For many years I have heard the refrain that consultants in the NHS are leaders, and should thereby take advantage of their position to affect transformation.
For almost as many years, I have recognised this to be a misunderstanding of the meaning of leadership. Consultants have a great deal of professional authority exercised with great effect often in the interest of a speciality, sometimes self-interest and not often enough in the interest of the whole, thereby explicitly accepting, sharing and managing the resulting losses (1).
In one of my previous guises, I led a regional tertiary service. I learned a great deal about the pain of leading change and the real psychological, almost physical pain that comes with practising leadership. I voraciously sought knowledge and of course wish that I knew then what I know now. I am proud of some of what I achieved, but also recognise where I went wrong. Early in my tenure I ferociously and mercilessly defended the service, increasing resources for my speciality; I learned to play in the culture I lived in and learned from. Did we need the resources? Some, but not all. I defended every inch and every paper clip using shrouds of fear that managers were hopeless at countering. I was so wrong, it pains me to think back how I must have let down so many who needed a share. That was not leadership. I sensed the injustice I had become part of when I learned to follow the money – always follow the money. The inequitable calculation of tariffs, the inequitable distribution of resources and the layers of waste in our NHS are visible, palpable and deeply disconcerting. I contributed to that inequitable distribution and resulting injustice. Returning from a secondment where I was privileged to acquire, and practice, the knowledge and skills needed to more effectively lead change (2), to my then comfortable and well-resourced job, organisation and region made the inequity yet starker. Seeking to share resources and redesign of systems to eliminate resources to support others was as futile as it was alien to the culture that I was now alien to. I could not justify the demand for more when less was possible and when so much in the primary and generalist services are left floundering, the price being paid by patients; five children a day die needlessly in our country, compared to best, not for want of larger paediatric nephrology services, better access to cardiology units or bigger cancer centres, and how many adults? My thinking had changed, so I had to change as well as change the work I wanted and needed to do to help address, even in the minutest way possible, the inequities and injustices. By delivering change, transformation and challenge, I always seek the academic and evidence base, my clinical professional DNA staying true in my new context.
I have moved further away from the comforts of clinical medicine, where I know a lot about very little and away from incentives designed to keep me loyal to the system. It would have been so much easier if I had stuck to kidney disease in children; for all its complexity, it was easy; for all its advances, it was easy; for all the ethical dilemmas, it was hard, and easy. But it was easy because it was my sphere of almost complete competence, acquiring knowledge, learning skills and applying both by practising academically, each case and each encounter a moment of application as well as reflection, learning and improving. As I entered the world of leading and practising leadership, where I had to acquire new knowledge and new skills, having to get used to living beyond the sphere of competence (1), it is evident why so few fellow consultants would want to step out beyond that sphere (3). Practising leadership is much harder, because stepping into and taking colleagues into the unknown has to become the norm (1). To begin to make leadership survivable requires the acquiring of knowledge, learning the skills (4), applying both by practising academically, each encounter a moment of application as well as reflection, learning and improving.
I am sometimes asked why I have chosen the tougher option. For that you would need to know more about the journey that continues to mould me. For now, the answer is how else and where else do I get the opportunity that is a privilege to face up to the inequities and injustices experienced by the patient and population in need, work with the staff that carries the responsibility to transform, and serve the citizen that pays for it all.
The work I do now is the toughest I have ever done, but then I have never had a greater opportunity to influence as many lives, and have as much fun, practising academically at every opportunity (5).
1. Ronald Heifitz; three books and teaching worth the random checks at US immigration
2. The Improvement Advisor Programme, The Institute of Healthcare Improvement, www.ihi.org
3. The NHS Leadership Academy’s Executive Fast Track Programme; probably the first senior NHS leadership programme to enable and support those that wish to take that step beyond their sphere of competence
4. Warren Bennis; a multitude of papers and books
5. Muir Gray; several books, including the ‘How to’ series, a programme (http://www.bvhc.co.uk) and so much more. Also, for telling me to never shy away from openly practising leadership academically