on a NHS tariff rate which was not in place prior to this pilot. These problems have been overcome due to the strong leadership and collaborative working between the trusts. With consistent leadership throughout the various roll out phases of this pilot, things have become easier as lessons are being learnt and collective efforts are being made to overcome any mistakes made.Leaders involved in this project have been required to engage staff at all levels, set clear objectives, provide inspiration and also lead in the ability to fail and learn lessons from failing empowering staff to lead the change and putting in place mechanisms to raise concerns and address them, also form a part of high quality leadership through this project. Another area where considerable leadership was required was in trying to engage colleagues in this new method of working. This project has been successful due to a strong open leadership culture which encourages change by setting an example inspiring staff at every level, setting clear objectives, being supportive, and engaging of staff, constantly learning and innovating and inspiring effective team working. My proposal is that we take the success of the EMRAD vanguard project from East Midlands and apply its principles across Sussex to create a radiology reporting system that is modern, capable of keeping up with current demands and innovative. To do so will require effective leadership skills across various institutions. In order to understand how leadership theories can be applied to this model, I conducted a literature search of web based articles using leadership theories and change management in healthcare as key words. I also referred to Library books such as Leadership in health and social care – An introduction for emerging leaders by Louise Jones and Clare L Bennett and Leadership and management in Healthcare,by Neil Gopee and Jo Galloway. Of the literature search conducted, the most relevant and contemporary article that could be applied to my model was the ‘The King’s Fund – Leadership and leadership development in health care: The evidence base’ and also the article from the NHS leadership academy – ‘towards a new model of leadership for the NHS and Healthcare leadership models.Analysis of the above articles clearly shows that there is limited research of leadership theory on healthcare particularly in the field of medicine. Although it has to be noted the greater amount of research that has been conducted in the field of nursing and nurse managers.From the limited research in medical leadership, I feel that transformational leadership along with a component of transactional leadership will be required to be implemented in this project9. From a transformational perspective leaders will need to engage their staff beyond the framework of what currently exists9. Leaders will need to be proactive and create new expectations within their staff. There will also be the need to have good vision, strong people management skills and the ability to develop strong emotional bonds within the staff9. To establish a new system as above leaders will need to motivate their staff by setting goals and rewards for expected performance as seen in a transactional leadership and also create opportunity for learning and stimulating followers to solve problems9.An alternative leadership model that could be applied is the one described by Storey and Holti based on the 4 category classification proposed by Gary Yukl( Yukl 2012)10 . This is a 3 pronged approach where by firstly, leaders would need to provide a clear sense of purpose and contribution10. This would mean focussing on the needs of service users and seeking to improve the quality of service provide. It would also require the leader to work closely with other organisations to ensure success. Secondly, the leader would require to motivate his team to work effectively and this requires clear goals for the individuals within the team. The leader would also need to encourage staff involvement whilst allowing autonomy and building a positive team working environment. Good leadership would also require managing the team’s performance with openness and empathy. A good leader will also listen to the voice of their staff and help support any concerns that they have. The third step for the leader would be to improve system performance. This would revolve around changing the service based on problems encountered and learning new ways and behaviours to improve effectiveness.A good leader can also use change management models such as Lewin three stage process of change (1951) apply change within the organisation11. The first step in this process is for the leader to recognise the need for change and overcome any reluctance by the staff to this change in this process11. The second stage of this process would require the leader to incorporate new attitude behaviours and ways of working11. This is also the phase whether staff will require a lot of support and guidance to implement the change. Once this change as been implemented then a leader can move on to third stage of freezing11. An effective leader would ensure that the positive change is sustained through good supportive mechanisms and appropriate policy implementation. An alternative model of change is the Kotter’s 8 steps9. This requires a leader to create a sense of urgency then build a team that can bring about a change. Leaders have to construct a vision and communicate this whilst empower individuals to execute the change. Leaders are able to use short term goals and reward staff on achievement of these. Leaders will need to maintain and sustain the change long term.One of the issues of health care leadership theories is that there is lot of methodological weakness. Study designs have been noted to be weak by a variety of authors. For example, Gillmartin D’annuo 2007 and Wong et al (2013)13. Various weaknesses noted include inadequate sample sizes, failure to measure control variables, excessive reliance on self reporting and cross sectional designs. Another issue with the studies is the extensive focus on individual leadership instead of team or strategic leadership. Instead a multilevel analysis would be more useful and applicable to the model of change I have suggested. Another aspect to consider is the organizational climate in healthcare. West and colleagues (2016)13 have demonstrated, in their longitudinal study, a link between policies and practices on patient mortality. This would suggest climate in an organisation can influence performance outcome. This is an important consideration when applying the EMRAD vanguards to Sussex. Infact, a later large scale longitudinal study from 2011 (West, Dawson, Admasachew and Topokas)13, showed a link between climate and positive leadership and quality of patient care. Therefore, there is clear evidence that supportive management along with staff perception of effective leadership results in a climate that is associated with excellent healthcare outcomes. This is clearly an important consideration that must be taken into account when deploying my proposal.Using one of the above leadership theories or a combination of several; it would be possible to apply the EMRAD vanguard model of reporting across Sussex. One successfully implemented, under good leadership this model will help reduce the current protracted waiting time experienced by the patients for their images to be reported. The knock on effect of this implementation will also help reduce the time taken for a patient to get their diagnosis and then move on to their next stage of treatment. Overall, I expect this will improve patient satisfaction across Sussex and positive feedback from this will be a strong motivator for the staff and leaders involved in this project.Conclusion: 1. The service I proposed is one that requires open and strong leadership that would encourage a cultural sea change from the way we are working at present. It will require leaders to lead by example and inspire staff across various levels and trusts to do the same. 2. My analysis of current research into healthcare leadership would suggest that there are a number of weaknesses in the study designs as well as a focus on the individual rather than on the team. This is in contrast to how the NHS works as a multi-level team.3. The transformational leadership theory is the one with most evidence that can be applied to my suggested project (Wong et al, 2013). 4. Another key component that has evidence linking it with positive patient outcomes is the organisational climate. Large scale longitudinal studies provide evidence to support this theory. I also feel that this is clinically relevant to my project as without a positive climate this project will not be successful.5. The project will also require a mentality change ‘to fail and learn from the failure’10. Engagement across a wide range of staff will be required to lead the change. But at the same time, staff will need to be able to have a formal mechanism by which they can raise issues, feed back their concerns to the leaders. High quality leadership will be needed to set clear clinical targets and manage staff across all levels. Only with good leadership will such a project succeed. 6. My analysis also leads to the conclusion that further multilevel analysis is required in healthcare leadership along with better study designs. Data from such future research would be more clinically relevant in its application within NHS organisations.References:1) Dalton Review- RCR clinical radiology proposal radiology in the UK new case service model[Online] [ 2014][ assessed 2019 Jan 29]; available from: https://www.rcr.ac.uk/sites/default/files/RCR_Clinical_Radiology_response_to_Dalton_Review.pdf2) Clinical radiology UK workforce census report [Online][ assessed 2019 Jan 29]; available from: https://www.rcr.ac.uk/system/files/publication/field_publication_files/cr_workforce_census_2016_report_0.pdf3) Radiology in UK– case for new service model[Online] [Sept2014][assessed 2019 Jan 29];available from: https://www.rcr.ac.uk/sites/default/files/Radiology_networks_position_paper_published_sept2014_0.pdf4) Gopee N, Galloway J, Leadership and management in Healthcare. 3rd ed: SAGE Publications Ltd;2017.5) NHS providers N. Learning from the vanguards [Internet].2019 [accessed 2019 Jan 29] Available from: https://nhsproviders.org/learning-from-the-vanguards/staff-at-the-heart-of-new-care-models.6) No hospital is an island : learning from acute care collaboration vanguards, new care models[Online] [Jan 2018][accessed 2019 Jan 29];Available from: https://www.england.nhs.uk/wp-content/uploads/2018/01/acute-care-collaboration-learning.pdf.7) Next steps on NHS five year forward[Online][assessed 2019 Jan 29];Available from: https://www.england.nhs.uk/publication/next-steps-on-the-nhs-five-year-forward-view/8) Case Study:East MidlandsRadiology Consortium, NHS providers.[Online]; Available from: https://nhsproviders.org/new-care-models-harnessing-technology/case-study-east-midlands-radiology-consortium.9) Transactional & transformational leadership [Internet].2016 [accessed Available from: https://aishahalhady.wordpress.com/2016/05/18/transactional-transformational-leadership/.10) Towards new model of leadership, Storey J, Holti R. [Online] [assessed 2019 Jan 29];Available from : https://www.leadershipacademy.nhs.uk/wp-content/uploads/2013/05/Towards-a-New-Model-of-Leadership-2013.pdf11) Jones L, Bennett C. Leadership in health and social care- an introduction for emerging leaders. 1st ed. Banbury: Lantern Publishing Limited;2012.12) Successful change management –Kotter’s 8-step change model [Online] [accessed 2019 Jan 29];Available from: https://www.leadershipthoughts.com/kotters-8-step-change-model/13) Leadership and the Leadership development in Health care : The evidence base; The King’s Fund. [Online][assessed 2019 Jan 29];available from: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/leadership-leadership-development-health-care-feb-2015.pdf.