Leading through uncertainty: a conversation with Dr Fay Gilder and Matthew Rice

Key:

RR:     Ruth Robertson - Interviewer

FG:      Fay Gilder

MR:     Matthew Rice

RR:        At this point it is stating the obvious to say the health and care system is in an extremely difficult position, one that continues to have an impact on staff and leaders.  So what is it like leading in such uncertain and challenging times and what is helping?  Hello and welcome to the King's Fund Podcast, where we explore the big issues and ideas in health and care.  I'm Ruth Robertson, a senior fellow at the King's Fund and today I'm delighted to be joined by two really fantastic guests, Dr Fay Gilder, Medical Director at The Princess Alexandra Hospital NHS Trust in Harlow and Matthew Rice, who is one of our senior consultants here at the Fund.  Welcome to both of you. 

FG:         Thanks, it's great to be here. 

MR:        Hi, yes, likewise. 

RR:        A start off question to you Fay.  Before becoming Medical Director at Princess Alexandra Hospital, you worked at Cambridge University Hospital for many years, what inspired you to make that change? 

FG:         I had been a consultant and anaesthetist for 18 years with particular interests or a particular interest in liver transplantation multivisceral organ transplantation and also perioperative medicine and I had worked with colleagues to develop what remains a really good service there and I also led the anaesthesia side of the transplant team and I had become senior and very experienced but I also recognised I had some other skills.  I had taken on an additional role which was around clinical director for improvement and transformation there which in the end half of my time was spent within that role which was a cross organisational role, and I was looking to take my leadership further and then an email went round all of us to say that this role was offered.  So I explored it and the thing that inspired me to move was actually a conversation with my current chief executive officer who I immediately felt a connection to in terms of shared values particularly around making a difference for those, if you like, populations that are underserved and Harlow definitely has a fairly large proportion of that.

RR:        And can you say anything more about how that has panned out your passion to focus on underserved communities?  What's that challenge been like at the Princess Alexandra Hospital?

FG:         Well it's not specific to Princess Alexandra actually, it's about NHS leadership and the challenges NHS leaders face when they're trying to make a difference because I would say that the majority of NHS leaders that I meet are there because they want to make a difference.  I think what I hadn't predicted was how difficult that is because many of the things that make a difference to our staff are things that you don't have a lot of influence over, so that would be for example the state of your hospital.  So we know there are lots of hospitals that need rebuilding, at least 40.  Then there are the workforce strategies and the approach to workforce not just into who does what, when and how, but actually how many you need and then how of course that is funded.  It's a huge proportion of our budget goes on workforce, doesn't it, in the NHS?  Huge, and yet what you constantly read in not just our staff survey but many staff surveys is we wish there were more people and if you speak to our junior doctors, and this isn't just Harlow junior doctors I know other junior doctors, one of their big reflections is there are not enough staff.  So what you're up against is two things that are really difficult to influence.  So then you have to think … I had to think about well what is it I can make a difference, where can I make a difference?  So I would have said I'd spent the first two years really, really challenged by how I can even feel that I'm making a difference because the answer that comes to me is around culture and everyone knows that culture takes five to seven years.  So how you can feel you're making a difference to the culture of an organisation it takes a long time to begin to sense that.  I do feel that NHS leaders are rather set up to fail because of the things they have very little control over and, yes, we can speak up but I don't even think we have a great deal of influence in some areas either and the things that we do need to influence are going to take time.  So a hospital from inception to completion these days is about fourteen years, isn't it?  If you think about the announcement of the new hospitals and when we might expect to get ours, and again there's always an if, isn't there?  And if you think about how long does it take to implement an electronic health record, five years, doesn't it, because you've got to go through a whole series of hoops in terms of business cases and then you need to put that in place?  And that will make a difference, but there's a whole culture change that goes behind that as well.  And then in terms of workforce strategy we all know how long it takes to train a nurse or a doctor or a physiotherapist or an ops manager, all of that takes a huge amount of time.  So there are no real quick fixes to the things that you wish you could fix quickly and that you know when you talk to people when you ask them what would make a difference, these are the commonest things, but it's tricky because of what you don't have control over. 

RR:        Matthew, is that something that comes up in your leadership practice, this issue of working on cultural embedded issues that have such long timeframes and how do leaders get a sense of achievement and understand their role and worth within that really complex environment?

MR:        I think we would say the primary purpose for leadership is in relation to developing culture, creating culture, but of course the culture, as you might find it, when you make the transition into a huge job like Fay made, also is very powerful in influencing what it feels possible to do as a leader.  So there's this interesting dynamic, isn't there, and I think most people can relate to it, about the extent to which leadership shapes culture and/or indeed culture shapes leadership or indeed the felt experience of the leaders?  So I think it's both ferociously difficult and absolutely an intrinsic part of the primary leadership task and one I think that generally we're not particularly good at preparing leaders for.  I don't know whether … I don't know what you think about that Fay particularly, but I think it's known, it's implicit, it's implied, but finding your feet in all of that is tricky, isn't it?  It's hard.

FG:         Yes, I do tell the people I work with that I probably knew how to do about 1% of the job when I started and there's a huge ask and I'm going to speak only about the medical directors' portfolio now but of course I'm sure it's very similar across all of my executive colleagues' portfolio, but the portfolio is enormous and being able to lead a portfolio requires an understanding of your portfolio, and so for quite a long time I spent getting into the detail in order to then move away from the detail in order to lead it in the direction that was the right direction.  So, for example, I'm the executive lead for risk, now I know a huge amount of clinical risk, about clinical risk, it was my job is to judge clinical risk and manage clinical risk and mitigate clinical risk, but I have never had to think about risk on an organisational scale and yet all of a sudden I was executive lead.  And so I've gone from a position where I am an expert, I absolutely was an expert in anaesthesia and the elements that I was practising, to not being an expert at all and I think the most powerful tool I have in my armoury for that is that of humble enquiry or curiosity.  A good example of that would be how I give myself permission not to be an expert, how I overtly describe to others that I'm not an expert and then how I use questions to still enable people to trust me because I've just said I don't know what I'm doing.  Ad so the really wonderful piece around trying to work and humble curiosity is that it enables you to say I need to understand your experience, I need to understand your work in order for me to do the work I need to do kind of thing.  So there are open ended questions, I give myself permission to ask those questions and then I continue to ask questions and they're open questions so that I learn more about the scenario that I'm facing at that particular time. 

RR:        I'm really struck by that change from being a medical expert into this executive team role where you're leading and no longer an expert and I just wonder what support you get when you make that shift, the shift you describe I'm sure would resonate with many people who are stepping up into those executive roles.

FG:         I maintain that the medical director role is somewhat unique from this perspective because many of the other executive roles effectively there's a training program, isn't there?  You're an ops manager and then you're a senior ops manager and then you're a deputy chief operating officer and then you're a chief operating officer, but my career pathway didn't do that at all.  My roles are very much grounded in on the ground making a difference to patients or staff either through running a good service or through improvement, which is all about what matters to you for staff, isn't it?  I don't think that that is recognised necessarily by other executives.  Now my executive team are extremely supportive, my chief executive extremely supportive, but nevertheless I think the medical director experience is quite different to many of those who join, particularly the traditional roles which is chief executive, which is chief nurse, which is chief operating officer and director of people.  Those are all fairly described and proscribed trajectories.  So the support I required was fairly considerable.  I had an executive coach who I had had in my prior role, but I also then found a coach around emotional intelligence not because I lack it but I think I have so much of it, it is actually quite hard.  It made it quite hard.  So I needed that.  I did at some point go for some counselling just to deal with the impact of feeling so responsible and I really relied quite heavily on my family.  There is something about self-care, isn't there?  And so for me I learnt about self-care through my executive coach and I understood what I needed to do.  It's the discipline of doing it and so in my case quite a lot of it was around meditation or journalling or recognising where I get my energy from, which is outside, running, it's exercise but it's also being in the natural environment, and then more recently what I recognised is that I had begun to feel very one dimensional in that in any conversation outside of work I still talked about work.  What I have had to do is make myself read about other things and I don't know if you know the book Atomic Habits, but I've read about two pages of it, but the two pages that I read gives you permission when you build a habit to literally spend one minute a day on it.  So most of us think we've got to do half an hour of exercise every day, don't we, otherwise bad?  Whereas I'm the opposite, I read this book and thought ah brilliant, somebody has given me permission to say you can do one minute of exercise every day and all you have to do is one minute and from my perspective turn that into reading I only have to read one page.  That's actually quite a supportive approach to the discipline of self-care, even if it's just lighting a smelly candle for five minutes, but there is something about taking a moment for yourself because it goes back to if you don't look after yourself  you can't look after others, but I needed a lot of support over the last two years really.

RR:        And I love that idea of just doing something, helping to build a habit rather than it having to be the intimidation of a 30 minute run or what have you.  Matthew, I know you work with medical leaders across the system, is there anything you wanted to add from your experience?  Does any of what Fay was saying particularly resonate with what you've heard elsewhere?

MR:        Yes, it certainly does, Ruth, it resonates with many stories of doctors in leadership roles at many levels of organisations and systems, but I think the transition that Fay is describing into one of an executive medical director role does bring with it I think some particular transitional issues or challenges I think, the like of which Fay has begun to speak to.  That also speaks perhaps also to the particular role that doctors have in our organisations and in our health and care systems and also the kind of roles that we put doctors into in our health and care systems.  I'm talking about the kind of roles that aren't necessarily the preserve of something like a formal leadership role for example, but some other kind of projections that we put onto doctors, the expectations that we put onto doctors, the kind of things that doctors can't possibly live up to but we almost unconsciously expect it of them.  I think in my experience that plays out 100 times over when people like Fay take up an executive role around a board table and in particular what comes the way of the role when things are feeling really, really, really uncertain, when everybody is extremely anxious.  What is that happens to the experience of people in the medical director role?  And I think as Fay has articulated, that isn't necessarily anything particularly to do with the person in role but it's what that person in role represents and what they have to hold for and on behalf of the system I think that is uniquely the preserve of that role.  Yes, I'm a bit in awe Fay of that really disciplined approach to self-care that you've taken and your ability to ask for help.  What you're describing I think for me are a set of leadership practices that don't get written about a lot and often don't get the attention they deserve because possibly they're badged under the guise of self-care, but these are really for me hardcore leadership practices that keep you safe and the system in which you're taking up leadership in as safe as possible.

RR:        Fay, we all know that people in the health and care system are facing many challenges at the moment, but what are some of the key issues for you as a leader working in the system?

FG:         That's a huge question, isn't it?  For me it goes back to what does it feel like to work in this system?  One of our big challenges and this is nationally I'm not specific to my organisation, is about retention of staff never mind recruitment, and I often think the holy grail is how do we feel valued and how to (inaudible 00:15:37) that.  In my case I lead, feel valued, how do we make them feel valued?  And for me it goes back to how do we understand their lived experience?  How do we listen to their lived experience?  How do we hear it and how do we respond to it?  I don't think people that we're listening to expect us to magically wave a wand and fix it.  What they want to do is say, "Look, you're leading in this organisation, and I want you to know what it feels like to work here," and I think just taking that time to ask questions about that is extremely powerful and I can describe feedback I have had because when I have gone out into our clinical areas the questions I ask are that, how does it feel, what does it feel like for you, what are you up against?  I do ask the question what would help and then I'm honest with what is possible and why some of those things are actually not possible or take time and I think that's the other piece, it's about fairness, honesty, transparency and the final thing is that people understand and feel when you actually care about them and the wonderful opportunity you have when you do speak to people and you do go out and you take the time and that can be a virtual conversation, it doesn't have to be physically on the ward, is that people come away thinking, gosh, well at least they care.  That does really matter.

RR:        Yes, as a medical director you've got such a lot of influence but also responsibility Fay and I just wondered if there's anything more you want to say about what it's like shouldering that during the really unsettling times we're in at the moment?  How does it feel?

FG:         So I referred before about asking for … having some counselling and that was because of the sense of not being good enough and that is I know plenty of colleagues who suffer from that and it's not necessarily imposter syndrome I don't think, it's just you don't feel good enough because 95% of the emails you get are asking you to think about things you don't know enough about.  Yes, it's got better now, definitely, because I've had two cycles, two full years.  I think that's one thing is not feeling good enough, the other is fear.  I don't think we talk about fear very often.  I think people see it as a weakness, but actually it is frightening.  One of my roles is the voice of patient board and therefore patient safety, and another of my roles very much is about responsibility to the people who work in my  hospital and what I can do in terms of the context or their daily lived experience and I feel very fearful.  So there's a direct link, isn't there, about your daily lived experience and then the care patients get?  Absolutely direct link and absolutely passionate about patients, patient safety, but if we don't get it right for staff we're not going to get it right for patients.  People listening to this podcast will recognise that this is being recorded around the time of the second period of industrial action, so I feel fear for my colleagues and I feel fear because of the pressure they're under, fear because of the emotions that are going to arise and perhaps the behaviours that may inadvertently appear.  Obviously you fear for the care our patients are getting, although certainly in my organisation it's being delivered brilliantly by consultants and it was last time as well and we have evidence that we have really delivered very good care under the circumstances.  And I feel fear for the impact on the organisation particularly when there is so much that we need to do to bring our organisation forward.  It's full of good people but it has a lot of challenges and I feel fear for those initiatives being derailed by things like this where so much of and particularly my headspace has been taken up either with planning or overseeing our hospital at the time.  So yes, there is that and then it's about so what do I do when I drive to work and I feel fear?  How do I deal with that?  The answer to that by the way is I listen to books to try and help me reflect on what I'm feeling.  So I've listened to an awful lot of books around leadership and management practices not necessarily in health care context at all, going to work anyway.  I don't listen to those on the way back.

RR:        Which have been your favourite audio books to listen to about leadership?  Are there any that you would recommend to our listeners as must listens or must reads?

FG:         There are a huge number I have to say because I've listened to a huge number of books.  Amy Edmondson's book Fearless Organisation because it talks a lot about psychological safety and there's a fantastic example of how a particular leader in a hospital goes around asking people did they have a concern about patient's safety today.  That was really … that's a brilliant book.  So that would be one.  I have listened to Chris Voss' book on negotiation, which is absolutely wonderful, completely different, but absolutely wonderful because if we think our whole practice is around negotiation and the art of negotiation, and I don't mean that in a business like hardnosed way, I mean it's about how do we talk to each other, how do we listen to each other, how do we get to a common ground and then how do we move forward understanding the different positions that we're in.  Obviously Carol Dweck's book on mindset is very powerful, isn't it?  And talks about sensed emotion.  An awful lot about sensed emotion.  So where do you feel emotion?  So we see emotion, we hear emotion and then we feel emotion and again Susan David's book on emotional agility is absolutely transformational around understanding emotion and the power of it and how we process it, but this particular book talks about interoception which is when you … so when I'm anxious I feel sick.  I never get sick, but it's all in my stomach.  That's interoception and then it's what do you do with that information?  So okay my stomach is feeling sick, what am I feeling sick about?  And then trying to use that as data and this book pulls it all together in a way that's quite influential to me but I'm still yet to process the last two parts of it, which is about the future, future change at organisations, how do we work with change with the wisdom at the beginning of the book.  I can go on and on.  Those are just a few.

RR:        That's fascinating and I feel like I'm learning a lot from you today about the importance of listening to your body and observing your reactions to things and using them as data to support you in working better and it's so powerful to hear you speak so vulnerably and honestly about the challenges and your approach to leadership Fay.  I'm just wondering Matthew, if there's anything you can add about what tools leaders can use to help them cope with these emotions like fear and these powerful emotions that they are faced with at the moment when leading in the health and care system? 

MR:        Feeling vulnerable is an intrinsic part of being able to lead or lead effectively and that's my view.  Leadership for me is in part about connecting to humanity.  Our own humanity and the humanity of the others, and that feels just particularly and especially relevant right now in a sociocultural context and in a health and care context.  So if we're working with what it means to be a human doing in a leadership role, then for me how you create spaces in order to be with your own vulnerability first and foremost I think is absolutely critical, and inevitably the moment you start to connect to your own vulnerability I think that space gets flooded with all sorts of difficult emotions and not least of all fear and anxiety.  And I think fear and anxiety for most people working in a health and care context certainly so, fear and anxiety is omnipresent, it's everywhere, it's in the ether and it can't be avoided.  So I think the ability to find a space in which it's possible to be able to lean into these emotions just as Fay has described, to be able to notice and name them, so to develop I suppose what sometime is called emotional literacy.  So you become really adept at being able to notice and name what it is that you're feeling and in that embodied sense, as Fay has described, to be able to locate it perhaps somewhere in your very physicality so that you … both a way of storing it and also getting to know it and also using it, seems to be important.  I think that's not work that you can do on your own, those aren't spaces necessarily that you can create just in relationship to yourself.  So I think some of those spaces that Fay has spoken about not least of all maybe working with a coach who can hold that space for you, and who can be with you, be compassionately with you.   I'm reminded about the meaning of compassion which is about being with the other in suffering, being with suffering, feels to me to be absolutely fundamental.  If you're not to get completely overwhelmed by the felt experience in relationship to leading or you deny the feelings in relationship to leading, both of which I think are equally dangerous places to be.  So I think developing a broader emotional vocabulary, finding a safe space whoever that might be with, maybe some coaching, absolutely acknowledging that to feel in relation to the leadership role is not only normal but also desirable, but knowing also that you have a right to a safe space in which you begin to decompress and make some sense of what those feelings are telling you both in relationship to what might be going on for you, but as Fay has so articulately put, in relation to the other or the system seems to me to be really essential.

RR:        There's such an important insight when leading in such uncertain times that we're in at the moment, it's been a real privilege to talk to both of you today and hear about your experiences and your approach.  It's all we've got time for, but thank you so much for joining me today.

FG:         You're welcome, it's been a pleasure.

MR:        Yes, likewise, thank you.

RR:        You can find the show notes for this episode and all our previous episodes at www.kingsfund.org.uk/kfpodcast and you can get in touch with us via Twitter our account is @thekingsfund.   The producer for this episode was Emma Sheffield and it has been edited by Bespoken  Media.  Don't forget to subscribe, share, rate and review this episode wherever you get your podcasts and of course thanks to you for listening.  We hope you can join us next time.