You don’t need a piece of paper to be a leader: my experience of NHS leadership

Alongside his role as Director of Development and Improvement at OneMedical Group, Manjit Purewal has been a GP in Yorkshire for over 20 years and remains a Senior Partner at a large practice in Leeds. With a strong history of board level and strategic leadership throughout his career, Manjit has a wealth of expertise and is passionate about developing individuals and teams to bring out their potential to work innovatively together. Manjit has kindly shared his experiences of NHS leadership in this blog: reflections on his own journey, challenges, successes and what leadership within the NHS truly means.

When I qualified as a doctor in 1993, I had no understanding or experience of NHS leadership. I’m not sure that I have all that much understanding to this day – it’s incredibly complex! – but having taken on a leadership role through the course of my career, I do have plenty of experience to share.

The NHS is a complex organisation. This was brought home to me when I was fortunate enough to visit Intermountain Healthcare in Utah, USA in 2013. I was rather surprised by their perception of the NHS as a fantastic single organisation. There is no doubt that the NHS is a fantastic healthcare system, but the reality is, although it is branded as one organisation, it is, in my opinion, an umbrella organisation made up of many individual businesses. Each of these are inter connected and dependant on each other, but in reality, are independent businesses. This results in difficulties in knowing who to talk to where decisions are actually made. It always feels there is another tier above you, which you did not know existed, who need to be involved to agree things.

My first experience of NHS leadership was sitting on a hospital board as the junior doctor representative for psychiatry. At this point I had no understanding of how the Board worked, or what roles the individuals played or how this fitted into the wider NHS landscape. The only thing I knew was this was a forum at which front line workers voice was heard. I did not understand the importance of this voice until I managed to negotiate a change to the way the junior doctors on-call system worked and was reimbursed. This was achieved by using my passion for data to influence change, resulting in an increase in pay for over 20 junior doctors along with improve fairness for the way they worked. I did this by asking the doctors to keep a log of the work they were doing and the time it took; I then collated this data and presented it to the Board.

My shift from psychiatry to General Practitioner only increased my curiosity in leadership. During my time as a GP registrar I was exposed to leadership within General Practice across two different practices. The only thing common to the two practices from a leadership perspective was the fact that they both had partners, a Senior Partner and a Practice Manager. However, despite this commonality the two practices were run very differently; one with a traditional hierarchical leadership style, with the Senior Partner making all the decisions, and the second taking a more collaborative approach. The experience of these two has undoubtedly influenced my leadership style. I recognised that my preferred style was a collaborative approach – I believe a Practice Manager is vital to the running of a business, but the Partners need to remember they own the business and create the direction of travel and vision. The thought of a single person running a business worried me. It is a lot to ask of one person to do all the work. I believe that this is a significant factor in many GP’s reluctance to become Partners.

Once I became a Partner in a GP practice, my understanding of leadership started to grow and change. It was a steep learning curve developing my understanding of what it meant to be at ‘the top’, an employer responsible for staff. It is interesting that during my time on the Vocational Training Scheme (VTS) to become a GP, there was very little time spent on leadership or being an employer. The VTS was solely aimed at making sure I had the right clinical skills to being a GP and very little on leadership in Primary Care, despite how vital it is in order for Primary Care to function effectively. It was only when I became a GP partner that I learnt about contracts, performance indicators, and how the money flowed. As a result I have worked with the salaried doctors in my practice and developed a career path whereby they can gain understanding of the role of a Partner. I have delivered presentations to GP registrars about what it means to be a Partner. Also in my leadership roles outside of the practice, I have mentored and coached other GPs and practice nurses to take up managerial leadership roles in the NHS which need a clinical voice.

My journey into NHS leadership

My journey into becoming a Leader in the NHS outside of my practice came in 2004 when my then Senior Partner felt I would be a good advocate for GPs at a discussion regarding two weeks colorectal cancer pathways. I found this experience valuable but also frustrating. It was my first experience of the cogs of the NHS turning slowly and the different levels of bureaucracy that existed within the hierarchy of the NHS, but also within different providers. I was also used to being a GP partner where decisions resulting in change could be made quickly. In this role, I saw meetings attended by managers who had to take discussions back to their own organisations before progress could be made. A great example of this (and a personal frustration) was the time it took over 6 months to agree a letter which would be sent to all patients referred under the two week colorectal cancer referral pathway, informing them they would be going straight to test, rather than the traditional face to face out-patient clinic appointment. The main thing which held this up was the lack of clarity of who was signing this off. Sadly, in my experience, this is still the case on the whole, but there are some changes taking place, especially as more GPs have become involved in leadership.

This exposure to the Primary Care Trust and other NHS providers led to my involvement in other pieces of work, increasing my collaboration with peers in General Practice and other providers. I believe building relationships and representing colleagues in the wider system resulted in me being elected to the role of Director for the NHS Leeds North CCG. To say I was surprised by this is an understatement, but in hindsight it was having this support that has led me to where I am today.

In my role within the CCG, I began to gain more understanding of the complexity of the NHS and the various levels of assurance required at each level, and how this is translated to the levels below. Experience has taught if you collaborate with your allies, then you get much better outcomes. Different parts of the system are now being urged to collaborate more. It is leading to change, though in my opinion there is still a lot of work to do. Many parts of the system have little understanding of what others do, but base decisions upon assumptions. I have noted when looking at other health economies that the stronger the relationships the better the outcomes for patients, employees and better value for money. Unfortunately when things get tough, organisations tend to buckle down and become introverted, focusing on their own needs without realising the rest of the system would be willing to support them. As the old saying goes “a problem shared is a problem halved”. During my time in the CCG, I was very fortunate to have a lot of personal development in my leadership style. Along with the rest of the Executive, we had several development days with the Institute of Directors. They helped me gain understanding of what it meant legally to be a Director, and the implications of such a role. I also gained experience in Media training. I have never enjoyed being in front of a camera (who does?), but to be told I came across as warm, passionate and caring was rewarding. I also learnt about the art of storytelling. This in my opinion is integral to being a good leader. You need to be able to explain the why and what, before approaching the how. A person who I admire for this is Simon Sinek. If you haven’t heard him speak or read any of his books, I would thoroughly recommend this.

What does it mean to be a leader?

I also had the opportunity to attend a five day residential course at Ashridge Business School, an established leader in the business world who excel at delivering transformative and experiential executive education programs to have a long-lasting, positive impact on individuals, organisations and society. This was a very daunting but also an amazing experience and influenced my leadership style. The first day of arriving at Ashridge was akin to going to University. The accommodation was like being back in halls of residence and, just like your first day at university, you don’t know anyone. On the first day, when introductions with twenty other people took place, the nerves increased. I questioned myself and wondered what I was doing there. I felt very much out of my comfort zone, mixing with some very high flyers from the business world. It was also interesting to see their response to me as a Doctor. The majority were surprised that I was there, as they perceived the role of a Doctor as a very senior leader and much higher than them. They had very little understanding of how the NHS was run. They were surprised that GP practices are private businesses who hold an NHS contract. They also had no idea how the money flowed, or the multiple layers. There were two others who had some understanding of complex systems, and both of them worked for the public sector, which I think says a lot! However, as the first day progressed it became apparent that the issues and problems we faced as leaders were the same irrespective of an individual’s background.

Two main things emerged from my time at Ashridge. The first was how society perceives doctors. I now recognise that Doctors are seen as leaders, just by having the title Dr. I have discussed this with many of my colleagues and, despite their role in society, I can assure you they do not see themselves as leaders. This influenced how I have supported my peers with their leadership development. It has made me think how influential titles are, and how we all have our own perceptions of what a CEO is. At times when chairing meetings and asking people to introduce themselves, I have asked them to simply give their name and the organisation they come from, rather than their title. This enables a much richer conversation, as it means we all sit at the table as equals rather than the assumption of one title being more superior than the other. When I have applied this, in my opinion the meetings have been richer in debate, and some great ideas have come out of them.

The second thing that emerged from time at Ashridge was the realisation that imposter syndrome affects many of us. Impostor syndrome is a psychological pattern in which an individual doubts their skills, talents, or accomplishments and has a persistent internalized fear of being exposed as an “impostor”, despite external evidence of their competence. Those experiencing this phenomenon remain convinced that they are frauds and do not deserve all they have achieved. I was amazed at how many of the senior leaders around felt this way. Prior to this I had thought it was something unique to me! Simply sharing the way I felt has generated some rich conversations and observations. I have shared this when coaching or mentoring other people, and encourage them to embrace this and accept it as being normal rather than shy away from it. If anything it can be a great way to start conversations and act as an ice-breaker. We need to remember we are all human beings with a brain which thinks and has ideas, but are we willing to share them? All of us have to find a way to reconcile that imposter syndrome we feel as a leader, but also what society expects from us given our title, especially as we work in such a public domain. This is not an easy balance, as everyone has their own thoughts and assumptions about roles and their function. The most important thing in my opinion is to be yourself and honest to yourself.

Leadership learnings

The main thing I have learnt about leadership is self-awareness and taking the time to recognise how you are feeling. Transference in psychological terms is defined as the redirection of feelings onto someone else. If as a leader you are feeling frustrated or angry this will be transferred to your team and can impact on their performance. This can lead to teams feeling unsettled and not understanding what is going on. So as a leader, I believe it is really important to reflect on your own feelings, understand how they are impacting you and what impact they are having on others. This not only leads to a happier you, but also a happier, empowered team. It is interesting that as a GP we are taught how to empower the patient to make the right decisions and choices for them, but as leaders we are not so good at this. I have also recognised one of the functions of a leader is to look at succession planning. During my time in leadership there has been an incredible shift to encourage more doctors and practice nurses to take on these roles. Whilst at the CCG I took 2 groups of 12 people (a mix of clinicians and managers in primary care) to visit a festival of microsystem and change. The investment was small, but the return was large, as the majority of people who attended have gone on and taken leadership roles. One person, who had been a GP for over 15 years, said they would never have given themselves permission to go on a trip like this, but being given the opportunity gave them time to think, see how other systems work, but more importantly to connect with others who would normally be in their circle of work.

Since joining OneMedical Group, I have continued to keep an open mind about my approach to leadership. I have met lots of different people with different skills and I have been able to support others with their own leadership journey. I have done some mentoring and coaching to help clinicians identify their leadership styles and development needs, and I have raised the profile of the clinical voice within the organisation.

Seven tips for leadership

Finally I am going to end with a question I am often asked: how did you become a leader in the NHS? There is no simple answer to this. I have been very fortunate as stepping out of my comfort zone has led to my career in leadership. I don’t believe it is about doing the right courses, or having the right qualifications. I believe my journey into leadership came about due to:

1. The willingness to stick my head above the parapet

2. Having the support of others who believe in you, even if you doubt yourself

3. Understanding that as a doctor (or any vocational job) you will be perceived as being a leader, even though you may not believe this yourself

4. Your voice counts

5. Being curious

6. Being adaptable; acknowledging one’s learning and development needs and addressing these over time

7. Accepting you will never be perfect!

More doctors are needed in leadership roles as a manager and there is a need to support them in this. Our nursing colleagues have a much better, clearly defined career pathway. Leadership is not for everyone – some people would not be comfortable in these positions, and they shouldn’t be shoehorned into roles if they are not ready or willing. For those who are comfortable, there should be a supportive environment that allows them to migrate into leadership roles, secure in the knowledge that their skills and experience are valued and that they are still part of the team. I believe it is also OK to support clinicians to move into managerial roles. Moving away from clinical work can sometimes provide an opportunity to improve the system and lead to better outcomes for all.

Follow Manjit on LinkedIn here.