My Notes on Leadership and Success

Thanks, Musty. I was born in a country called Rhodesia, which is now Zimbabwe. At about the age of four, I had an accident, broke my arm, encountered orthopaedic surgeons and thought, wow, this is pretty interesting. And from that moment on, really, I wanted to be a doctor.

Then when I must have been 11 or 12, I was listening to a green and white Philips transistor radio underneath a tree in the garden. There was a programme about the National Health Service in England, and I remember thinking, that's fantastic — a place where people can get really high quality care, they don't have to pay for it, and you don't have to worry about your background in any sense. I went into the house and asked my mum more about it. She explained some of the principles to me, and I said to her, I'd like to go and work in the NHS one day. That set me off on a long ambition.

But having said that, the route wasn't entirely straightforward, because I didn't do very well in my A-levels. I had to go to a crammer and have a second go. Then I worked to earn some money, with some support from my dad, and I arrived in England in 1973 with a rucksack and 250 quid. In total, I was rejected by 19 medical schools that I actually applied to, and I was told by several others not to even bother applying. Eventually, I got into medical school through clearing. And that was the beginning of my journey.

I had a cousin who was working in Nottingham at the time. I couldn't get into medical school, even though I'd tried visiting almost all of them in the country. But in a pub, I met somebody who happened to be in charge of admissions for parts of the University of Nottingham, and I got in there to do a degree in chemistry and biochemistry. I was completely hopeless at the biochemistry and the chemistry — but I was saved, because in clearing at the end of the first year, I got into medical school in London. A place called Charing Cross Hospital Medical School, which doesn't exist anymore. It's all been incorporated into part of Imperial College.

That's a fair comment, and it might do to people now. But I was brought up in what had been a British colony, so in some senses there was a centre of gravity towards England. There were other things going on too. I was very disturbed by the social and racial inequalities in the country at the time I was growing up. I couldn't see a future there in the longer term. My dad said to me, forget you were ever here — there's going to be trouble, this current system doesn't work. And he was absolutely right.

It was the proximity to some of those very serious inequalities that gave me a deep sense of social justice, and the importance of the idea that everybody's essentially the same and should be treated the same, particularly when it comes to health.

Not long after I'd done my A-levels, I was working as a porter in a hospital in Harare. There were two big hospitals, one for whites and one for non-whites. I was going into work one day and a guy got hit by a car just outside the white hospital. He was a black guy on a bike. The ambulance came very quickly, scooped him up, and took him to the other side of the city. You didn't need to be a neurosurgeon to recognise this guy was in serious difficulty. In a just and equal society, he would have been taken into the hospital which was 300 yards away. I was left with a very deep and sad sense of what the social structures in the country meant, when that was the effect on an individual needing immediate and intense medical therapy. And that just reaffirmed my conviction that I wanted to practise in the National Health Service.

I think that's a really good question. Being an accomplished clinician is helpful in some forms of medical leadership roles, but it's by no means essential. Attitudes in the medical profession have changed. There used to be a perception that you weren't a proper leader if you hadn't been a proper doctor. Well, in my last role I found myself asking, what is a proper doctor? A proper doctor is a person who understands anatomy, physiology, diagnosis and treatment, and can speak the language and communicate with other doctors. They don't necessarily have to have spent years on the front line doing all sorts of stuff that's not necessarily relevant to whatever leadership role they're going into.

It happened that for the role I was going into as national medical director, I needed the credibility that I'd achieved in my own right clinically. But if you're a young doctor starting off in life and there are other, entrepreneurial things you want to do, I think having a medical qualification — understanding the language, the values and the purpose of medicine itself — is enough.

It was quite a long route. When I first became a consultant at the Hammersmith Hospital in London, I arrived, I had an empty desk, I had a couple of patients who'd been referred to me, and strangely, not much to do. I thought, if I want to succeed in the specialty, what do I need to do? First, I need to prove that I'm an adequate surgeon. Second, I need to make a contribution to the specialty. There are two ways you can do that: by becoming involved in the specialist association — the group of cardiac surgeons — and by doing research. And I thought I'd do all three.

I had an academic job, so I had to do research and I had to do the surgery. But I also thought about how I could make a contribution to the group. Cardiac surgery is really expensive. People are going to be asking how effective it is, and whether our surgeons are good enough. Just as I was thinking that through, I got involved in some research to operate on very sick people. The perceived wisdom of the day was that you should never do a coronary bypass operation on people in heart failure, because they just died — no sensible surgeon did that. I was working with an Italian research cardiologist, and we were using PET scanning to see whether we could identify hearts that might recover if they got a better blood supply.

It looked as though we had the wherewithal to do that. The trouble was, I was a new consultant. If our science worked, that would be fine. If it didn't work, I'd have a very high mortality rate that would be quite difficult to justify. That got me interested in how you measure outcomes and expected outcomes for patients with different severities of illness. And that took me into a whole practical and research area of risk-adjusted outcomes. As it happens, the PET scanning methodology worked perfectly — we did quite a significant number of patients and there were no deaths. But it might not have ended that way.

I then went on to develop a system with colleagues in this country for measuring cardiac surgical outcomes for every operation performed on the heart. It took us about 10 years to get that up and running. What it demonstrated was that cardiac surgery in this country is pretty good, and it provided a basis on which to undertake quality improvement. I'm quite pleased about that, because it's been running now for many years, and a lot of people find it useful to be able to measure their outcomes and know how well they're doing.

So I had those things I was developing: research, trying to become a better surgeon, and understanding the measurement of outcomes. And just as I was getting into the outcome measurement stuff, there was a massive problem with paediatric heart surgery in Bristol, which was followed by a big public inquiry in the late 1990s and early 2000s. That brought cardiac surgery outcomes right under the spotlight. Fortunately, we were already on the way to measuring outcomes quite reliably and responsibly, and the fact that I was central to much of that activity meant I had the opportunity to meet a number of interesting medical leaders at the time.

It became quite a political issue — the government wanted increased measurement of clinical outcomes. I was then asked by the chief executive of the hospital in Birmingham to develop clinical governance. This wasn't some big formal appointment. He summoned me and said, we've got to do clinical governance. You know about outcomes. I said, yeah. He said, well, I want you to sort out clinical governance for our organisation. That was all a bit scary — but that's how clinical leadership in those days kind of happened. Somebody gave you a bit of a leg up and you had a go. It wasn't as professional as it is now.

So suddenly I found myself with not only a little bit of influence and profile nationally in terms of cardiac surgery outcomes, but I was now being drawn into setting up clinical governance in a pretty big trust. As time marched on, the focus on clinical outcomes grew. I was asked by the Department of Health and others to help them think some of this through. And then I ended up on the board of something called the Commission for Health Improvement, which was the first healthcare regulator we had that was looking at outcomes in the health service. So there wasn't any one big thing — it was just a series of serendipitous events that enabled me to develop my clinical leadership, so that by the time they advertised for a medical director of the National Health Service, I'd already done a number of the things that were required, and could tick the box on many of them.

I agree with you. But the first thing I'd say is you probably need to distinguish between leadership and management. Leadership is about getting people to see common cause — getting everybody aligned around something, whatever that thing is. Management is about making things happen. You can align people to have common cause without being a very good manager. But it's quite difficult to be a really good manager without also being a good leader.

So, for example, the skill of persuading people to come out of a trench into gunfire is a different sort of skill to the person who has to organise the food, the ambulances, the bandages, everything behind the scenes. People often use the terms leadership and management interchangeably. They are not. Quite often courses labelled as leadership courses are really management courses, and some management courses are leadership courses.

But in any event, the point you're making — that you can't just learn it on a course, come back and practise it — has quite a lot of truth to it. You can learn some of the principles of both. But ultimately it's how you put things into practice when you're presented with a challenge. Can you come up with a reasonable way of tackling it? Can you convince other people your solution is a good one? Can you help other people achieve the change they need? That's not done in a classroom. That's done in your day job.

It might be slightly more than three, Musty. Let me try and piece something together for you.

When you graduate, it's a great leveller, because everybody who comes out of medical school is pass or fail, and everything's recalibrated. Your opportunities, or mine at that time, were, in my head, abundant. It was a chance to take stock of where I wanted to go and to recalibrate. Over the years, I've thought about what the drivers for success are, which are quite similar to the drivers for good leadership. There are two inherent values — the first is compassion, and the other is fairness. Then they're coupled with four principles: discipline, integrity, respect and responsibility. Let me talk about each one in turn.

Human knowledge is growing exponentially. Here's something you won't believe: when I was a medical student, I was taught that the endothelium was simply a semipermeable membrane with no function. By the time I was a research fellow, as a middle-grade registrar, I was doing research on the endothelium, and it was becoming apparent to us that it's probably one of the most important organs in the body. Medicine and medical science advance exponentially. The self-discipline and the perseverance that you show in your approach to work, learning and staying up to date will distinguish excellence from mediocrity, success from failure, professional happiness from despair. But that discipline has to come from within you — nobody else can force it on you. There's another bit of discipline that's really important, too, and that is: never, ever speak ill of your colleagues.

But discipline alone isn't enough. You've got to couple it with personal integrity. In the academic world, there are always challenges over credit, recognition and attribution of scientific work — people squabble over that. In management, commerce and industry, there are challenges over personal recognition on a competitive corporate ladder, or personal financial gain — you see it in private practice. Harry Truman once said something along the lines of, you can achieve whatever you want, provided you don't mind who gets the credit. When I think of the people who brought me on and helped me in my career, they've always given me free rein and never claimed the credit. So many things go wrong in medicine when people want the credit. If you treat other people the way you want to be treated, and you're not trying to get credit for their efforts, then people will treat you very differently. It's a real key attribute of leaders.

Then, respect. Respect is so important. You've got to recognise that everybody's got something to bring to the party, something to offer — and all you have to do as a leader is take the time to find out what it is. Mutual respect is the absolute essence of effective teams. Arrogance, particularly in times of economic and social crisis, is a terrible enemy. It's very easy to be dismissive of those you think have less intellect, different beliefs, a different lifestyle, a different job, or simply those you think come from the wrong social class. All that does is utterly demean your own intellectual honesty and integrity. That kind of approach makes us lesser people. But it does more — it stops you achieving your own personal potential.

And then responsibility. You should take quiet and gracious responsibility for the good things you do. But you need the courage to never hide from your mistakes, your errors of judgment, your lapses of personal values. We all make them — every single one of us, and more than once. When I was a very senior trainee in heart surgery, about to take up a consultant job, I was working for a pretty scary and impressive senior consultant. I went to see him and said, Mr Parker, when I go to be a consultant in three weeks' time, what's going to be different? Because I see the patients in the clinic now, I assess them for surgery, I see them on the ward before their operation, I do their operation, I look after the cardiac intensive care unit, I take patients back to theatre in the middle of the night if they've got a complication, and I see them in follow-up. So what's different about being a consultant? He just looked at me and said: taking responsibility for other people's mistakes.

As I've gone up the leadership ladder, that has become more and more prescient. As a consultant, if your senior house officer or registrar makes a mistake, you look after them, you help them through it, but you take responsibility. And it's just a different level of responsibility for a different level of mistake that you take on, often for things over which you have no control, when you're in a very senior leadership role like medical director of the health service.

Clinical leadership takes many different forms. Let me tell you how I categorise it. The first group of clinical leaders, who are so important to all of us, are those who are just very good clinicians — people who put their patients first, are up to date, bring forensic scrutiny to their diagnoses, have great therapeutic knowledge and are kind. They are our most powerful leaders, because they inspire the rest of us to be good doctors, and they inspire the medical student to want to be like them. Another group are those who focus on innovation — consistently looking for new, better ways of doing things, whether in clinical practice or entrepreneurial activity in the technology space. Then there are those who want to be academic leaders, at the cutting edge of medical science. Then there are managerial leaders, who want to organise services in a better way. And then there are those who want to focus on training the next generation, on developing standards of clinical practice. So there are many opportunities for people who are young and want to think about where they might exercise some form of leadership or influence for the better in medicine, or the NHS in general.

I'd like to simultaneously, respectfully, agree and disagree. Let me explain why.

Firstly, there are two different types of leaders: those who want to change things for the better, and those who don't want any change because they're quite happy as they are and try to obstruct the former. And then there are another two types: those who quietly go about their business using the sorts of values and principles I described, versus those who think they can get change by being very vociferous. That's always a short-term game.

One of the things I learned as medical director was that I had to take the criticism, quite often, for things that were both thought up and done by other people. I had two choices: to say "not me, Gov", or to say nothing and try to change it behind the scenes. I learned that the latter is a much better strategy, particularly in a political arena. If you're very critical of people who've made decisions you don't agree with, you soon get cut out of the sphere of influence. If, on the other hand, you're quiet, you're discreet, and you use rational argument, your views are quite often welcomed. Megaphone diplomacy doesn't work in the long term. You win your arguments in private and you lose them in public.

That's a really complex question. You go into these roles thinking you won't be contaminated by politics in any way. But of course, inevitably, you're working in an environment, part of which is about politics. At times you do have to make judgments about which arguments it's important to win, and which are nice to win but don't really matter. The difficulty is that whatever the argument, there's always someone who thinks it's particularly important. You can't please all the people all of the time. With the passage of time in these roles, I've come to the conclusion that you lose some people along the way — who don't agree with what you've done, for whatever reasons, and who see it as a political issue.

You can't please everybody. I'll divide that in two. The first thing is, there's so much stuff you could do — so much. What are you actually going to do? In my head, I used to think about a particular problem along the lines of: how big a problem is it? I'd measure that in terms of mortality, morbidity, economic burden, contribution to social inequalities — and then whether there was actually anything you could do about it. There's no point worrying about something you can't do anything about. That helped me set some of the priorities. Of course, there were other people trying to set priorities too — it wasn't just the medical director.

The second thing is about responsibility. When you listen to people, you've got to listen — but ultimately someone has to say, we're going to do it this way. Frankly, if you listen enough, and if you encourage people to speak up and create an environment where they feel safe to change their points of view in the face of changing arguments, you almost invariably end up with a pretty good consensus. That's part of leadership.

Coming back to the listening — I was examining someone's doctorate of science, and at the beginning he paid credit to his dad. He said his dad had once told him: when you're having an argument with an idiot, make sure he isn't doing the same. It's an amusing quote, but it highlights the importance of listening carefully to what other people are saying.

Yes. Let me give you an example. Years ago — it must have been 2009 — I got summoned to an all-party parliamentary group I didn't really want to go to. They were worried about venous thromboembolism in the health service. The World Health Organization and the chief medical officer had been focusing on this, and they were quoting figures which said something like 38,000 people a year died in the NHS from the consequences of venous thromboembolism, and about 25,000 of those were avoidable. The figures seemed very high to me, but I arrived at this meeting and there were loads of researchers, and they weren't arguing about the figures. I thought that was a bit odd.

Anyway, it turned out I'd been summoned so they could tell me my job was to sort this out. I said, look, it's not my job as some dark agent of government to tell you what to do. Then the president of the Royal College of Surgeons stood up and said, Bruce, I did my thesis on this 40 years ago, and nothing's improved. In my hospital, every orthopaedic surgeon uses a different dose of heparin, and it's a shambles. You've got to do something. Then the president of the Royal College of Physicians stood up and said, you've got to do something.

As I walked back to my office, I thought, what's wrong when the leaders of the medical profession turn to me and say, you've got to tell us what to do? And then the penny dropped — that wasn't what they were saying at all. They were saying: make it easy for us to do what we know needs to be done. In other words, there was too much treacle, too many obstacles in the NHS system, to enable standardisation in this particular area.

So I called a meeting with the presidents of all the Royal Colleges and the 10 Strategic Health Authority medical directors, and said, is this an issue we want to focus on? Within about two minutes, everybody agreed it was a good thing to do. I went back to the NHS management board and said, this is an issue, we need to do something. They said, what? We said we needed to assess everybody being admitted to our hospitals for their risk of venous thromboembolism, and then ensure that anyone at high risk got the appropriate prophylaxis. As a consequence, and in consultation with senior clinical colleagues, we put a number of financial incentives and penalties into the NHS.

When this was first implemented, we weren't sure how many, but somewhere between 25% and 40% of people were being assessed on admission. At that time there were about 16 million admissions to hospitals a year. In just over a year, because of the incentives, that number was up to well over 90% — I think it was around 95%.

What I learned from that was: if you want to do change in the health service, find out from the clinicians what they want doing. And the deal is — you guys communicate with all your members of the Royal Colleges and specialist associations that that's the direction of travel, because nobody listens to the Department of Health or NHS England if they say it's the direction of travel. But they do listen to their peers. And then use someone like me, as medical director, to go back and put the mechanisms in place. That was such a powerful combination, and for me it was almost a perfect model of change — because we were doing what the clinicians thought was right, it was a benefit to the patients, and everybody was aligned. So, in answer to Warren Buffett's colleague — yep.

No, I don't think so. We did a number of very successful things in the cancer sphere, but that was all driven by a combination of clinicians and charities. It was the same in cardiovascular medicine, and the same in trauma. I was always keen — as were politicians, actually — that the views of the clinicians were harnessed first. Where I had difficulties was that we might know what needed to be done, but the arguments were around how to do it, and different people had different views. That wasn't always easy to achieve a consensus on. But incentives were clearly the basis of it all. It was just which incentives.

It's a really good question, and it's not morbid, and there's no need to apologise. I think the answer is yes — and it has to be, because you can't change things. But in terms of the sacrifices, if I were again giving advice to the 20-year-old Bruce in the pub as a student, I might say: when you make some of your choices, perhaps pay more attention to the impact those choices might have on those nearest and dearest to you.

As a cardiac surgeon in those days, rotas and things were very different. You were at work before the kids got up and you came back when they'd gone to bed — that was the norm, and it couldn't be changed. When I decided to take on a role at UCL, and then medical director of the health service, I stayed living in Birmingham because my wife had a job here and there were schooling issues, and I went to live in London during the week. So I'd go to London at 6 o'clock on a Monday morning and come back late on a Friday night or early Saturday morning. I did that for 14 years, and I got to a place where I felt that was normal. It wasn't until I stopped and came back to live at home that I really realised the sacrifices my family had made in order for me to do what I wanted. When I embarked on it, I probably didn't realise what it meant for them.

So in answer to your question, it sort of leaves me with that really difficult question that so many families grapple with — about how you get your work, your ambition, your family life balance right.