Decision Making in Health Leadership

I'm a clinician by background. I started life in dental surgery, but long before that I actually worked in retail — retail technology — then in financial services technology, and I did a bit in shipping and oil before I came back into the healthcare mainstream. When I qualified I worked in primary care for a while, in general dental practice, then in hospital services, then public health and health economics, before I decided to leave and go into consulting. That's where I really got stuck in properly — into data, technology, and how we can achieve transformation by using it.

Since then I've been lucky to have what people describe as a portfolio career, where I've been able to work in bits of the NHS as a clinician while also working in clinical commissioning and getting very involved in healthcare transformation — mainly digital transformation. That's where I've spent the main part of the last five years, and a large part of the last ten.

As most people find, it's often difficult to say no and give things up. I find it very hard to say no, so rather than give things up, I tend to accumulate — and that probably sums up a lot of my life. But I've always practised clinically. From when I qualified through to now, I've continued to practise — whether that's direct clinical care for patients or in public health. Alongside that, I've had to blend a career doing other things.

The nice thing about clinical practice is that it gives you flexibility: you can work clinically throughout, but also do less clinical work at times and more of other things. You can make it fit in and around your own life and ambitions. And one thing I learned early on is that there is a career structure and a career pathway, but you don't have to stick to it. As and when it suits you, you can come off that treadmill — or that elevator, whichever it is — step off, and start doing something a bit different.

I think the two go hand in hand. I'm sometimes better at roles in commissioning or management or leadership because I understand the clinical context, and it helps me run clinical services because I understand what everyone else in the system has to do. The two things fit together in a way I wouldn't have envisaged when I started, but now rely on as part of everything I do.

There are always times — whether in clinical training or otherwise — where we probably all feel lost. People feel overwhelmed; there's too much going on. Sometimes there's not enough happening and there's the boredom. Occasionally it's, what am I doing here, do I have to fill in forms all my life? Because that's what most clinicians seem to do. There'll always be times, whatever anyone happens to do, when they feel lost or unsure. And I think that's okay. There have certainly been times when I've been uncertain about what next, where do I go.

If I look at my own career, I've been lucky enough to work in clinical practice, public health, management consulting, bits of law, and a whole range of other things in clinical and digital leadership — but none of it was purely planned. Some of it happened because of things I'd done in the past, which meant opportunities opened up in the future, but they're largely unpredictable. If you'd said to me fifteen years ago that I'd be a director at the national level of the NHS working on digital development, I wouldn't have been able to predict it.

It's an accumulation of different ideas, thoughts and experiences that have taken me here. And I'd say to anyone interested in a varied career: don't let the structure of the system bound you. Let the fact that you can achieve anything you want be your bounds. The worst thing you can do is not try something — you're better off trying something that may not work, and learning from it, than not doing it at all. For some people a traditional career suits them, and that's fine. For others, who are looking for much more, it's worth branching out. If you've got the ambition, the drive and the determination, give it a go.

I probably should have learned to say no a lot earlier. I wish I'd been a bit more discerning about which things I said yes to. What I've learned is that I need my own framework: what are the things that are really important to me, that align to my values and to where I want to get to? I keep saying yes to those — either because I need to, because they earn me an income, or because I'm super interested in an area I want to change or develop. But I also need to learn about the things I shouldn't say yes to, and I wish I'd done that sooner. It's only through going through it that you discover the things you're not interested in — you have to try things to work it out. I'm probably close to that point now, learning to say no a bit more and give things up. Right now I'm realising it's okay not to be doing everything. Things go around in circles, and some things seem urgent, but rarely are many things that urgent.

It very much depends on the individual and what interests them. The worst thing would be to pursue something you're not interested in. So first and foremost, think about what interests you, what's going to keep you motivated. Whatever happens, anyone listening should avoid doing anything they're not interested in — if you don't have that interest, don't do it. There have been times I ended up in roles I wasn't 100% interested in. Even in training, as a registrar, there were elements I didn't like; in public health there were elements I definitely wasn't happy with. If that had been my whole career, I wouldn't have stuck to it.

The things that really interest me are working with numbers, looking at deals, working out the different risks — things other people might find boring — and, in consulting, helping people solve their problems. I'm probably less interested in being someone who runs a fund or an investment entity. I don't mind advising those entities, but running one isn't the sort of thing that personally interests me. That's just what I like. For some people it's the opposite — there are clinicians I know who are absolutely amazing at thinking about a fund: where to invest, how that investment will mature, how they'll make change happen in the health service by doing it. They love it and they're fantastic at it.

I'd arguably say I am a jack of all trades, but equally a master of none — because I like doing lots of things, and there are people much better than me at all of them. But I like having a generalised career where I can turn my hand to lots of things. Equally, there'll be people who want to do one thing and do it really well, and I don't think it's either/or. It's a bit like medicine itself: there are generalists — GPs, general physicians — and there are super-specialists and subspecialists. The same exists in portfolio careers.

Most people will try a few different things before they find the thing they like. I tried primary care, hospital practice, then consulting, then law — it took me four career changes to realise I like a bit of everything. So don't be too hard on yourselves, and don't expect to know where you'll be right now. The career ambitions people have finishing med school may centre on one specialty, but at that point they won't even have been exposed to so many other things. Give yourself time and space, find the interest point, and have lots of discussions — talk to people, get experiences, learn from others. Some of the people listening are going to create new career pathways, new areas of medicine, new ways of working. The blend between policy, technology and operations will change over time, and you can like all of those to different extents.

For me, I approach decision-making around degrees of urgency. The first thing I want to know is: how important is this decision? Do I need to make it, and do I need to make it now — or is it something somebody else can make? That's always my first sieve. If it's in the super-urgent category, I want to know what the risks are, how difficult it is. Is this something that needs to be made within seconds because the system is relying on it, or do I have more time? What information do I need? What questions do I need to ask? Nothing in decision-making is ever binary — certainly not in the public sector. So I find it's about asking the right questions around a decision.

Someone said to me years ago at the NHS Staff College — one of those NHS leadership programmes — that one of the things decision-makers need to be able to do is make progress happen. You're making decisions on the best available information at that point in time. None of us will have all the answers, but we've got to use our instinct to make the best guess that will get to a better outcome. So part of it is asking: what change do we want, what transformation, what do we want to happen in the system for our patients, our population, our clinicians? And with that lens, make decisions.

The one thing none of us should ever do is stand still. If we just stand still, change won't happen, progress won't happen. Sometimes we'll make decisions that, looking back, weren't right — but they were right at that point in time. You have to be willing to progress, knowing that based on the information you have right now, you can make a decision. You might need to review it or change it. But being able to decide, and not get paralysed or stuck, is really important. It's all too easy to say, I need more data, I need more evidence, I need to see how it goes. Those things are useful at points in time, but depending on the urgency, sometimes you just need to make a decision and use your instinct. Look at Amazon, Google, any big organisation — people are making what they call bets. Based on the information they have, they make a decision and go with it. In healthcare we do that all the time with our patients; from a policy point of view we're less good at it. We're not bad, but we're not great.

Totally. Even in my own businesses, my teams sometimes say, this is working really well. And I'll say, it might be — but how did we get there? Was it an accident, or did we plan for it? And what about all the things that didn't work so well? Sometimes we make decisions that are almost passive: they happen, they result in a good outcome, and then we accidentally assume the outcome was because of our decision-making, when in actual fact we didn't have a strategic approach — we just got there by accident. And vice versa: we look at bad outcomes and think we made bad decisions, when in fact we just didn't have the information at that point in time. So I do support that approach. We have to be cognisant that none of us knows everything, but also have a little foresight that outcomes may turn out slightly different from the decision we made.

It's possible it could. But even in healthcare and health tech, we can still apply the same philosophy — just not necessarily at the same pace, and with different safeguards in place. The notion still stands; it's the way we go about it that's different. We might take a different approach to risk assessment, and incorporate clinical safety into the decision-making. In any other part of tech we have multidisciplinary teams — agile teams — with different members bringing different expertise, sometimes subject-matter experts. In health tech we should do the same.

Where I see it going wrong is where there isn't strong clinical leadership in those digital health and technology projects. Where there is strong clinical leadership that can ask the right questions and take a risk-based approach, we can still operate just as quickly. It's about knowing what you can move quickly on and what requires more discovery or research, and having the right team members to do that. I've seen both. I've seen teams that were phenomenal but didn't have the right clinical expertise, so they got ahead doing things for the right reasons but didn't achieve the right outcome, because they hadn't thought about the risk profile. And I've seen teams with loads of great clinicians on board who weren't quick enough at making decisions, so they got left behind. Again, I don't think there's a wrong and a right — it's about asking the right questions to inform the next decision.

Some things aren't life-and-death — things dealing with health information, or connecting patients to clinicians — and can happen more quickly. Other things are closer to the diagnostic end, and there you'll want to take more time to assess the risk. So be good at assessing risk in a health tech or digital health environment, and be willing to be the person who says no — or not "no", but "yes, maybe" or "no, maybe" — and work out what can and can't be done within those constraints. I'll give you an example. Last week a team member wanted to change the way we do a certain diagnostic. On the surface it was a really good idea, and they wanted to launch the change within days. As I worked through it with them, I said, these are the clinical risks you haven't thought about — not because you didn't want to, but because you wouldn't know. Once you solve these things, you can go ahead. Why don't you take the next two weeks to solve them, so we're not left with the clinical risk? It's about having that kind of discussion with somebody.

Absolutely — I couldn't agree more. It's really important to pick the optimal team members who can work together and bring different strengths. But in deciding what the optimal team is, you also have to consider the cultures and values of those members, and the problems you're trying to solve. Take the NHS: it has 1.3 million employees and another half a million or so workers on top, so getting on for two million people. The population we treat is one of the biggest — 56 million in England, 65 million across the UK. So we've got a big workforce treating a lot of people. And people live in communities. If we want to treat them and reduce inequalities, we need people who understand those communities — who can think like them, put themselves in their shoes, experience the same problems — so they can come up with solutions for them.

If you look at leadership, management and hierarchy across the NHS, you see a distinct lack of diversity. It's a very polar environment, and not much has changed in the last ten years. That worries me, because if we're going to make the best decisions for the population, we need to be more inclusive in our decision-making, and we should respect and value diversity in our leadership. I don't just mean race — I mean race and ethnicity, gender, social deprivation, family status, single-parent families. We need everyone in the mix. There are good people out there with the right skill set who should be included in those leadership groups.

When I look at the NHS I still see a club — a club of people who are often interconnected through school, university, political arrangements, whatever it happens to be. And that group tends to pick people like them. Sometimes some of them can represent and connect with parts of society, but quite often you end up with a very homogenous group where people like us pick each other, and then you don't see diversity or inclusivity in decision-making, and you don't see better outcomes or a reduction in health inequalities.

I always advocate for the optimal team for the job — blending the strengths of different players who can work together and creating a diverse environment. Something I pride myself on: when I was in the NHS I had a very diverse team, a big mixture of people from different backgrounds, parts of the country, ethnicities and social statuses, working together because they brought different ideas. We could solve problems in another way — whether that's accessibility of products and services online, the language needs of different populations, understanding disabilities, whatever it happened to be. But at the moment I see a total lack of that diversity at the top of the NHS, and I haven't seen much change in the last ten years. I still see a club, and I still see appointments at senior level based on not what you know but who you know. It may not be intended that way, but that's how it seems to fall out. Things are getting a little better now, but I still don't think it's good enough.

My tenure was coming to an end, so my time in the NHS was coming to a close, and I was deciding whether to move on and do other things — which I chose to. As I was leaving, I noticed a lot of things. I noticed team members of mine who were struggling, facing challenges in the workplace. I noticed opportunities weren't being fairly distributed. And I noticed a lot of the checks and controls in the system didn't seem to exist — the appointment of senior people again seemed to be about who you know rather than whether someone was the best person for the job. This seemed commonplace, and not the sort of thing I wanted to be part of.

What worries me is how we ended up with an organisation responsible for such a significant part of transformation in the NHS that has so little structure around it — that didn't, at that point, even have a cohesive strategy. When you looked at the design of the organisation, it didn't have a structure that reflected the outcomes it was trying to achieve, and the resourcing wasn't built on the skills needed to do the job. It was based on what might be available within the organisation, and on existing, pre-existing relationships. That worries me, because it means we're not creating a public sector that's best for citizens and health outcomes — we're creating something closer to what people describe as an old boys' club. That's not an environment I'd thrive in, and many others wouldn't either. Many of my team members also left NHS England and NHSX in the weeks and months after I did, and are going on to do other things.

The important lesson is that we will lose talent — we will lose people who can make a difference — if we don't create public-sector institutions designed to make progress happen, and, more importantly, designed to nurture and support talent. Unless we do that, we will not make progress for citizens.

There are lots of people and lots of e-learning modules out there, and I'd say that's almost definitely not the thing that's going to get us out of this. I personally feel the cultural shift is more important: make it acceptable for future clinicians and healthcare workers to use technology, make them part of solving the problem of technology, and make them part of the solution.

My own view is that we need a blended programme for undergraduates across any healthcare discipline. We should give them opportunities to get involved in leadership and technology — some will lean towards policy, some towards coding and designing technology. Second, we should create an ongoing learning mechanism so that when people are in their roles, we support their development — and again, that doesn't mean more e-learning. It means immersive opportunities: placements in healthcare technology organisations, the space to operate, which will teach them the skills they need to be strong in the future. I've seen this in other parts of the world in my previous career, engaging with colleagues in university teaching environments who create those immersive programmes. I'm keen, with the organisations I work with in England and the UK, to create environments where the medical students of the future get some leadership development, technology skills, design skills — so that even while they're undergrads they can start preparing solutions based on what they see.

People like me are at the wrong end of our careers to be coming up with all the solutions — we're too jaded, we've seen too much, our minds are cluttered with what we know. People at the beginning of their careers are more open and free-thinking. If I look back at myself twenty years ago, I wasn't constrained by the structure of society, so what I came up with was much more creative. If we can bring a bit of that, and support it, we'll have much better solutions. That's the kind of entrepreneurism we need to support. At the moment the structure of the system — the teaching, and almost an over-reliance on e-learning — is taking the fun and creativity out of what could be a better future. There's a place for e-learning, definitely around statutory and mandatory training, but it shouldn't be the only way we get creativity and skills to individuals. This is more than knowing how to use a smartphone or computer; it's about the thought process of how to design better solutions for patients.

It's funny we talk about this, because I didn't really understand this personal-brand thing. When I was working in retail and banking I noticed more people had these brands, and, really bizarrely, I've never purposefully tried to create one. I've just been out there saying things. So I'm probably not the best person to explain personal brand, because I don't think I do it that well — I just do it by accident.

But one thing I'd say: I tend to demarcate things. I think the last time I posted anything personal on social media was about five years ago, if that. And I stick to areas I'm comfortable with — public health, infectious disease, digital health and technology, dentistry, health policy, online services. If somebody came to me about some remote subspecialty I have no idea about, I wouldn't get involved, online or otherwise. I also like occasionally writing — I'll write a blog and post things like that. Having other people write things for me, I've deliberately chosen not to do.

My advice: have a go, write something, put something out there, think about what you want to say — but always remember that whatever you put out as part of this "brand" is almost there forever, so think carefully and sensitively about it. That shouldn't stop anyone. Whether you have a brand or not, and how you choose to exercise it, is a personal choice — some people like online platforms, others do it more quietly. There's no wrong or right. I'm not good with Instagram; I don't really get it. Even Facebook bypassed me. Those are platforms I'm not comfortable with, but other people are. Just do something you're comfortable with, that lets you express yourself in a meaningful way. And think about whether you want to mix your personal and professional. There's nothing wrong with mixing it, but know where you're going to draw your boundaries — because once you've done that, it's often very difficult to reverse.

I've had so many failures — everything from failing exams, to failing in projects I've run, to failing in bits of my job. I probably still fail at managing my time. We all fail in lots of things, but I've learned more from my failures than from my successes. Some things span all of them: setting the risk dial too far and making decisions that were probably too risky; not being organised enough or asking the right questions; not putting enough time into planning and forecasting. And the biggest one for me is taking on too much — that's probably my biggest point of failure.

I've had some big ones. I remember an oil and shipping transaction that went completely wrong, with very big financial losses — that was not good. I've worked in healthcare organisations where we failed to deliver services efficiently and on time, which comes down to planning and governance. There are things there we can all learn from, and I learn all the time — every single week I learn from something.

It's also about learning to say "I don't know". Passing exams is a test of your knowledge, and afterwards there's a tension: the same people who tested you, if you say to them "I don't know", there's tension there. But actually the most important thing is to say "I don't know" — and say it early. This is what it could be, this is how I could get to the answer, can you help me? So talk to others: I'll pick their brains for ideas, and they'll do the same with me, and we'll challenge each other to do something better next time. That's really important. Have trusted friends, a trusted safe space you can go to when you think things aren't working, so you can talk to that person. It matters from when you're first an undergrad all the way through — I rely on those people right now as I did twenty years ago.

I don't think I've ever thought about it in that careful way, but certain things that have helped me are forming relationships and networks — speaking to lots of different people with different views, connecting with them and maintaining those relationships. That's very important, and I like doing it. It doesn't suit everyone, but it suits me. And reading loads — I love to read, I like to know things, and that's always helped me. Having some facts and understanding numbers has always been a good place for me. That's very personal; what works for me may not work for everyone. But I like getting to know people, forming those relationships, and knowing things that will help me and help others. The biggest thing I've probably benefited from is talking to people and trying to help other people.

Most people you reach out to and connect with — by contact, email, or a conversation — will, by and large, be willing to give you some of their time. Often the only reason people can't is that they're already too constrained, too busy. But most will say yes. Think about what you both offer, because any relationship is a two-way thing: two people can talk and get on socially, but what do they have to offer each other? Think about what you're going to bring to the table. Being a mentor–mentee is very different from a relaxed friendship. Find people you can connect with, where you've got something in common — that's always a good starting point — and make sure not everything is about work. Some of my most interesting friendships started as work contacts, but you discover you've got lots of other common interests and just get on, and those things go on for years. It's a bizarre thing, because years later you're leveraging off those relationships and friendships — you'll be recommended for things, and vice versa. One of the things I value is being able to go to my network and ask for help, or connect people who can help each other.

If you've got an idea and you're interested in exploring it, find someone who's worked in that area or who can give you advice, and just meet them for a coffee — these days, online — and talk your idea through. You never know. The worst they'll say is that it's not a great idea, and you're better off talking about it than leaving it. Don't pick pathways based on what seems conventional; pick your choices based on what works for you. And what works for you now might not be what works for you in ten years — so don't be afraid to change your pathway and your course as time goes on.