Dame Clare Marx: Leaders in Healthcare speech

It goes without saying that this has been an extraordinary year. All of us have experienced this pandemic in different ways, but none of us are left unchanged.

For some, it’s been a time of real tragedy. Many lives have been lost, including healthcare workers.

These deaths represent not only a profound loss to their families and patients, but to our profession, which was made richer by their contributions.

If there’s some good to come from this time, it’s that the pandemic has afforded us a rare opportunity to re-focus. To cut through day-to-day complexities. To centre efforts where they really matter.

As doctors, we have the ability to make a fundamental impact on people’s lives. The efforts of healthcare workers in this pandemic will be celebrated and marked in NHS history. Public support has shown the profound support and depth of feeling for the service.

We know we also have the ability to make a really positive impact on the lives of the people with whom we work.

There’s a direct correlation between the environment in which a doctor works and the care their patient receives.

Environments that promote collaboration, communication and accessible leadership produce better outcomes. Environments where those factors are absent are, at best, unpleasant to work in and, at worst, downright dangerous.

In this time of uncertainty, getting that supportive environment right is more important than ever.

The power of leadership

The good news is that, despite the strains of the pandemic, there are encouraging signs.

In this year’s National Training Survey, most doctors reported positive experiences around teamwork, support and feeling valued in their role – even in the face of disruption caused by the pandemic.

This is something we’ll be looking at in more detail with the publication of our State of medical education and practice in the UK report next week.

While these general findings are heartening, we shouldn’t assume these benefits are felt equally.

Research we conducted last year showed that feelings of disempowerment are significantly amplified for BME doctors. In around 77% of trusts, BME staff reported higher rates of bullying, harassment and abuse from colleagues than white staff. All too often, BME doctors find themselves working in isolated roles without adequate support.

We’ve long known that BME doctors’ experience of medicine can be sharply different to that of their white colleagues. Our Fair to refer research shows that BME doctors are twice as likely to be referred to us by their employer than white doctors.

The pandemic has thrown these long-standing inequalities into sharp relief. As I wrote to the families of those doctors who died, it was clear to me just how many were from a BME background.

Tackling the underlying issues requires leadership. It requires us to be humble about what we don’t know and decisive in implementing solutions. There is no quick fix. But we know some of the elements that need to be in place. Chief amongst them is the right culture – open and compassionate, in which all staff have a voice.

As leaders, it is our duty to make this a lived reality. That is not a passive action – it requires active effort and focus.

The role of the profession

I’ve spent the last 40 years immersed in medicine – as an orthopaedic surgeon, a Medical Director and later in professional leadership roles, first at the Royal College of Surgeons of England and now the GMC.

Having had this wonderful career has made me realise that not everyone gets these opportunities.

There are intrinsic barriers in the system. Looking back, I remember multiple conversations with talented doctors who felt they couldn’t get on. I shudder as I recall one Sikh colleague who was told by a boss "we just don't think you'd fit into this department".

Perhaps I arrived at this realisation relatively late, because I just wasn’t looking. But around the time I became a consultant, and started mentoring, the evidence was stark and confronting. As doctors came to me for advice, I became aware that the scales are tilted in favour of some, but not others and by then I was in a position to be heard.

It’s all well and good saying “anyone can come and talk to me”. But we have to actually seek out opportunities for these conversations. As accessible as you may think you are, your door may not seem open. In a busy and virtual world, it is even more important to invite those different perspectives.

Medicine is hierarchical and tribal. Suzanne Shale’s excellent work for the GMC on medical leadership describes this beautifully. It’s too easy to fall into cliques, when we know everyone would benefit from just reaching across the divide.

It’s not just about making medicine a good place to work, where constructive challenge is welcomed and people feel free to speak out without fear of backlash.

It’s also about the insights that come from those interactions.

No one person is the repository of all good ideas. Junior colleagues often see things that the more experienced of us are blind to. Doctors from different backgrounds bring different perspectives, to the benefit of colleagues and patients alike.

When I think back to 1990, the year I first became a consultant, I’m struck by what has changed. The technological developments, the medical advances, the improvements in care.

But I’m also struck by what has remained fixed. The barriers doctors faced then, some still face today. Discrimination is still visible.

A recent survey by the Royal College of Physicians found that BME doctors are hindered in their search for consultant roles because of widespread racial discrimination.

I also know this to be true from my own experience. I thought that, when I reached more senior roles, the unconscious bias that had followed me would be a thing of the past. But it was still there even as President of the Royal College of Surgeons, and perhaps was more conscious than unconscious as I became more visible. Someone once said “you know the problem with Clare is that she’s a feminist!”. Well, if being a feminist is believing that there should be no barriers to prevent anyone achieving their full potential, then I don’t regard it as a problem.

These patterns of behaviour are not pre-ordained. Culture can be changed. But it requires an active effort from all of us.

The impact of a compassionate culture on retention

A more compassionate culture isn’t a nice to have – it’s essential to retaining and building the workforce we need today.

At the start of the year we worked with partners across the UK to undertake research into why doctors choose to leave UK practice.

Amongst the main reasons for leaving, or for deciding not to return, are factors relating to doctors’ experiences of the workplace. More than practical considerations, like financial reasons, pension concerns or visa issues, doctors cite dissatisfaction with their working environment as a primary driver. Over 35% said it was one of the reasons they left, and over 25% said it was a reason they wouldn’t return.

Worryingly, these figures are even higher for doctors who identify as LGBTQ+, with around 45% citing it as a reason for leaving.

Also concerning are the numbers of doctors who cited bullying as a reason they left, or wouldn’t return. While the average figure was around 5%, this rose to around 7% for BME doctors.

The survey also throws light on experiences across different parts of the profession. For example, around 22% of specialists highlighted burnout as a reason they left UK practice, with this figure rising to nearly 43% for GPs.

Meanwhile, around 35% of doctors who worked part-time pointed to burnout as a reason they left, compared to just over 25% for those who worked full-time.

We’ll be looking in more detail at these insights at our conference later this month. But even at this point, we can draw a clear conclusion.

The environments in which doctors work – the support they receive, the way they communicate with those around them, the ability they have to influence outcomes – have a material impact. Compassionate culture matters.

Leaders are made, not born

Culture is hard to shift once it’s been established. We all tend to resist change. Patterns of behaviour become baked into the system, not because they improve outcomes, but because “that’s the way things have always been done”. But the Covid pandemic has freed us to think the unthinkable and change the unchangeable.

Without change, there is no progress. The context in which we work is evolving constantly. To deliver excellent patient care, we have to evolve with it.

Doctors are leaders from the earliest moments of their careers. The privilege of caring for patients confers an enormous responsibility, one that only grows the more senior you become. So the right values must be instilled from the start, because they will define everything that comes after.

But leaders are not born. In the same way that, as an orthopaedic surgeon, I had to learn the building blocks of anatomy and perfect the technics of hip replacements, leaders have to perfect the art of leadership. This knowledge has to be seen as a core competency, because it is equally as vital for first-class care.

How do we learn? Well perhaps it’s not dissimilar to performing surgery. If you put the first incision in the wrong place, it makes the whole operation incredibly difficult. When you take the time to study, observe and think, make sure the team is working together, the chances of success are far greater.

And just, like surgery, you have to make the effort and take the time to improve.

Conclusion

We all came into medicine to make a difference, to use our knowledge and skills to care for patients. But to do this, we also have to care for those with whom we work.

Doctors must lead by example – valuing each other, reflecting on mistakes and speaking up when something’s not right. In every interaction, in every workplace. And remember a simple please and thank you make a huge difference.

Ultimately it’s how we treat each other that makes the difference. When I look back on the highlights of my career, that’s what I remember. I was welcomed, encouraged and valued. I felt I belonged, and I was given autonomy. It’s those things that will make the difference between a doctor having a long, fulfilling medical career, or not.

We don’t have control over the numbers of people, money or time in our health service. So we must make the best of what we do have control over – our own behaviour. Getting that right will impact on all those with whom we work and the patients we treat.

The leadership of the profession is in our hands. Let’s grasp the opportunity.

Thank you.