The longer you can look back, the farther you can look forward
(Winston Churchill, 1944)
by Air Commodore Rich Withnall QHS FRCGP SFFMLM
Headlines describe these as ‘unprecedented’, ‘unique’ and ‘exceptional’ times. As David Shukman, the BBC’s Science Editor, reported on Easter Sunday: ‘there’ve been so many grim milestones in this coronavirus outbreak, but passing a UK death toll of 10,000 may prove one of the most shocking’. He is right. Everyday life in this country has changed dramatically with profound impacts upon ourselves, our loved ones and our communities.1
Overseas, the Defence Medical Services (DMS) have witnessed similar scenes before. Between 2014-2016, West Africa experienced the largest, most complex Ebola outbreak since the virus was discovered in 1976. The Centers for Disease Control and Prevention reported 28,652 cases and 11,325 deaths.2 Between July 2014 and June 2015, the DMS designed, organised, trained and deployed an Ebola Virus Disease Treatment Unit (EVDTU) as an inter-agency, multinational medical capability within the UK national response to the Ebola crisis. In partnership with the Department for International Development and Save the Children, the DMS also trained a significant number of Sierra Leonean healthcare workers, provided disease and non-battle injury medical support, and operated the Air Transportable Isolator for strategic medical evacuation.3
Just as one should ‘fix a roof in dry weather’, sharing leadership lessons is an important day-to-day investment that pays dividends in times of crisis. The FMLM Leadership and Management Standards for Medical Professionals, the NHS Leadership Framework, the Healthcare Leadership Model and the General Medical Council’s Leadership and Management for All Doctors guidance are invaluable handrails. In the military context, Churchill encouraged us to learn from the past to help shape the future. So, what leadership lessons did the DMS learn from our Ebola experiences? In short, the need to be PREPARED: patient-centred; resilient; ethical; proactive; adaptable; risk-aware; empowering; and diplomatic.
Right from the start of our deployment to Sierra Leone, the importance of being patient and people-centred was obvious. Adherence to the principles of good clinical and corporate governance brought clarity from complexity, and provided a sense of familiarity despite the challenges of new signs, symptoms and surroundings.
Rising numbers of cases quickly inferred Ebola would be a marathon not a sprint. We needed to know and understand ourselves, and look after each other. Personal and organisational resilience strategies ensured our ability to provide class-leading patient care didn’t diminish with time, even when the patient load increased.
We found ethical frameworks useful when making difficult clinical decisions and to support fair and appropriate allocation of resources upon which there were competing demands. Valuing diversity, learning, reflection and feedback, transparency, openness and candour built a successful multinational and multidisciplinary organisational culture.
The fog and ambiguities of war4 also occur in times of humanitarian crisis. Rather than just looking ‘down and in’ at the immediate problem, proactive forward thinking and consciously remembering to also look ‘up and out’ helped us: prevent some problems from arising; prepare for new challenges on the horizon; and plan how best to help our patients and ourselves to return to life after Ebola.
Leadership in times of armed conflict is necessarily hierarchical and delivered through orders. As a foreign military force invited into Sierra Leone at a time when uncertainty, anxiety and fear were running high at population level, we needed to adapt our leadership style, decision-making and action-taking to have the maximum positive impact in others.
Our decision making was informed by regularly assessing and managing potential risks, always considering the likely impacts upon patients, colleagues and partnering organisations. Ebola necessitated some risk tolerance, but the acceptable level of risk needed to be constantly reviewed as the situation changed. Remaining calm and objective under pressure, even when not all the information we would have liked was available, proved important.
Clear objective setting, even though strategic Leaders were geographically distant, established our direction of travel. Empowerment of others then delivered effective team-working. Appropriate delegation, the provision of feedback, and holding people to account whilst affording them freedom to deliver, improve and innovate boosted personal morale and organisational efficiency. We also learned, however, that the more finite the resources, the less empowerment can be given as there needs to be more prioritisation of activity.
Finally, through the DMS being a diplomatic, humble partner that demonstrated appropriate sensitivity when supporting a wide range of stakeholders, we were able to establish, and since maintain, strong professional and support networks.
As everyone now works flat out to beat the SARS-CoV-2 virus, the DMS is proud to support the staff of the fantastic NHS and care sector across England, Scotland, Wales and Northern Ireland, and beyond. We hope our experiences with Ebola make us well PREPARED to do so.
1. The Prime Minister’s letter to the nation.
2. https://www.cdc.gov/vhf/ebola/history/2014-2016-outbreak/index.html
3. Bricknell M, Hodgetts T, Beaton K et al. J R Army Med Corps 2016; 162: 169-175.
4. Carl von Clausewitz, On War, Michael E. Howard and Peter Paret, eds. (Princeton, NJ: Princeton University Press, 1976), 120.