Advancing cancer control in the future through developing leaders

The need to advocate for the appropriate care of cancer patients remains significant. The population of the world reached 6.9 billion people in 2012, with best available data showing that during that year there were 14 million new cancer cases, 8.4 million cancer deaths and 25 million people living with cancer across the globe. It is predicted that the incidence of cancer will continue to increase, and numbers will have reached a further 70% by 2030.1


Introduction
The need to advocate for the appropriate care of cancer patients remains significant.The population of the world reached 6.9 billion people in 2012, with best available data showing that during that year there were 14 million new cancer cases, 8.4 million cancer deaths and 25 million people living with cancer across the globe.It is predicted that the incidence of cancer will continue to increase, and numbers will have reached a further 70% by 2030. 1 Over the past 25 years, many countries have seen improvements in cancer survival rates and treatment for major cancers, with these advances occurring as a result of significant investment in the rational organisation of cancer services by governments, and because leaders have advocated for improvements within their systems. 2However, the next 20 years will see a significant increase in the burden of cancer, both numerically and in complexity.It is possible that the pace of change will overwhelm less-experienced leaders, with a shortfall in available funding and the challenge of integrating molecular medicine into the current paradigm. 3e past decade has seen several amazing leaders, with the likes of Nelson Mandela and Barack Obama.During the same period, we have experienced and been warned about a major crisis in leadership. 4Is there anything that can be done about this, and should we be concerned that future leaders may be less able to deal with the formidable challenges facing them?Most have concluded that the leadership crisis is not about too few leaders, but mainly related to an increasingly bigger gap in the quality of leadership. 5Although this may seem like splitting hairs, if the current gap in leadership is more about poorer quality than fewer leaders, then it is possible that there may be an opportunity to influence this conundrum by developing skills. 6This article will attempt to show that some of the critically important missing leadership competencies in cancer care may be taught if potential leaders are influenced early on.It will describe the kinds Background: Developing leaders is a critically important activity, especially in cancer services that depend on strong advocates for funding or sustained leadership of organisations.Many global think tanks have warned us about a crisis occurring in leadership.This crisis is not related simply to a lack of leaders, but probably secondary to a lack of competencies in leaders.This distinction allows us to ask whether it would be important to develop skills that will improve the quality of leadership in the future.The author postulates that competencies that will change this perception can be taught.of leaders most likely to succeed and will suggest some of the approaches that could be used to prepare leaders for the roles they will assume. 7

What allows Calgary to highlight these issues?
Whereas previously physicians aspired to senior leadership roles within society and many were celebrated in those roles, this has changed over the last two decades.It may seem artificial to be concerned about this, and it is daunting to suggest that any of us has an answer to this dilemma.The Oncology Leadership Development Office (OLDO) in Calgary was established in 2011, after a succession planning exercise revealed the systemic gaps in being able to fill leader roles in their programme. 8This is the fifth largest cancer programme in Canada, with approximately 200 000 annual outpatient visits, 8500 new patient visits, 70 inpatient beds and clinical programmes that stretch across all disciplines and all tumour sites.The programme also supports research across all pillars (basic, translational, physics, clinical, health services, prevention and palliation) and has training programmes in all of these domains.This represents a large academically based cancer centre with 850 staff members, 200 cross appointment from other departments, 20 senior leaders and 50 managers.Leadership sustainability is, thus, a major focus, which coincides with our maxim that 'people buy into leaders before they buy into vision'.This led the office to offer tailored programmes to different levels of leaders between 2012 and 2017, graduating 150 individuals from a variety of programmes.Before setting up a formal leadership development programme, it reviewed the trends on required competencies, the types of leaders needed for roles and the tools needed to teach skills and evaluate performance.It is this experience that allows it to make some recommendations to a broader audience. 7

How should we define leadership and what leadership levels are important to consider?
Leadership is the ability of an organisation to set and achieve challenging goals, take swift and decisive action, outperform the competition and inspire others to perform well.Publicly funded organisations often argue that it is the ability of an organisation to respond to a 'big hairy goal' that should set them apart, rather than their ability to be competitive.Leaders who can move groups in similar ways are the kinds of individuals we seek to develop. 9Simplistic definitions that focus all attention on individual executive leaders are impractical in cancer control, where interdependencies are significant.For this reason, OLDO rejects definitions that split executive leadership and management into distinct silos.Leadership in cancer programmes is best exemplified when a group has both superior outcomes and achievement of altruistic, patientcentred goals.
It is vital to acknowledge the context (cultural differences) of cancer systems.However, many of the challenges faced by leaders transcend cultural differences, and there is evidence to show that leaders across countries require identical competencies to face these challenges. 10Although it is impossible to describe every cancer centre accurately within a few categories, it is helpful to recognise that there are four major clinical domains in cancer care.An environmental scan in 2012 found the following domains:

Clinical academic enterprises
These are enterprises where success is possible in both clinical care and progress in scientific productivity.Many of these institutions also are involved in training future oncologists, with most being co-funded by governments and private sources.Many categorise such domains as 'tertiary' or quaternary.'Successful leaders within this domain have had to rise through the ranks by being academically productive and are effective at working across multiple disciplines, and complex environments'.

Regional cancer centres
These mostly operate within publicly funded systems and are located in large towns or smaller cities.They have minimal organised research infrastructure, with a reduced number of formal training programmes.Most of these allow care closer to home, and focus on provision of systemic and radiation therapy elements.They are less likely to have formal surgical oncology specialists embedded in their centres.
Successful leaders may not have a strong academic background but work well within teams and are able to attract consistent staffing and provide excellent clinical care.They also work collaboratively within a network of other centres.

Provincial or national cancer programmes
Many of these exist within under-resourced countries or regional areas.Many have no coordinated approach to providing resources, nor sustained financial investment from their funding agencies and, often, there are no formalised cancer prevention or screening programmes.
Successful leadership here is variable.It often can be seen as the ability to advocate for basic treatment (such as megavoltage equipment and systemic agents), and for palliative care for terminally ill cases.Most leaders are heavily involved in the clinical care of patients.

Small, privately operated departments or cancer centres
In many countries, there is insufficient funding to provide high-level care to all of their society, resulting in the establishment of operations that provide a limited number of clinical services to a subset of financially independent patients.Some of these operations also have an academic relationship with a university.Successful leadership in this domain is complex.At a minimum it includes having the skills to ensure that there are finances to fund staff and operate clinics.Additionally, these leaders are expected to attract excellent staff to remain in the clinic, and to have a healthy relationship with their professional staff.
Although this categorisation helps identify where a reader's centre may fit, it does not help them understand what kind of leaders to consider developing.OLDO would suggest that there are three levels of leadership and that these transcend the above clinical domains (e.g. an emerging leader in a regional centre in South Africa will require similar competencies to an emerging leader within an academic centre in Canada).
It seems to us that this is the first critical observation for the reader to grasp and that the leadership levels of all domains will include emerging leaders (which include residents or registrars and early career staff), developing leaders (midcareer) and senior or executive leaders.

What are the obstacles to investing in career development approaches?
Whereas there is significant literature within business and corporate entities about career development, less has been written about this in medical circles. 11More mature medical institutions are recognising the relevance of formal career development strategies for the three levels of leaders, with the most significant obstacle to starting their formal programmes being cost.However, there are several other fallacies that have limited investment in developing leaders, and they should be acknowledged by you as you set out to find investment to improve the quality of leaders.Fallacies include the following: • People are not interested in being a leader, and do not want development.• Great leaders are born that way, making it less critical that we develop others.• The major benefit of development is to provide training to senior leaders.• It is not easy to recognise who to develop, therefore do not try.• Do not waste your time on developing physician leaders -they are ill equipped to lead modern day health care anyway.
OLDO has had to deal directly with each of these fallacies and had to demonstrate the hollowness of many of them by showing the benefits of implementing development programmes.The second important point for the reader to grasp is that many will attempt to thwart efforts to implement formal approaches to leadership development.Be resolute about the benefits of development and resist the negative responses from status quo groups.

What competencies are important and does teaching them build better leaders?
The long-term target of leadership development should be to prepare young leaders for more senior roles, where they will be able to make major decisions, and set strategic direction.However, the more immediate goal should be to raise both the skill level and emotional intelligence of leaders at all levels.
It is important to stress the last point, for skills training without practical experience often results in leaders who cannot regulate their behaviour and be socially relevant to their societies.
The process of developing leaders, therefore, involves competencies and building up emotional intelligence, with this always starting with teaching core skills.These skills enable people to develop self-confidence, and be effective at actualising their own goals.Having self-awareness motivates potential leaders to be personally effective in their professions, families and communities.As new leaders apprentice in new roles, it becomes critical for programmes to support them by offering apprentice leadership opportunities and individual coaching.Coaching then allows for the development of behaviour regulation and social empathy. 11at competencies are important? 12Effectiveness in health care is most likely with individuals who have the ability to think strategically, and who can: • Lead employees.This is a highly variable skill, requiring strong self-awareness and interpersonal savvy.This competency is demonstrated by seeing leaders invest in others, being skilled motivators and strong delegators.It also drives leaders to develop employees' confidence, consistently coach them and to provide challenge and opportunity.Skilled leaders find and attract highly talented and productive people.• Adopt a participative style.This competency is demonstrated by leaders involving others, building consensus and having influence in decisions.Leaders with this competency encourage others to share ideas, information, reactions and perspectives.They are superior communicators who keep others informed and know how to lead change.• Build and mend relationships.Leaders with this competency are able to establish and maintain solid relationships that are respectful, diplomatic and fair.They relate to all kinds of people and easily gain support and the trust of peers, higher management and customers.They are skilled negotiators and get things done through collaboration.• Enhance their self-awareness.Effective leaders have this competency, allowing them to have an accurate picture of their strengths and weaknesses and the impact of their behaviour.Most individuals with this seek feedback and value reflection and learning.A self-aware leader admits personal mistakes, learns from them and moves to correct them.
• Have a broad organisational perspective.Leaders with a broad organisational perspective have worked in multiple departments or functions over time.They have experience working with groups or on teams with competing interests, expertise and points of view.They have developed tactical or technical skill, but also appreciate strategic and organisation-level issues.• Build and lead a team.Effective team leaders demonstrate the ability to set clear goals and expectations of their groups.They are able to resolve conflict, motivate team members and help individuals understand how their work fits into the goals of the organisation.They select the right mix of people for the team, bringing together people who collectively have the expertise, knowledge and skills needed to complete an assigned task or ongoing work.

How should you respond to these ideas?
Many of you will react with scepticism to the information in this article (it sounds North American; it is impractical; it is too ambiguous, etc.).May I make some bold statements about the evidence being presented to you in this article?
• We need more cancer leaders, both locally and nationally.OLDO contends that the continued struggles of highlevel leadership in cancer care and health systems cannot be overlooked, and there is a serious need to develop strong future leaders.Training more people with the right skills should be our mantra for all cancer systems in the future.OLDO has demonstrated that connecting with potential leaders early not only increases the likelihood of stronger senior leaders in the future but also helps emerging leaders be more effective at a personal level early on.A secondary benefit of such a process is that it forces senior leaders to be on their toes and to cast vision that allows new leaders to have something to respond to.

Conclusion
The most effective leaders help their organisations set and achieve challenging goals, take swift and decisive action, outperform their competition and inspire others to perform well.What does this look like in cancer control?If our systems are to contribute to improving the outcome of patients, work broadly with other organisations and prepare leaders that will take organisations into the future, then we need leaders who will motivate staff members to want to make a difference.Successful leaders also are excellent advocates for investment in their programmes.
Without such attention, we will not be able to maintain a patient-centred clinical care approach and will be unable to respond to patient care constraints, molecular medicine and targeted radiotherapy demands in the future.This article has highlighted evidence demonstrating that leaders need to have certain competencies to be maximally effective.Many of these competencies can be taught, including self-awareness, being able to lead employees, having the ability to build teams and understanding how to lead change.Furthermore, there are other competencies that can be introduced to potential leaders early on, such as strategic thinking and being able to build broad-based collaboration.Our local experience is that leadership development is a strategy worth considering for all cancer programmes, as it does not leave the future of cancer leadership to chance, but invests in people early on.

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Start with identifying potential leadership gaps in your group.If you seek to establish a formal programme for helping your group, ensure you formalise this by entering into a relationship with your local business school, or by getting a few internal people to gain skills that will help you take emerging and mid-career leaders through didactic skills development.Do not be scared to ask for help from others! • If you choose to invest in doing this, make a commitment to measure the success of your programmes and tweak your approach where needed.The most significant measure of success in the beginning will be that emerging leaders want to attend, because they see this as a step that gives them a competitive advantage.