Becoming an accidental leader

When I sat down to write this blog, I kept crossing out the word leader.

It felt pretentious. It carries, for me, the connotations of power,  someone standing above others, telling them what to do. That is not how I want to work, and it’s not how I think of myself. I have always wanted to be part of a community, a team, not above it. I have wanted to serve, not to hold power over others.

And yet, here I am, writing for a readership of people who are interested in leadership and management. So let me start honestly. The discomfort with the word is real, and I have sat with it for a long time.

For the first decade of my working life, I did not realise I was leading. I thought I was just a GP who was frustrated by care that could be safer, kinder, more timely; by colleagues struggling with systems that did not serve them; by patients bounced between services that did not speak to each other. I said so often, and I kept saying so. One thing led to another, and I found myself in rooms where change was being discussed, and then in rooms where it was being decided, and then in rooms where I was expected to help steer it.

Accidental, then. I was an accidental leader.

The first time I understood this, I was the long-term conditions lead at Nottingham City CCG. Most of the role was advisory. But I grew increasingly uncomfortable with how fragmented end-of-life care had become. People were not being told their prognosis early enough. Clinicians hesitated to have difficult conversations. Even when prognoses were shared, the plans did not always follow. I asked my line manager if I could work on it. He said yes.

What I found, when I started looking, was that I was not alone. There were clinicians across the system who cared about this as much as I did. From that shared concern, an end-of-life group began to form, and over time it was formalised across the CCGs. We took our case to system leadership together. We worked on clinician education. We supported the roll-out of ReSPECT forms. I still hesitate to call any of it mine, because it was a team effort from the start but I was in the room, and I had helped bring the room together.

Around the same period, still at the CCG level, we rolled out a shared digital platform across our general practices. It was ordinary work - standardising back-office systems, keeping guidance current, and retiring what was out of date. During the pandemic, it made a real difference. It gave us, as a system, the resilience to keep information flowing between practices, to update guidance quickly as the situation changed, and to keep colleagues informed of what they needed to know to manage the day in front of them. 

None of it was heroic. All of it was collaboration, driven by the desire to improve patient outcomes.

Later, as a deputy medical director at an integrated care board, I was no longer only in rooms. I was helping to design the agenda. Much of my focus was on workforce initiatives for primary care. Supporting the general practice GP role, the non-GP clinical roles that have become so important to how modern general practice works, and the non-clinical workforce across primary care. Whole teams of people whose work makes primary care possible, and who often sit outside the conversations about its future.

Later still, as associate medical director for an ambulance service, the scope widened again. Working with colleagues across other ambulance services, we focused on frailty and on how the sector responds to older people who have fallen. We contributed to a review of national guidance in that space. By then the room I was in was a national one. I had not planned any of this. I had simply kept asking, in each new setting, the same question I had been asking as a long-term conditions lead. How could this be better?

Through all of this, a second question has stayed with me. Who am I working for? My answer has not changed. I am working for the people, the patients, the public, and the workforce who support them. And from that follows a simple logic. If we look after our workforce well, patients and the public receive good care. So the real question, most days, is how do we look after our people?

The neighbourhood health space, where I now work as a local improvement coach, is the first place I have found where the shape of the work matches that question fully. It is population-first by design. It asks us to lead across institutional and professional boundaries. It asks us to treat colleagues across health and care as equal partners, and to have the courage to walk in their shoes. It has taken real personal effort to be comfortable here. To hold lightly the identity I have carried as a medic, and to sit with the discomfort of not always being the expert in the room. But it feels close to the reason I became a GP in the first place.

If any of this is useful to colleagues walking a similar road, here is what I would say.

Many of us in healthcare become accidental leaders

We are good at what we do. People come to us for advice. We find ourselves in places where the path is not yet well worn. Others have walked it before us, but there are not many, and the work still calls for someone willing to keep going. And before we know it, we are in management and leadership roles we were never formally trained for. The question that follows is always: what training, what support, what development do I need?

Formal training matters and is worth doing.

The honest answer has two parts. The first is that formal training matters. The skills and qualities of leadership are different from the skills of clinical practice. They can be learned. Seek out the development, and do not be put off by the feeling that you are not the kind of person who needs it. You probably are.

The second is that training alone is not enough. We are often too busy doing to learn from what we have done. The coaches and mentors who have walked alongside me over the years - I cannot thank them enough. Their greatest gift has not been advice. It has been making me stop, and helping me look back at work I had already done, and find the learning that was sitting inside it. Self-reflection is the key. It is also the hardest thing to make time for.

The problems in front of our health service will not be solved by any one of us alone. They will need curiosity, to explore what could be better. Courage, to go where others have not gone. And compassion, to lead our workforce to a better place.That is the kind of leadership I am still learning. I did not set out to be a leader, and I am not sure I will ever be fully at ease with the word. But I have come to accept that if leadership means serving a purpose larger than yourself, alongside others who care as much as you do, then perhaps it is not so pretentious after all.

Perhaps it is just the work.