Thinking Aloud – the value of unexpected learning

Wow. Where did the last six months go?  I last blogged the day before I started my new job.  So I guess that’s my answer.  Thoughts rich, time poor.  But here I am enjoying the last few days of a two week break, thus giving me the time to order those thoughts and commit them to this post. So much material to choose from, and I’ve settled on a reflection of my personal learning since joining a new organisation.

As my last post indicates, this has been the most mindful job transition I have ever made.  In its build-up, I focussed less on whether I could do the job itself (it’s familiar territory), and much more on how I would find my ‘fit’. I’d been pretty thorough about it and was embarking on this new journey attentively and proactively…wasn’t I?  Well yes, I think I would still maintain that was the case, but of course this doesn’t mean I possess the power of prescience. So, here’s the learning, the things I had not anticipated, or under-estimated.  It fills the gap between my preparation and my real experience:

1.  I didn’t realise til I left it just how much of me I had invested in my last job, and therefore how difficult it was to be separated from it, and the people who made it.  Familiarity and shared history are enormously comforting in tough times. I didn’t have either anymore, and my time with it was over. Letting go was harder in the aftermath than it was in the moment.

2. I was a stranger to my new colleagues, and I hadn’t anticipated the impact that would have on my ability to make a positive impact at pace.  What I know about me and what they knew about me was worlds apart.  I know enough about my impact on others to understand it can be difficult to know me (why remains a mystery to me), but I don’t think I had really tied that up with being able to get on with the work at the pace it so needed.

3.  the spotlight was brighter than it has ever been, not because I had done anything to earn it but because there was a huge sense of expectation of the new post holder (as distinct from me personally). It’s not my natural place of comfort at any time, but more than that, it wasn’t right.  I’m of the very clear view that the days of the hero/villain leader are over, and the focus on a single post holder to hold the destiny of services in their hands is wrong in every way.  Yet a new approach has wide-ranging implications for everyone which means it won’t be achieved easily or overnight.

4.  the status quo bias amongst people is real – it doesn’t matter how illogical it may be, it does get in the way.  We know the status quo is unsustainable but we are so weary with change that we just have nothing more to give. I really struggle with this and it’s been the toughest of all my learning – connecting with it, trying to address it in a way which isn’t about judging it, but is about validating it and building the energy and capability to break away from it.

5.  an executive job title brings with it a whole load of assumptions and prejudices from others that bear no relation to me and my values as a person or a professional.  Rationally I understand why this is.  Personally, not so much.   The idea that I should be motivated by  anything other than helping people, including me, to be the best we can be is offensive and exhausting. I spend much more time than I expected talking with people about this shared purpose as the basis for our shared effort.

6.  talking about things once, or twice, or even ten times may not be enough.  There’s no right number. I have learnt to reassess constantly, check in, encourage, coach, clarify, seek feedback, to understand if we are all in the same place.  And if we’re not, to talk more until we are, while trying not to let any frustration on my part show.

7.  going home at the end of a long day and wondering ‘is it me?’ is OK. The important thing for me is to have space for reflection and objective challenge from people whose judgement I trust, and to come back the next day to push forward with what I believe to be the right thing to do.

If I had known these things six months ago, would it have made a difference?  Actually I’m not sure it would, because this is an adventure and I feel I am better for the experience.  While I hope that familiarity will, in time, help me to create a smoother flow in my leadership of our services, these lessons are valuable at any time.  I try hard every day to approach them with humility, courage, quiet confidence and an openness to learning.  I get it wrong at least as often as I get it right, but I hope my new colleagues can see in me a determination to do the best I can for as long as I am here.  If I can achieve that, I will be happy.

Be brilliant!



Thinking aloud – the job that changed me

It’s two months since I last blogged.  In that time, I have been asked frequently if I have been ‘winding down’ as I worked my notice period in my job.  If only!  It’s been busier than ever, and despite having several topics in my head, blogging just hasn’t hit the top of the priority list.

Endings, we are told, are important, and easily usurped by exciting new beginnings.  My job over the last 3.5 years has been such a huge part of my life, that I want to bring it to a conscious end.  It’s the job that I have lived and loved; the job that has changed me.  It has taken me to a new understanding about what I am about as a leader and even as a person. So forgive a self-indulgent reflection and help me say ‘goodbye’.

One of the defining moments in my early career was the experience of sitting in on  a ward round on a busy acute mental health ward.  I was so appalled by the way in which the consultant psychiatrist spoke to (at) the patients he ‘reviewed’, reinforcing misery and hopelessness in disrespectful and inhuman tones, that I knew I wanted to stick around and make a difference.  That was 12 years ago.  My approach to making that difference was to become technically competent in my work. I thought what I needed to do was to build up a knowledge base, develop management skills, know how to handle situations that arose, and drive service improvements so we were always pushing forward.  The focus was on the execution of the job.  Success was based on delivery of tangible goals.  Of course all those things are necessary and to be valued, but it wasn’t until I was nearly a decade into my career that I realised this just wasn’t enough.

People are rarely inspired by competence.  They may respect it, trust it, rely on it, take it for granted, but it’s unlikely to light a fire in their belly. People are inspired by people.  That means allowing the person behind the job title to show.  Now this is where it becomes difficult.  On top of my introversion preferences (already well documented in my blog!), I grew up in an environment both at school and at home where reserve and modesty were the prevailing values.  Quiet diligence, cleverness, belief and courage, alongside self-effacing humour, characterised life. That conditioning runs very deep.  So the idea that I might have to talk openly about my values in my work, what drives me to do what I do, was pretty intimidating.  Couldn’t I just be competent? No, actually.

So what brought about this revelation? Two things and some perfect timing.  I began a year-long leadership programme at the same time as I was co-leading the most comprehensive service redesign our organisation had undertaken, the most important feature of which was cultural transformation.  The programme gave me new insights into the way I worked and the impact it had on others, while the redesign gave me the opportunity to put new approaches into practice.  I made a huge personal effort to let go of some of those inhibitions, and verbalised the longstanding passion I have always had for better services which value the person ahead of all else. And I know it’s an old cliche, but yes, it has been liberating.  I nurture things that I used to dismiss as unimportant to my work – my personal narrative, my values, my connectedness, me.

I have a chronic uneasiness with aspects of leadership behaviour in which said leaders ‘big up’ how fantastic they are at doing it.  The obvious question is, by whose measure? It should only be their ‘followers’ of course.  Showing the human side often seems to tip over into self-publicity and a worrying absence of humility.  I have been overwhelmed with the generosity of comments from all sorts of people, who have nothing to gain in offering them, as I leave this job.  While these comments often leave me feeling awkward or embarrassed, I also feel a real sense of achievement, to an extent I have not felt in any other job.  From that, I conclude that a conscious re-evaluation of what is important in the way I work, what I pay attention to, has produced a real impact for people working in and accessing services.  I walk away from this job knowing that I have achieved good things, learnt from and spoken about the mistakes I’ve made, and found in myself a better leader.  I doubt those enduring values engrained through childhood will ever leave me, nor would I wish them to, but I have learnt to harness them rather than being constrained by them.  So perhaps this is not an ending, but a staging post in a lifelong journey.  Either way, this is the job that changed me.

Be brilliant!



Thinking aloud – just thinking

Have you ever been exhorted to stop doing something which is so fundamental to who you are that you might as well be asked to stop breathing?  I have, for as long as I can remember.

‘You think about things too much’.

‘Stop thinking about it’.

‘Tell me what you are thinking?’.

‘You’re over-thinking’.

It’s stifling.  The external interference in the internal conversations is perpetual, and ultimately futile.  I am not having thoughts of brilliance or genius.  I’m not breaking new ground.  The world is not benefitting from my thinking.  Often neither am I; it can feel burdensome and tiring.  But it is who I am, and it anchors me to life.  There isn’t an off switch.

Until quite recently, I would resent that interference,  hearing only criticism or judgement in those messages.  When did thinking become a problem?  An enquiring mind is something to value, isn’t it?  What I have come to understand better over the last couple of years is that my thinking preference has an impact on others, as well as me.  And for that reason, it matters.

I work in a field I love, doing a job I love, and I feel confident that I can and do make a difference.  I also know that self awareness of my impact on others has the potential to bring about a step change in my effectiveness as a leader.  This is still work in progress, a lifetime’s effort, but I know that I have moved positively and markedly in that direction over the last couple of years.  The insight I now have arms me with a perspective previously absent.  Thinkers amongst groups of speakers can come across as distant, aloof, detached, arrogant.  That hurts.  It’s so far from my intent that my first instinct is to be distressed by it.  When faced with that realisation, I went through a period of thinking (!) that I must be in the wrong line of work.  I was starting to feel myself being led to a conclusion that leadership just didn’t fit with me.  A conclusion I was reaching for myself, yet driven entirely by external influence, leading to self doubt.  When I triangulated that conclusion with other self knowledge, experience and consistent feedback over many years, I had a stern talk with myself and realised this just wasn’t true.  It didn’t fit with the other evidence about my job performance or career.  I was lucky that this ‘moment’ coincided with a fantastic learning journey through a leadership programme with the King’s Fund; an experience that will stay with me for life and for which I will always be enormously grateful.

So the conclusion I came to was not that I needed to change who I was to do the job I love.  Instead I needed to become more adept at self mastery, a concept I have connected with again recently through the inspiration of Helen Glover.  For me as a leader, that means working with what I’ve got, conquering my limitations by managing them, and maximising my positives – like knowing my own mind, being confident to make tough decisions, having faith in my judgement, seeing things from a different angle, and being unwilling to settle for conventional wisdom.  It also means putting the work in – pushing myself, committing to ongoing personal development (including learning how to ‘quieten’ my mind to give it a rest), and taking risks. As I contemplate starting a new job this summer, joining a very well-established and, I’m told, ‘lively’ team, I do so with more insight and mastery than I have known, and I can’t wait.  For the first time, I’m not worrying about being a bit different in my peer group.  As my new boss said to me, ‘just be yourself’.  Clearly someone worth listening to.

For anyone thinking this is just all too self-obsessed, a couple of years ago I would have agreed with you.  All I would say now is try it for yourself.  Seeing yourself as others see you can be scary in so many ways, but if you grab it and master it, and use it alongside your natural talents that others also see and value, you will see your personal impact in any aspect of your life increase significantly.

One last point.  Self disclosure is not something that is top of the list for most introverts, so why write this blog?  Of course there is a selfish element to it.  I started to do it to create a bridge between my introversion and the rest of the world.  But I also do it because I know I am not alone, and I know that talent is being lost at a time when it is so needed, because the world of leadership often seems biased towards extroversion.  I have learnt that I can master the natural abilities of people with extroversion preferences; it just takes more effort, practice and perseverance.  If I can have a tiny part to play in helping others to see that diverse contribution is something to be embraced and valued, and that introversion is something to cherish, not fear, then it’s worth the risk.

Be brilliant!



Thinking aloud – meeting the compassion challenge

I’ve started, abandoned and re-started this post several times in the last couple of weeks.  Quite often I find myself wondering if the hundreds of thoughts that run through my mind in the course of a day are unique to me, or if others are experiencing the same.  There’s something I just can’t seem to shake off at the moment, and wherever I look, I see it.  It’s  fast-becoming the byword for success in post-Francis health care.  Compassion.  It’s squeezed into every political speech, press article, CEO communication, tweet and blog about the NHS.  If you’ve got a role in healthcare and you’re not talking about it, you’re just not ‘on message’.

So why is this bothering me? This is a good thing, right?  Yes, I agree, it is, and I have written about it in several earlier posts.  But there are some aspects of the discussion that just don’t sit comfortably with me.  Maybe I’m misinterpreting.  Maybe the language we use is the barrier.  Maybe I just need to stop thinking about it.  So let me get it off my chest, and try and put it to rest.

Here are some of my thoughts.  Those that feel insufficiently attended to in the current debate.

Compassion starts with self.  Learning to come to terms with my own limitations and frailties is key to my ability to be compassionate towards others. So I worry when I see the romanticising of nurses.  Most nurses I know are extraordinary people with very special talents who are often under-valued and under-estimated.  They see the joys and agonies of life, day in and day out, and play a part in people’s journey that most of us never experience, but they are not angels.  They are human beings with human limits. Reaching that understanding, and accepting it, is key to their effectiveness.  Helping nurses (and other clinicians) to discover and handle that in the early days of training may be more helpful to their long term capacity for compassion, and wellbeing, than imposing 12 months of washing and feeding patients.

Compassion is unconditional.  It’s non-discriminatory.  The offering of it is an act of generosity from one individual to another.  It’s a gift of humanity.  It isn’t earnt, or deserved or based on some sense of the recipient’s worth.  It’s all in the giving, rather than the receiving.

Compassion in healthcare is indivisible from the clinical intervention.  It isn’t added afterwards as the icing on the cake.  It is the cake.  It can’t be separated or commoditised because it’s integral.

Compassion and paternalism are at risk of getting muddled up.  When I use health services, I want the clinicians I see to show me humanity and empathy, but I don’t want them to take away my freedom to be me.  The dehumanising effect of ill health can be devastating, and a paternalistic approach may often exacerbate this, albeit unintentionally. Showing human kindness shouldn’t tip over into stifling loss of choice and control.  Even the most vulnerable of adults are still adults, and compassion mustn’t come at a cost to independence.

So I guess what I’m getting at is that in the post-Francis whirlwind in the NHS, we guard against talking of compassion in a very limited or unreal sense. There’s no fairy story in the NHS.  I’d love to see some grittier discourse on the subject.  Something that measures up to the the grit that staff on the frontline see every day, and also have to demonstrate. It’s tough to exercise true and consistent compassion in every interaction, even impossible.  We need to create the safe space for clinicians and all NHS workers to reflect on those challenges, and talk about the dilemmas and natural human reactions they experience.  Leaving clinicians to feel it’s unacceptable, or ‘off message’, to talk about these challenges is asking for trouble.  Nurses are not angels.  Doctors are not gods.  And while I’m at it, managers are not devils. To stop at the ‘motherhood and apple pie’ stuff would do a huge disservice to the people who need our compassion most.  And it’s just too important for that.

So, is it just me?

Be brilliant!




When I wrote last time about compassion, and particularly the role of the environment on culture and behaviour, I had planned to pitch the next post at a lighter (and shorter) level.  However it seems that what I said chimed with a lot of people, and so my thoughts over the last week have continued on this track. I’d like to reflect on NHS managers this time. Please keep reading.

The Secretary of State spoke recently about an NHS management culture of ‘ticking the box but missing the point’.  It’s not difficult to see how he got there.  I wonder though how many managers out there get a real buzz from the next target to be met, the next penalty to be imposed, the next efficiency to deliver or the next constraint to be bound by.  How many rely on these things to gain their motivation and commitment to a role which…

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Thinking aloud – you don’t know what you got til it’s gone…

Last time I posted, the Francis Report had just been published and I was reflecting on what it would take for the NHS to become patient-centred.  That was over a month ago, and normally in that period I would have posted two or three times.  So why haven’t I?  Well, there are some practical reasons – work pressures as we build up to the new year in April, and also being knocked off course by a winter bug.  But more than that, I haven’t known how to organise my thoughts in the wake of Francis.  Most days, there are more headlines about new investigations, new revelations, new allegations, and confidence apparently leaching from the NHS at an escalating pace.  I’m told we’re ‘coasting’ by the SoS.  This provokes all sorts of emotions in me – conflict, shame, grief, anger, shock, fear, despair – but most of all, an immense sense of sadness.  When a gulf emerges between intent and experience, it is really difficult to stay motivated.  And it’s not as if working in the NHS is easy at the best of times.

Amongst so much negativity, it’s easy to find yourself succumbing to the media bias, generalisation and political spin, and even to join in.  The legitimate outrage over Mid Staffs is likely to run and run until there is a sense of justice for the families, and we’re nowhere close to that yet.  But meanwhile there are services to run, patients to be seen, staff to be supported to be the best they can be.  Today, tomorrow, next week, next month.  It was NHS Change Day last week that snapped me out of my post-Francis slump.  The idea was that thousands of people would pledge to take action that would make a positive difference – big or small, it didn’t matter.  I watched as the value of this day was debated on social media.  All views from blind faith to outright dismissal of its potential were aired.  I found myself responding to a doubter on Twitter.  To me, it was about galvanizing the passion of thousands of individuals who share a common set of values and who together are a force for good and need a channel for their energy.  Now more than ever, we need our staff to ‘feel good’ about what they are doing.  They are human, and indeed it is their humanity which is their most precious offering to the NHS, yet as devastating events have demonstrated, it can be squeezed from them in an environment which loses sight of what is important.  I don’t think even the most fervent supporters of NHS Change Day claimed it would be the turning point, or that if we just did this, all would be well again. Our responses have to be multi-faceted and tailored to the infinite complexity we face.  But what it did do was create a vehicle for 100,000+ people to stand up and re-state their commitment to doing better, striving for more, and re-connecting with the values that motivate the vast majority of NHS staff to do the work they do.  It’s good to know that the most popular pledge, with nearly 56,000 supporters, was about sharing hope in the face of despair – so impressively championed by Dr Alys Cole-King in the context of suicidal thinking.

There are plenty of commentators who lead us to believe that the negativity around the NHS is exactly what is required to create the political and ideological platform for the break-up of what we have known as a national health service for more than 60 years.  The perfect storm is brewing.  I don’t know if this is true or not, although my own observation is that bad things happen more often through cock-up than conspiracy.  What I do know is that it’s easy to lose sight of what we do have, and by the time we realise it, it’s gone.  Yes, the NHS and all those with an interest in it have got a lot to do to make it fit for purpose.  Yes, there are tough decisions ahead.  Yes, there seem to be circumstances conspiring against us.  Yes, we need a greater distance between political influence and service delivery.  But next time I hear a headline and feel a sense of irretrievable despair, I’ll be thinking about the line in that song – ‘you don’t know what you got til it’s gone’.  Will you?

Be brilliant!



Thinking aloud – what would it take to be patient-centred?

This week’s blog is published in collaboration with Steve Appleton, Director of Contact Consulting @contactconsult

Wednesday 6 February 2013. A date that will remain in the memories of thousands of people who rely on, work in and pay for the NHS. It was the day that ‘outed’ what has been known for a long time – that the NHS can’t go on as it is. The second Francis report was published, and in over 1800 pages revealed the findings of the public enquiry into the Mid Staffs scandal. Hours of airtime, thousands of column inches, blog posts and tweets have poured over what happened, how it could have happened and how it might be prevented in future. So many angles, perspectives, themes and concerns – culture, compassion, accountability, regulation, targets, money. What is the golden thread – Francis urges us to build a patient-centred NHS.

There can be no doubt that Francis will be a catalyst for change. It has to be. But is it within the capability of the NHS, the Dept of Health, the government and the public to optimise the learning? What would it take to become patient-centred?

1. The needs of patients would have to be placed before the needs of politics, and politicians. This requires brave political leadership, candour even, which may be at odds with widespread public opinion. It requires a horizon which extends beyond the five year intervals of general elections. Or, if this is pure fantasy, recognition that political and patient needs do not always coalesce. Quality is a function of investment and system design. If you alter the former without tackling the latter, cutting corners and reckless risk taking become perverse coping mechanisms, and bad things start to happen. That’s not patient-centred.

2. Paternalism still has a stranglehold on the NHS. We would need to treat the public as adults, quite capable of understanding the case for change if only we had the collective bravery to set out the narrative. This won’t happen if we stop at the ‘how can you place a cost on human life?’ argument. The fact that there isn’t an adult dialogue about this issue doesn’t mean it’s not real. It’s an inevitability of any system operating within finite resources that decisions have to be made about who gets what. Many of the older people who suffered poor care in Mid Staffs should not have been in hospital. Their care might better have been provided closer to home or through respite services and more effective supported accommodation. And over the next 20 years, as the population ages and lives longer with complex needs, this is going to get worse, unless something changes radically and quickly. An over reliance on hospital care is not sustainable.

3. The fragmented system of health and social care, commissioners and providers, primary and secondary care, physical and mental health, would need to be orchestrated in ways it is not currently incentivised to be. Decisions are made by each of these stakeholders which do not always benefit the patient.

4. Patient-centred means being people-centred. People have a tendency to be unique, so the rate-limiting factor of individual human need doesn’t suit the conveyor belt of NHS delivery. The system has long been incentivised to change the people, not the conveyor belt. Inconvenient as it may be, people’s needs can’t always be addressed through blanket targets, yet we shoehorn them in regardless, or risk the wrath of the centre.

5. Setting and regulating standards as a means of spotting the need for remedial action has its place, but it’s externally imposed on a system which is made up of people who have enormous capacity for values-driven, compassionate care. Creating a fear of inspection won’t lead to sustainable improvement; it risks driving poor practice underground. What do we need to do to create and nurture an environment in which that human capacity for change is engaged, and is stronger than any other drivers of behaviour? What it means to be patient-centred can’t be captured in surveys, or Tripadvisor style reviews or tests. It’s not mechanistic; it’s not a holiday. It’s complex, human and vital. What counts isn’t always countable. The satisfaction of those who use services will need to be given a higher currency when considering both quality and service development.

6. Collaboration is increasingly the norm between organisations. The NHS will need to recognise that it can and must learn from other agencies and sectors, public, private and voluntary. At the same time the divide, real or perceived, between clinicians and managers will need to be bridged. The skills and expertise possessed by both must be pooled to develop approaches to care delivery that are effective, evidence based and result in improved outcomes.

7. Stop restructuring. It’s a distraction, it delivers marginal gains at best, it costs huge amounts in terms of money and lost time, and the NHS infrastructure is a mystery to most patients in any form. If the same level of investment of money and energy was placed in cultural, attitudinal and patient-centred reform, we’d all have a great deal more about which to feel hopeful.

So as Trusts up and down the country frantically start writing Francis action plans, even before the government has announced which of the recommendations will be taken forward, they are doing so in a culture and environment in which the patient-centred characteristics of the healthcare system remain inadequate. In all the column inches I’ve read, I haven’t seen anyone say they want to limit the learning from Francis, yet I have seen commentators reserving judgement on the ultimate impact it may have. The gap between rhetoric and reality will remain unless these fundamental aspects of healthcare planning and delivery change. How? That’s a topic for another blog….

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Just another day in the life of a passionate health worker & lifelong learner.