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8 August 2012
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Wanted: medical leaders who can ‘walk through walls’

The Holy Grail in NHS reform is integrated care. Being a Clinical Commissioning Group Board Member, it has brought home to me the importance of leadership that can work across organisational boundaries to achieve transformational change. This is not easy as all the players - acute trusts, partnership trusts, CCGs  and local authorities- have differing cultures, accountabilities, priorities and budgetary restraint.

 Take the case of end of life care. The improvement challenges are enormous and the national case for change is strikingly clear. Most people die in hospital when they want to die at home. There is enormous variation of care: 92,000 people have an unmet need for palliative care; there are gross health inequalities based on diagnosis and post code; non cancer end of life care tends to have poor outcomes.

 Just 57% of bereaved people in the recent VOICES survey – a groundbreaking piece of work - said that hospital doctors always showed dignity and respect and less than half (48%) said this was the case for nurses.


 A new deal for people who are dying is needed. As doctors we need to up our game. It was Dame Cecily Saunders, the founder of the modern hospice movement who said that “How people die remains in the memory of those who live on“.

 I think medical leaders can make a difference in this area in two ways.

 First medical directors should continue to support their front line doctors by increasing their confidence in communicating end of life care issues. I have learnt a lot from the Canadian communications expert and physician Professor Stephen Workman.  

 My Top Three Tips:

  •  Be compassionate but direct when talking about dying. Doctors speaking to relatives about an ill patient who is giving cause for concern, should not just say "your husband is seriously ill", but should add "It is possible that he could die".
  • Be honest and don't offer false hope. Think twice about offering a false choice of procedures like cardiopulmonary resuscitation (CPR) or ICU when someone is actually dying and chances of recovery are minimal.
  • When doctors diagnose a serious illness they should ask the patient whether they would like to talk about what they can expect and what is likely to happen (prognosis). 

 Most people die from frailty in old age, and will be well known to health and social care services.  These communication tips will give opportunities for talking about end of life wishes and advance care planning.

 Secondly, no matter who you work for as a medical leader, your contribution is essential. Improvement in end of life care requires systems transformation across multiple providers, multiprofessional working and the third sector. We need medical leaders who can ‘walk through walls’. This was a phrase use by the American political strategist Mary Matalin in the context of government to describe effective people who can work across departmental boundaries and between governments to achieve results. (Source: quoted in the Alastair Campbell diaries)

 Do we have medical leaders who can walk through the walls of the health and social care system? The document, Teams without Walls by the  RCP and the RCGP can help. (

Professor Mayur Lakhani CBE FRCGP FRCP, Chair of The National Council for Palliative Care, Past Chairman of the RCGP

Mk.lakhani [at]





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