System leadership viewpoints: Sally Davies

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Professor Dame Sally Davies is the Chief Medical Officer for England, she retains responsibility for Research and Development, and is the Chief Scientific Adviser for the Department of Health.

This interview is taken from our report on the practice of system leadership.

Do you see yourself as a system leader?

By definition I am a system leader, yet I don’t like the word. It makes it sound as if you are trying to manipulate the pieces rather than trying to help people to do the right thing. Perhaps I am a reluctant leader in one sense, because I am not interested in power. It goes back to your question, do we want charismatic leaders? No, we want facilitative leadership. And I worry that if you talk too much about leadership you almost defeat the object of the exercise.

What are some of the challenges?

It is a difficult issue because the system has to be led. But then there are so many different levels of the system. And in this building [the Department of Health] it usually means how do we play out stewardship of all these different bodies, with different legal powers doing different things, and yet try and bring it together into something that is greater than the sum of its parts?

We do, in the health sector, seem to have lost strategic planning.

The Forward View is wonderful, so there is not any longer a visionary vacuum now we have got Simon Stevens. But in the implementation, is everybody doing what they are supposed to be doing, and are they talking to each other? I think the strategic health authorities played a big role, and we are rueing their loss, because at their best they used facilitative leadership, and even sometimes, when it was needed, bossy leadership. They weren’t all good, but there were good ones.

Will others come through and fill this role? I don’t know. The good bit of the present system is we are giving much more prominence to public health, and on preventable deaths and all of that. Simon Stevens is very supportive and concerned about public health. But that’s a much more difficult system because it’s got so many partners and players, and they’re not all statutory. Everything about it is disseminated. So we need totally different leadership styles. We need to look at how you create a social movement.

How did you achieve change?

How can you do something when you are not in control? And that’s not the strength of people in the NHS, is it? I think Duncan Selbie [Chief Executive of Public Health England] is very good at that, and he is building good relationships with local authorities.

You can take the R&D stuff [development of the National Institute for Health Research] as a study of system leadership. You develop an inspiring vision, you sign people up to it, you persuade people you should be allowed to do it, and you get on and deliver it.

Many of the powerful academics didn’t like it at first, and the powerful hospitals in London, because they reckoned they would lose money. But where I came from (a district general hospital), all wanted it because it was based on the values of fairness and competition, and the good shall get it, and no one has a right to the taxpayer’s pound, which must be spent fairly in the patient’s interest, and openly and transparently.

It was all based on those values. So whenever anyone stood up to shout at me, and many of them did, I’d say, ‘but if you are as good as you think you are, then surely you will win the money back? But even if you lose some money can’t you see that that’s fair and just? The money is in the system and you will be able to get it back if you are good enough.’ Now they turn round and say ‘yes, you were right, and it is a much better system’.

We took a long time. And we didn’t come in and just say ‘this is the vision, boys and girls, let’s go and do it’.

I didn’t know the best way of doing it. I had a kind of idea. But we went out and built it, and we built it with everyone, with meetings all around the country, asking people what was wrong with the present system, and what they wanted. And we published a consultation document, and changed some of it when we got the answers in. A lot of it happened under the radar. You never saw me stand up and say ‘I am a leader and I am doing a big thing.’ It was much more ‘we want to be the best nation in the world at this, and our patients deserve it’. And I did, in the end, have the backing of government to do it. We did it with a three-year transition, which actually turned out to be four or five years.

And we’ve resisted giving the programme more to do. The minute something looks successful, everyone says ‘oh, that’s good, let’s give it this or that’. And I have to say ‘no, keep its focus on what it was supposed to do’. Because if you give it the next job that needs doing, which wasn’t what it was set up to do, and it doesn’t have the skills, then the wheels come off.

What skills does it take, and what qualities are needed?

So we need this visionary leadership, we also need this collaborative, facilitative leadership to get the change. And I don’t think that it is bossy leadership that is needed.

You can train people to help them do this. I was very lucky. Ron Kerr [currently Chief Executive of Guy’s and St Thomas’] ensured I learnt emotional intelligence and leadership back in 2000. It was life-changing and career-changing. So you can learn. A lot of us can learn different skills, and what to do. Think about where the other person is coming from, try and find the win/win. In the end,

I’ve woken up to the fact that the whole of life, but definitely all of work, is a negotiation. And good negotiators know they have to close the deal somewhere.

In the old days, I can remember wanting to change how the service was run in my hospital and it didn’t work – because I said ‘this is what we have got to do’. So I did learn years ago that I’ve either got to get other people to say it, or I’ve got to find a way of doing it very openly so that people can then buy into it. I mean, I give myself a brownie point every time somebody comes back to me with my idea. I say ‘that’s great’. I don’t say ‘I told you that a week ago’. I say ‘well done’.

So it is perpetual negotiation, and I have no line control. So much of what I do is advise. And the antimicrobial resistance work is going quite well globally. We are managing to get people signed up, and the Foreign Office is working on it, and it is just amazing how fantastic they are. They are doing masses. Because they can see it’s good for Britain and also good for everyone. Persuading people around that sort of common interest is how you get change.

Read the next interview: Professor Sir David Fish >