• medical leadership
• continuous improvement
• engagement
• learning
• productivity

Let me start by introducing myself. My name is Navina. I am chief executive at Health Education England. I am a woman of colour. My pronouns are she/her.

I am no expert, but I have a voice. I hope what I say will stimulate debate, an internal one and with others. I hope what I say may challenge us all to think differently about the meaning of leadership and push the boundaries of all of our responsibilities.

Focus on the people and the rest will follow. I am not going to discuss why. We are like-minded people, we would not be here if we were not. I hope we have a conversation about how.

By people I refer to those we serve as patients, as the population, as citizens. I refer to those we work with as colleagues and those we lead as managers. I refer to those we teach as educators.

We have begun to understand and articulate the influence of ‘our National Health Service (NHS) people’ on our values and our behaviour. Which influences what we do for the communities we serve. The link between how we collectively feel and what we collectively do, is undeniable.

Hundreds of different people coming together for a shared purpose is a remarkable thing. A magical thing. In other circumstances, we would not be drawn to each other.

I have personally been a concerned relative on many occasions and am now a patient with a stable, chronic condition. During my personal encounters with services, I find myself in the patient role most of the time, in the doctor role some of the time and in the Chief Executive Officer (CEO) role occasionally. As a patient I value the small acts of kindness; not specified in job descriptions. As a doctor I am curious about appetite for positive risk taking among fellow clinicians. I feel the frustration of clunky systems and processes which get in the way. As a CEO small acts of kindness must take centre stage and frustrations minimised.

I learnt the value of the patient voice, once you do this there is no turning back. The rationale seems obvious; get the users of services you provide to help you make them better. Simple, right? Not so. There are many barriers and concerns, for example, issues of confidentiality, fear of appearing tokenistic, governance issues, how to ensure ‘real’ representation, fear of reprisal. These should not stop us, they should become the ‘to do’ list, with focused effort they can be overcome. The benefits are worth that effort.

I propose what has come to be known as people participation must be part of nearly everything we do. Strong people participation is linked to better outcomes, happier staff, financial viability and stable leadership.

Those of us who have taken steps to engage service users with some success; being open, admitting failure and asking for help, it is now time to be bold. It’s time to take engagement to the next level. It’s time to reduce variation in engagement, to spread good practice with more robust accountability and then to spread our learning.

We can no longer avoid hearing what we don’t want to hear and not knowing what we need to know. We can listen, especially to messages which make us uncomfortable. I am amazed by the generosity of patients and carers, in the wish to help make things better for themselves and others. I hope they never stop.

Ask, Why is patient and carer involvement crucial to fulfilling your leadership duties? I say, because they are your ears, your eyes and your conscience.

Let’s talk about Inclusion

It’s time to have difficult conversations which allow for disagreement, debate and struggle. We should not be comforted with reassurance like, ‘ours is a colour blind organisation’ or ‘ we have more women leaders now than ever’ or since we serve a predominantly white community this issue is not really a problem for us.

Why does diversity matter? Diversity brings challenge and richness to debate. It guards against the comfort of false assurance. We know our current leadership is not diverse and this may take time to address, how do we ensure we find other ways to bring diversity into the important deliberations wherever decision are made?

I have questions. Do you use the precious time which brings you close to staff and patients wisely? Do you use this time to listen and observe carefully? Do we look for examples of inclusion, are we sensitive to warning signs for concern? Can we make the connection between equity, quality of care, staff well-being, patient safety and patient experience?

Are we addressing the barriers and enablers in our respective organisations so we can celebrate well-earned successes and be part of the solution when the inevitable difficulties arise?

Are we open and transparent? As leaders, we should be able to tolerate being exposed at the same time as holding on to hope and solutions. We must be held to account by those for whom it matters.

Is it a struggle for you? I suggest if it is not a struggle, we are not adequately addressing this issue.

Has improving race equality become business as usual? As we demonstrate collective leadership, we own race equality as a thread which runs through everything we do.

Right now, there are many more voices speaking up. These voices contribute to a genuine, sincere and meaningful discourse, engaging in areas where they were previously conspicuous by their silence. These voices come from different quarters, no longer just the ‘usual suspects’. Some from people with power and influence. I believe this represents a significant and important change. I believe this represents a different level of understanding of the complex issues surrounding race. I sense a nervousness though and have heard, people express such concerns as

What if I say the wrong thing?

Surely, it can’t be as bad as all that

I am trying to imagine what it must be like, but I can’t.

Is it like what I experienced as a working-class boy going to a top university?

I have recently engaged in different and challenging conversations with white friends and colleagues. It has been a revelation as to how many versions of equality and equity exist even among people who I identify with and have much in common with. I have reflected on how I myself must engage in this discourse in a way that helps move the narrative on and not alienate those who have the power to make change. I must be aware of the potential danger my input might shut it down. To my fellow BAME friends, colleagues and family, I’d like to ask, are you mindful of this? In addition to doing our jobs to the highest standards we carry a further responsibility. We bring the BAME perspective into the leadership function. We act as role models. As Lorraine Sunduza, Chief Nurse at East London Foundation Trust once said, ‘I represent what is possible’.

To my white family, friends and colleagues, I’d like to acknowledge the change in your commitment. You are open to this, when you have the power not to. You are hearing and listening. Your active curiosity and interest make you different. You are able to accept a different truth and sit with discomfort which arises as a result of engaging.

Can I now please ask for more? Can you share how these stories and experiences affect and change you? How do you perceive these issues from a position of power and privilege because of the colour of your skin? Why does this matter to you? What difference is it making to how you live your life and influence others?

And there’s more

This is a call-out to all men who work in the NHS. To the brothers, fathers, grandfathers, partners, husbands and friends who believe in us, women. To those who are humble, kind, respectful and authentic in their support and understanding of the complex issues facing women in the NHS.

I have the pleasure of working and interacting with many strong, inspirational women all around me. However, I have personally experienced some shocking interactions as a woman and am aware of other stories which are disturbing and distressing. Many of these reflect deep-rooted inappropriate attitudes and bias, descriptions of which range from prejudice to boorish behaviour to sexism and even misogyny. There is an assumption as the number of effective women leaders grows, things are better than they used to be and we are making progress. There is still much to do.

Women in the NHS hold the key to unlocking many solutions to the problems we face now and into the future. We can make a difference to recruitment and retention, to culture and leadership, to improving quality, respect and dignity. And much more.

This is a time that will really test our ability to be kind and truly non-discriminatory in our approach to our work and do the right thing.

I have only spoken about race and women.

An equal world is an enabled world. So many people promised to work towards this. this is our moment to do something different

I am part of an army of public sector employees who serve our communities and our country.

The evidence to focus on the people is beyond moral, ethical and even economic. It is to me to shine a light on values, culture and behaviour. This is critical for the delivery of change which is so closely linked to the future of the NHS. We need to look beyond the usual places for solutions. We need to understand the impact of technology and innovation. We need to understand how future generations want to work and live. There is a need to do something different from everything we have done before.

Who are the people with the power to make the difference? You are. Do you believe in these solutions? Will you venture into a world which is uncomfortable and different? Will you acknowledge the past of which you have been a part has only delivered so much and therefore must change?

This is an incredible time to be part of the history of the NHS. We have the honour to shape and take care of something as precious as this health service. We have a huge responsibility to the communities we serve. We also have a duty to staff and colleagues who trust us as leaders. We must look after them and create the conditions for them to do the right thing. We will increasingly have to make difficult decisions and take personal risk, prioritising the needs of others over our own.

There is some urgency for a different style of leadership. We cannot expect the old solutions will be adequate for the future.

It is my job to deliver improved experience, improved outcomes and better value under many different conditions. I am reminded of this description in the Triple Aim, ‘To act with the individual and family; to learn for the population’.

I took the opportunity to remind myself of the the NHS Constitution. These four principles stand out for me.

• The patient will be at the heart of everything we do.

• The NHS works across organisational boundaries.

• The NHS is committed to providing the best value for taxpayer’s money.

• The NHS is accountable to the public, communities, and patients that it serves.

I observe the behaviour of leaders with far greater experience and wisdom than I. I do so in the hope of learning and acquiring skills for bold, not timid transformation, truly putting staff and patients first.

A lot depends on how we step up to the task. Behaviour, solutions and models of the past should inform what we do in the future. We simply cannot do more of the same, just more loudly, with more effort and more cost. This means we can no longer lead as we did in the past.

We should on the other hand be given the responsibility to support the type of culture which will be required to turn transformation into reality. I welcome this and want to be part of it. I want to be challenged and to be held to account as a leader in systems. We need to do this with openness, transparency, and humility.

From my observations of other leaders, I learnt not to:

• Prioritise protecting my silo.

• Put self-preservation and career first.

• Look for change in structure or organisational form because changing our behaviour is too hard.

From leaders I wish to emulate I learnt to:

• Acknowledge there is room for improvement.

• Ask for help

• Ask what I am prepared to give up.

Respect and dignity, everyday

I was recently involved in an interaction which troubled me. I was offended by the way a colleague treated me. It isn’t often I feel this way. I am a confident person in a senior position in the NHS. This really got to me and has led to a lot of reflection since. I’ve had numerous and varied conversations with others, I’ve made my own observations and I’ve paid particular attention to sources of information about behaviour among professionals or colleagues. Some of this has been at times distressing and occasionally appalling. It may or may not be a coincidence there have been some recent high-profile reports about unacceptable behaviour in the NHS.

I must stress there have also been some wonderful examples of kindness, support and caring for one another. It is so important to celebrate and hold on to these stories, make sense of these extremes and work towards having much less of one and more of the other. It is without question how we all behave has a direct impact on the quality of care that people receive.

I have been examining my own behaviour and the impact on others, both directly and indirectly. There were and will be times when my behaviour will be lacking or not appropriate. I may not realise this straight away, though I usually do and feel very sorry. When I don’t see it I want to be told, so I can make amends and learn to not do it again.

I don’t think this dilemma applies only to our behaviour as leaders. Those of us with power whether by virtue of our professional position, class, gender, race and physical attributes (eg, height) are all in danger of acting inappropriately. The use of perceived or real power wisely is a significant challenge. We all will at some time or another get it wrong. It is a huge responsibility for everyone and requires some considerable effort not to misuse it.

The way we are treated by others always affects us. It impacts on our enjoyment of work and influences our ability to do the right thing. Our NHS is a complex system, rich with emotion, wonderfully rewarding. It is also too easy to be divided and behave inappropriately when under pressure.

We do well to remember we are united by a common purpose. To deliver we must care about and be careful with one another, we must quickly see when our own behaviour is wanting and strive to do better.

Here are some questions to explore.

• How do we have difficult conversations with one another?

• How can we disagree with one another and remain kind and respectful?

• How can we effectively manage performance without behaving in a bullying manner?

• How can we speak up and be constructive when we feel uncomfortable about how others behave towards us?

May I share a personal story. I have recently been looked after by a physician and a surgeon. This led me to reflect on how medical leadership behaviour affects outcomes of care. Both clinical leaders treated me with respect and dignity. They were kind and patient, not in any way patronising. They were understanding, calming and used language I could understand. They answered my foolish questions without making me feel inadequate. Both enquired about my feelings. Both listed to what I wanted and tried to accommodate my needs. Not always possible, but I felt heard. I felt safe, with some degree of control at a time when I was most vulnerable.

Their behaviour had a direct impact on my acceptance of my condition and thereafter on my ability to function and my co-operation with the treatment plan. Hence the good outcomes which in turn meant minimal use of services.

It is no coincidence that such human characteristics are associated with improving patient outcomes. Successful team working with better staff satisfaction. Higher service productivity and improved value with more effective use of resources.

For me, the NHS really is the best place to work. The abundance of pride, love, and fierce loyalty evident during the pandemic was a welcome reminder of this fact. There is, however, far too much variation in such feelings and the experience of many staff does not always reflect this.

I believe there is a lot that can be done right now, within existing resources, to improve this. This will only be possible if the thousands of people associated with the NHS make it happen. All this requires behaviour change at all levels of leadership.

Cynics will express eloquent views about why this cannot be delivered. Remind us of previous failures to deliver. Failures attributed, in part, to lack of will, lack of ownership and to systems and processes which we, the leaders, create that get in the way. ‘Every system is perfectly designed to get the results it gets1', Demming, always go back to Demming.

Are you a leader with authenticity, humility and vulnerability? Are you comfortable with listening to difficult feedback and admitting when you are wrong? Do you think it’s OK to fail? Will you ask for help without fear?.

As Aidan2 said, ‘Leadership is doing the right thing on a difficult day’ (when no one is looking). Focus on the people does not come with your role or title or position. It is your duty.