Keogh lecture 2021: Leading by accident
From Boston to Whitehall: reflections on science, clinical leadership and the Covid-19 pandemic
The third annual Keogh lecture – and the first since 2019, due the Coronavirus pandemic – took place online this week. The lecture was given by Professor Jonathan Van Tam MBE, England’s Deputy Chief Medical Officer and member of the UK Scientific Advisory Group for Emergencies (SAGE), co-Chair of the Global Health Security Advisory Group (GHSAG) pandemic influenza working group (PIWG) and Professor of Health Protection, University of Nottingham.
Peter Lees MBE, FMLM Chief Executive, welcomed Prof Van Tam as the Keogh lecturer for FMLM’s 10th anniversary.
Professor Stephen Powis, National Medical Director for NHS England, introduced Prof Van Tam as his close colleague, clinical adviser and “an incredibly important scientist and clinician at the top of government” for his role in driving the policy for the UK vaccine programme.
Prof Van Tam began his lecture by reflecting on an early lesson from his military training: “Any fool can be miserable, and it doesn’t matter how hard the job is that you have been given to do, it is your choice whether you remain cheerful or not – and that has stuck with me.”
He outlined his life/career journey from a small market town in Lincolnshire, through medicine, science and a clinical leadership path to Whitehall, including his role throughout the Covid-19 pandemic. It began inauspiciously, when he arrived at medical school in Nottingham in 1982, feeling unworthy of the opportunity he had been given, due to his less than optimum A-level results. However, he determined to grasp the opportunity with both hands and not dwell on regret, advising the audience:
“Always be grateful for the opportunities you get…usually, the opportunities you most regret are the ones you didn’t take”.
Targeting the just-graduated National Medical Director’s Clinical Fellows in the audience, he added:
“In general, you are limited only – or at least mainly – by your own determination and drive. Hold onto that and don’t be held back by the system.”
A clinical training can take you anywhere
Prof Van Tam credits Professor Rex Coupland, the Dean of the School of Medicine at Nottingham (1981 – 1987) for impressing upon him the importance of being authentic by remembering his background and whom he was going to be serving:
“A clinical training can take you anywhere in life. But one of the things I have found important in my leadership journey is to remember my roots”.
He presents this as the reason for not taking himself too seriously, despite the seriousness and the seniority of the position he finds himself in; he continues to remind himself that he is just a lad from Boston, a small town, state educated and who only just got into medical school.
Describing healthcare as a broach church to be explored and not to be rushed into, Prof Van Tam also cites his friend and mentor, the late Professor Richard Madeley, for encouraging him to spend time working out what made him tick and what he was particularly good at, as well as to always reinvent himself and think about the evolution of his career and leadership journey. He admits he has applied this by always trying to think two jumps ahead, to not lose sight of the bigger things he wanted to achieve.
He urged that whatever the career or leadership journey, it is important to always try to be the best and to be reflective throughout: “Always look for your USP”.
Coronavirus "threat story"
Shifting his focus to the pandemic, Prof Van Tam described the Coronavirus “threat story” as beginning in 2003, with SARS, and acknowledged people will ask why the current situation could not have been better predicted, which he admitted he will continue to think about.
Talking through the early charts and graphs of Covid-19 cases and hospital admissions, Prof Van Tam pointed to the UK’s lack of diagnostic capacity in the early days as one of the biggest lessons going forward. Also, using a heat map, he explained the chain reaction of infection and the threat of “NHS overwhelm” and the use of non-pharmaceutical interventions (NPIs), particularly lockdowns, and emphasised how ventilation has emerged as an incredibly important NPI. However, he referred to NPIs as “very blunt tools”. He said:
“They cause immense collateral damage to [people’s] lives; to the economy; and to other bits of our health and wellbeing, and it makes for exceptionally difficult political choices. So, whatever your views are – and my views are – about lockdowns, and about whether they’ve happened too soon, too late, all of that[…]you can see from case rates after lockdowns, they do work. And that’s the unfortunate truth.”
An astonishing journey
On the issue of Covid-19 treatment research, Prof Van Tam spoke of the incredible collective achievement of disconnecting the illness and disease rates from mortality, and how the NHS and clinicians have been exemplary in terms of research leadership at local level, which has contributed to the rapid establishment - “far more quickly than other parts of the world” - of treatments that either did or did not work.
In what he described as “an astonishing journey”, Prof Van Tam talked of his leadership role in the UK’s vaccines work. He described the work starting in March 2020, following the UK’s early decision to pursue the vaccine route, but in the stark knowledge that, typically, there would be a nine in 10 failure rate of finding a vaccine that could work in the timeframe needed. So, there was early agreement for considerable investment in vaccine research and development, in the hope that some of the vaccine candidates and “hoped-for quantities” would make it through to licensure and successful manufacture to become “real quantities”. He said:
“Without the vaccine taskforce and its ability to drive clinical trials research through the NIHR [National Institute for Health Research], its ability to just go out and spend money where it needed, to secure these early contracts, we’d be in a much worse place.”
He highlighted the criticism received over decisions to delay second doses and prioritise first doses in the vaccine programme; pointed to the evidence of how vaccine effectiveness had picked up over time and how data now show the enhanced antibody response gained by the extended interval between doses for both Pfizer and for AstraZeneca vaccines. He said:
“So, we have been vindicated in terms of our approach to dose interval, but it has been very challenging to hold that line in the face of quite a lot of criticism.”
Very, very successful vaccines
Prof Van Tam was unequivocal about the perceived success of the UK vaccine programme, stating that seven million cases of the virus and almost 30k deaths had been averted through the roll-out of the vaccine programme in the UK. He said:
“These are very, very successful vaccines, of an order more successful than we could have dreamed of at the beginning. So, if someone had said to me back in March or April 2020, I’ll give you a vaccine that is 50% effective, and I’ll give it to you by the end of this year, I think I would’ve bitten their hand off.
“We are of course now facing the Delta wave which is different, much bigger transmissibility, so the question is how the vaccines are holding up against the Delta variant. You can see there’s some loss of protection against symptomatic disease with dose one, but it’s still very strong indeed for dose two.
“Our vaccine programme has converted us from a really suffering nation into one that’s doing exceptionally well.”
Pearls of wisdom on working in government
In the final section of his lecture, Prof Van Tam addressed the “pearls of wisdom” he had learnt both through and from working in government. He explained the need to recognise and respect the role and instincts of politicians and to approach accordingly. He said:
“You must remember, in government, you are a technical adviser; advisers advise and ministers decide. They are the elected representatives and its right that they make those decisions…remember where you are in the food chain and make sure you stick to doing what you’re meant to, which is to advise.”
He called the civil servants he worked with as “the brightest of the bright” and private secretaries as “the oil in the machinery, the unsung heroes” who keep the show on the road. And the permanent secretaries, who are rarely seen, know everything there is to know about the Whitehall machine, how it works and how to manage things.
He described working in government during Covid-19 as a “once-in-a-generation health ecosystem shock” which no amount of preparation could have changed. Also, how rapidly it became clear that there were just no easy choices and only hard decisions. He advised that recovery will take some time and for the need to be sanguine about that, but to recognise that there will be an important leadership role in both recovery and in continuing to lead UK healthcare through the crisis, which may involve different people.
Prof Van Tam announced himself as a devotee of The 7 Habits of Highly Effective People[1], which he discovered after being sent on a leadership and management course about which he had originally been sceptical, but now hails as “life changing”. The ‘habit’ he remembers most is Habit 2: Begin With the End in Mind, but he advised against framing a vision too tightly:
“Don’t over-engineer the end, try and get to the principle of the thing you want to change or manage rather than jumping into the detail. Because there are usually many ways to get there and there are often people in the system who know more than you do about how to get there.”
Battles, integrity and ethics
He talked of the importance of choosing battles carefully and having a clear view as to whether winning a particular battle is mission critical or merely beneficial, or the ultimate sanction, where it becomes a resigning matter. Also, the need to think about the cost of the process of winning or losing in terms of political capital. He advised to always plan fall-back positions – which he did not truly understand himself until he went to Whitehall and worked with the Civil Service.
Ultimately, in the process of active leadership, Prof Van Tam advised: “Never, ever be tempted to compromise on integrity and ethics” and to be prepared to say to whomever, whatever their position, what you believe to be right.
On the issue of communications, Prof Van Tam advised caution as well as deliberate intention, when appropriate. He equated the importance of documenting all decisions in leadership and management with those in clinical medicine and being clear about justification for a decision as well as the rationale – being slightly different things – as sometimes one is more important than the other. He also recommended frequent reflection and suggested taking time out to think about management situations, including what has gone well, and to reflect on how and why others who are doing better. He said:
“You can never defend a bad decision for long, so it’s better to admit the error and fall back to a more defendable place. Don’t leave bodies behind in your leadership journey.”
He went on to explain the bonus systems he had experienced in two former organisations, where a good bonus could be won for achieving objectives, but if that achievement had incurred a ‘high body count’ due to individual and team conflicts, then it was not possible to achieve the optimum bonus. However, if objectives were not achieved but were only narrowly missed, and the team and organisational feedback relayed a positive working atmosphere, then the bonus could rise to 110%. It was this approach that made him think about the performance of an organisation and how it all links to collective success.
Prof Van Tam’s penultimate advice for a difficult or hostile meeting, was: “Don’t shoot. Wait” and work out what the key point is before delivering a killer remark which could carry the day.
And finally, he advised:
“Never lose sight of what makes you tick, because there’s life after work.”
Prof Van Tam thanked a range of individuals, teams and organisations for their support, but reserved his final comments for the NHS:
“And for all health and social care staff who have fought tooth and nail to save lives over the past 18-months in this awful pandemic, thank you.”
The Keogh lecture is instituted in honour of Professor Sir Bruce Keogh, a tireless supporter of the FMLM-managed National Medical Director's Clinical Fellow Scheme (NMD CFS), who delivered the inaugural talk in 2018.
The 2021 lecture followed the annual NMD CFS graduation event, chaired by Professor Stephen Powis, England's National Medical Director and current sponsor of the Scheme, which was attended by 30 graduating clinical fellows and Scheme host leaders from national healthcare organisations.
[1] Covey, Stephen R., (1989) The 7 Habits of Highly Effective People. Free Press