The Power of Visibility: Building a Culture of Transparency in Healthcare with Dr Manjit Obhrai

Introduction and leadership background 0:00

So, welcome back. Today on the Safe Space podcast, we are joined by a truly transformative figure in UK healthcare. Today, I have Dr. Manjit Abrai, a former consultant obstetrician and gynaecologist turned NHS executive leader. Dr. Abrai is known as the go-to leader for restoring struggling trusts. From his work at Mid Staffordshire and Queen Elizabeth Hospital, Kingslin, to his role as Associate Postgraduate Dean in the West Midlands, his leadership has been defined by transparency, courage and unwavering commitment to patient-centred care.

In this conversation, we'll explore what it takes to lead through crisis, how trust is rebuilt from inside out, and why honesty, even when it's uncomfortable, is the foundation of healing in healthcare. Let's welcome Dr. Manjit Abrai. Welcome. Thank you very much. Thank you for that introduction. Very kind. My pleasure. So, getting right into it, you've been called the go-to leader for NHS trusts in crisis. What do you think has enabled you to step into those spaces and make meaningful change? I think if I go back a bit, I think it was one of those invitations, I suppose, one of a better word, to leave my NHS obstetrician directorial job, to go to mid-staffs as the medical director.

And I think it was in 2009 when medics weren't doing this sort of stuff. They weren't going into senior leadership positions because of, for whatever reason, it was termed as going to the dark side, as I said. We go into the dark side, which is the management side. So it's going into that learning what you learn and applying it, I think what makes you genuine in terms of what you bring to the party. And yes, you make mistakes, you get things wrong, but it's not necessarily going to stop you if you stick to your values and your beliefs, because obviously not everybody is going to be happy with what you've got to say and how you're going to say it.

And our message was to have respectful challenge as a group of executives. One of the things we divide was the respectfully challenging what was perceived by some people to be normal practice. It wasn't from our perspective. I feel like that's quite powerful, that the idea is that confidence comes from values and process. So can you share a moment when you saw frontline staff starting to believe in the process that you were bringing? I think one of the first things we did was increase visibility of the execs.

the first number of weeks, we actually went around every single area in the hospital as a group of executives and met people, whether it's a group of nurses, group of porters, anybody who was around, we just met them and made ourselves available. And I think that started the ball rolling to say, These are a group of executives who are willing to come to us rather than expecting everything to be delivered on their terms. And I think that started the ball rolling. And suddenly then you've also got to deliver.

Visibility and trust on the wards 3:25

If there are areas that need changing, you've got to start changing, showing the changes that people want to see in terms of ward leadership, particularly some of the ward leadership areas were grouped together in a number of ways. wards were managed by one person. And you can't run a ward when you're not there all the time. So I think one of the big changes we made was that each ward should have a ward leader, you know, a senior manager who would lead patient care. So introducing early change quickly gains trust.

And I think we found that quite useful and people suddenly started trusting people that we were true to our values, that we would be available for people to see and talk to. We also changed the way we went for lunch, for example. A group of executives would go to the canteen and deliberately not sit together and sit with different tables to meet different groups of people. And just over lunch, having a conversation. Again, making ourselves visible in the areas that everybody else went. I'm hearing a lot of visibility, transparency and connection.

So kind of like breaking down the hierarchy and making yourselves more personable to your health care colleagues. Yes, very true. I remember one of the conversations that comes to mind was I was on the wall. I was in my office one evening at about seven o'clock. and somebody knocks on the door, and this is a healthcare support worker. And her opening line was, I may not be important, but I need to talk to you. So I said to her, I said, you know, everybody's important in this organization, the fact you come here.

And she had issues that she was concerned about on the wall that she was working on. But until you listen to those other conversations and welcome people in the office, just because it's seven o'clock, doesn't mean you say, I can't see, you know, come and tell me what's happening. So it's building those little bridges that makes a difference, that everybody has a role in healthcare, healthcare safety, whether you are a senior executive or a healthcare support worker, we all have a significant role to play.

And it's making people feel valued throughout that. journey. I think her statement is one of those key examples of where we're getting it so wrong in healthcare. People don't feel valued, they don't feel important enough to make their opinions heard. So they say, oh, what I feel, or my experiences don't matter, because I'm just a cleaner. I'm just a receptionist. And that's so toxic. It's so damaging to our whole health care system. Everyone has a place and everyone has equal stance and equal stake in our health care system to make it a functional society and workplace.

So frustrating. Totally agree with all you said because until we establish that connection, We know we're going to have franchises that are different, that are coming from different agendas. We've got to start connecting the dots. And everybody matters. And I think as a doctor, you can't deliver care on your own. You have to rely on your colleagues. With great healthcare specialists, nurses, et cetera, you've got to rely on them. And they've got to rely on you in the times when they want you. And you want to be available, as you said, visibility.

And honesty is important that we just don't just use the word because if you look around a number of trusts, if you look at the values that are on their websites, how many of them actually live those values? And I think that's a key question I'd be asking you, you put those values on respect. So when a consultant goes on leave at short notice, canceling a clinic, How is that showing respect to the patients who have taken a day off work to book their appointment, et cetera? So I think we've got to be fairly challenging in terms of the ways we manage the service, that you can't just cancel it to make a short notice, because it's convenient to you, but you've inconvenienced 20-odd patients.

Yeah. So what your leadership demonstrates to me is that it's not a quick fix. It's about sustained demonstration. And you sort of added relatively fast changes, but then also the sustained changes that showed people that you were motivated and you're listening and you're trying to change things for the better. I think leadership, there is no one style of leadership that works. I think you've got to be adaptive to what the circumstances are. And sometimes you're a follower rather than a leader, because sometimes what's happening is entirely appropriate.

All you need to do is to put your weight around it, behind it, so that the processes that are in place are being followed, for example. Having all these guidelines are fine, but nobody's following them makes a difference. So I think adaptive leadership and also acknowledging there are numerous leaders in the system that we work in. You're not the executive leader so you know everything, no you don't because there is something you have no idea but you've got to listen and change comes from the bottom up rather than top down.

I think we've got to start looking at how do we change systems and the top down leadership model hasn't worked and we still keep on applying it and we get this edict from you know certain departments and we've got to then imply it because Changes in each place are different. You cannot have the same size fit all because you can't. You need the buy-in from the people working the system.

Adaptive leadership and bottom-up change 9:20

Absolutely, absolutely. They won't just be told, we don't live in a feudal system anymore like the medieval times, much as the billionaires would like us to live in. People are very cynical, aren't they? So I feel like whenever there is policy change and it's implemented from the top down, Unless people are given reasons to be passionate and the reasons why these policy changes will work and benefit them and benefit patients, then there just isn't going to be the buy-in. And until then, it's going to be lip service.

And you won't have staff motivated to get the work done in that way. Very true. I think it's sort of, you know, the key message we use in coaching circles is to be curious rather than judgmental. So if people aren't implementing something, it's a question of finding out what is it that stops them. What is it, you know, for us to be more curious to say, well, what is it that you find difficult about implementing such a thing? Being judgmental, they say, well, they will never change because I've been here 10 months and they don't want to change.

It's probably too judgmental. It's sometimes often to step back to say, internal or external that's stopping people. And sometimes it's mistrust in the organization because the numerous organizations have changes of leadership that are so fast that before the next leader stepped in, the previous leader said, what do we do? The other people wanted to do another change again. A, we've got to stop some of this constant churn in the system to say there are people put into place and particularly in challenging circumstances give them some time and space to say do what you need to do in the time scale that you have.

Obviously not unlimited, but you've got to start sure and change it. For sure. I mean, this leads really nicely to my next question. Looking back at your experiences working in mid Staffordshire, what would you say your experiences taught to you about the limits and the possibilities of leadership in the NHS healthcare system? One of the things is to make sure that the team that you are a part of are signed up to the whole remit of that you signed up. So you can't have team members and executive members who think differently.

So you've got to have your chairman, you've got to have your chief exec and the other execs on board with what you're trying to do. So you've got to sing from a single hymn sheet in a way to say, this is what we are trying to do as a group of execs. So for example, if money needs to be spent on buying equipment, the finance director has got to be on board to say, yes, I'll find the money. rather than having this perpetual thing is oh we need this but we haven't got the money. So one of the things is to have a strong team with ethos that are all aligned, that the message is aligned as to what you're trying to do because you can't do it on your own.

Second thing is to have a mentor in somebody who you can go to. And I was very fortunate because I had a fantastic chief exec and a chairman who I could actually physically knock on their door to say, this is challenging. How do we go about it? And picking on their wisdom often was helpful to say, sometimes stand back from it. And sometimes it's a goal for us to be ahead. You know, it's one of those things you've got to judge each situation according to the merits of what the seriousness of the situation is.

I think the most powerful thing about a great leader such as yourself is the security to have such humility and modesty, knowing that you don't have the answers, but then seeking out solutions through the team and using leadership less as a kind of command top down approach, but more as stewardship. And I feel like that's the best way that you get the best out of people, the people that you're working with, because they all feel like they have a stake in what they bring to the table, rather than being told what to do, and then feeling more like just a cog in the machine.

I think valuing each contribution, whatever it is. However, Trivial, they feel it is. Coffin is not trivial, like the example I gave you, I may not be important. Nothing is trivial, because if they have the courage to come and speak to you, there is a reason behind it. And only allowing them the time and the space. And I said humility is important, because we don't always get the plight. we do get things wrong and acknowledging the fact that we tried this, it didn't work, as a group of execs understanding that sometimes it won't work and we have to be honest that maybe we tried it too soon, maybe we didn't have the right infrastructure, all that.

Were human first and then healthcare professionals or leaders second? Absolutely, absolutely. And I think it's recognizing that humanity that makes us all a bit more compassionate to each other and kinder when we make those mistakes or when we are celebrating our successes because then we're more likely to celebrate them together. Absolutely. I think in terms of celebrating big wins, we had an employee of the month competition, which was across the board, for example. and anybody could vote onto it.

And at the end of the month, the chairman or the chief exec would present this award to the employee of the month. And that sends a very powerful message that a simple thing, once a month, they've been all voted for across the trust. It could be a porter one week, could be a senior consultant next week, or a resident doctor next week, get the terminology right. But it's important that we make sure that people feel valued and somebody would nominate them and the people would vote for them. And celebrated.

And celebrated. Absolutely. Yeah. I just thought of a good quote. I feel like the lesson in terms of the way that you lead is not about control, but creating conditions where the truth can be spoken or acted upon. Absolutely. Yeah. There's only one version of the truth, isn't there? Whatever it is, there's one version. We may see it from different perspectives, but we've got to understand what those perspectives are. Yeah. The fact of what actually happened. How would you say you personally handled the weight of public scrutiny during that time around 2009? I'll give you a sort of 2009. The trust was in a difficult place.

the report had come out. And we, the chairman and the chief executive decided that we're going to have our executive meetings, board meetings in public. Because if you go back, there weren't many trusts in 2009, 2010, having public board meetings. So our board meetings were in public. where members of the public could come and all the media would attend.

Accountability, openness, and public scrutiny 16:55

And it was incumbent on us to discuss things in an open fashion. For example, we would be discussing our serious incidents in a public forum. So kind of like PMQs? Yeah, well not PMQs and people would stand up and ask a question, we'd answer them and whatever the appropriate board member was would answer them. And the critical incidents were obviously quite painful for some, but we still had to discuss them in public, showing that transparency, that we were able to accept that things in healthcare sadly go wrong.

And our job is to make sure that there aren't any systems issues that are contributing. I think that's how we approached it, that we're looking at the issues rather than the people. What is that issue that led to harm in that system? How do we prevent future harm? I feel like the issue with a lot of having board meetings or any sort of decision making behind closed doors, secrecy tends to breed suspicion, especially when there is already low morale and poor optics from an organization. So I can imagine that putting out the message that we've got nothing to hide, there have been failures.

That is a very vulnerable starting point. And it is a place where you can see where things might go wrong, but at least people can see that step one of the process where you are at least admitting fault is occurring. And I think that's a really powerful way to begin sort of cleaning up all the error of the previous ways. I think there's sort of two things on that you're absolutely right in that cleaning up and open transparency is to say, If you look at the current issues that are affecting healthcare in dissatisfaction and maternity services, my own specialty pages go, the message that coming out loud and clearly, there was no proper communication when the incident happened.

And that the patients are seeking more and more information and the organizations are more and more reluctant to provide it. between the providers of care and the people who are receiving care and even if you look at the board meetings I think even the local trust that I look around in the number of questions are limited and they had to be sent in before to the board level I mean where is the transparency in that that I need to send you the question so you can prepare an answer because we had none of that you know anybody could stand up and ask a question and sometimes they were uncomfortable no doubting, but we have to be able to honestly answer.

Now, there is no point in leaving things till it's too late, you know, open communication. If things have gone wrong, you've got to admit that things did go wrong and let us investigate. And this concept, though, we won't let it happen to other people. Some people don't believe that. we've got to change the system that people are seeing the change, that the next time it doesn't happen. I think current maternity failures have demonstrated that we need to be more consistent in how we communicate with people who come to harm.

Yes, I feel like regardless of the failings or whatever the personal tragedy that comes to a patient because of errors within within their treatment. Everyone appreciates apologizing and owning up to when mistakes have been made. There will always be the hurt. there is, that is the starting point for healing and repairing damage. So would you say that you've faced resistance from any colleagues at the time who worried that this level of openness and transparency might expose the organization to more criticism?

I think sort of, yes, you do, because I think people are wary of organizational you know, performance and organizational integrity, and they're worried about the reputational damage that you might cause by saying something that's correct. And I think if you're doing it for the right frame of mind as to where you're coming from, reputational damage is irrelevant to me. I think if you look at the mixed-staffs inquiry, Robert Francis' inquiry, then numerous examples of people, there were lawyers telling the trust to cover up what had happened before.

That is no longer acceptable. I know from the lawyer's perspective, it's their job to protect the organization. But as healthcare providers, we can't at that be the case, because that's not satisfactory. That's not normal. And that will create even more mistrust. What else are you covering up? So I think we've got to be honest upfront, as is that mistakes happen. You know, Robert Francis in his You know, Preface said that every hospital, even the best, will get things wrong. That doesn't mean that we're genuinely making mistakes.

Nobody goes to work with the intention of causing harm. Absolutely nobody, from the porters to the doctor, anybody. But things in a healthcare system which is constantly in changing flux, risk changes, And therefore, you've got to be able to, on the spot, manage it. And sometimes you can't. Sometimes there's a struggle. And that's not condoning it. But we've got to be honest that there are things that sometimes do go wrong. And our ability to honestly admit it and change the system for future reference to say, this ought to be different.

If you look at the simple concept of consultant availability now, there are more consultants available on the shop floor in most specialties now. That wasn't the case 10 years ago. So the system is safer because we have somebody to call on now. We don't have to wait for a phone call or oblique them. They're on the shop floor with you. We don't hear about this on the news. We don't hear about this, you know, in day to day media. So that's interesting to know, actually, that would you say in your opinion, health care is improving?

I think improving, but still more to do. If I was being honest, I think, if you were to ask me, what are the biggest changes that have taken place since mid-staffs and now? Yes, there are more systems in place. Is the healthcare system safer than it was? Yes, it is, but is it, well, the 10 years, 12 years that we spent, or more, if you count it, we could have done more. We probably should have done more. And I think, and we've got to start saying, what is it that we didn't do? If you look at some of the recommendations of Robert Francis, some of them are probably still not implemented.

And I think we have a habit of creating report after report without saying, where does it all lead to? Who is policing the fact that this is being done? Because the standard response is that a report comes out, it goes to trust board, somebody phones an action plan. And it's death by action plan that was the crisis in Stafford. They all had action plans. But there was no time scale as to when the action would be done. There was no time scale as to who was going to be responsible for the action. You know, the clinical director, who's the clinical director?

He changes tomorrow, she changes tomorrow. So I think accountability is hugely important. Personal responsibility and accountability in these areas, it's critical. Otherwise, you're not going to get things right. Yeah, I have noticed in a lot of management meetings, there is a tendency to kick the can further down the line, further down the road. My apologies. And I really feel like without a timeline, which I feel like sometimes can be maybe deliberate, not creating a timeline or deadline, just so that for the next meeting, the same agenda is in place.

And nothing has changed because that problem solving isn't really occurring for whatever reason, maybe because there's not enough budget or however many excuses there might be. But it does lead to a certain level of jadedness when approaching these meetings when so much good work can be done and so much progress can be made. But there is a maybe a preference for the status quo rather than towards creating that positive change? I think another example I can give you is that we had to make certain changes in Stafford and there was an action plan created by the team and each executive was responsible for certain part of the action that had to be done.

Obviously they don't have to do them personally but I've got to make sure they're done and the chairman used to meet with us every fortnight We had to sit through a room with every single exec to say, okay, this is your action, why is it late?

Learning from crisis and rebuilding systems 26:45

And then, okay, you could have explained, obviously finances or constraints, but you've got to give a reason and next week is that he wants something different. So there was that channel that we had to be accountable at that formal meeting. We had a very good company secretary who was very diligent in terms of making sure that your actions were completed before the next meeting. And he would literally badger you to say, you promised this thing, the meeting's coming up next week, what have you done about it?

In a nicest possible way. And, you know, very, very good at his job. Excellent. And we were kept on our toes all the time. That's brilliant. That's like aggressive accountability. Yeah. But it really, it really gets things done and moves, moves the organization forward. Exactly. And the time scale was specific and they weren't allowed to lapse. In times of failure, you've been known to choose to be open, even at personal cost. How would you say you balance accountability with pressures of organisational survival?

I think, again, I've been very fortunate that the execs and the non-execs that I work with believed in total accountability and openness. So I was fortunate in the sense that if I had a delicate issue to bring up, I would go through them to first say, I need to bring this up. How's that go? Now, there was one occasion when I didn't. I'll give you an example where I did, because I was worried about the reputational damage and what the public would think about what I was going to say. And I remember the chief exec asking me to come to see him in his office after the meeting.

And he said, why, what stopped you? And I'm not going to use the language he used at the time. And I said, I was worried about the damage it might do. And he said, so what? I said, well, so you might sack me because I'm the culprit who made it happen. So he said, so what? I said, well, so what? I've got two children. I've got a mortgage to pay. So that, so what? And he looked at me straight in the face. He said, never do that again because you will get a job anywhere. I would give you a job. So don't be worried about getting a job and not doing what you feel is right.

And I think that was a lesson for me to say, actually, as long as you run it past people, balance out what you're going to say, maybe change some of the, not the language as such, but in terms of the message in a way you deliver it, that you can deliver uncomfortable messages. If you look at anybody delivering bad news, there are ways of doing it. And we've been trained to do it. Some people do it very well, some people struggle. And what you mentioned earlier on, that we need to take account of our own emotions to say, how does that make me feel?

I'm not doing it for personal gain. I'm doing it for the future of the patient that this organization will look after. for making sure that you have people on board with what you're about to say and have that kind of maintain that moral courage, that integrity, even if it isn't always rewarded because I guess it's kind of like being quite aspirational. It's about more than just yourself. It's about maintaining that integrity and trust in the healthcare system itself, rather than just yourself. It's a team, the exact team.

People forget, as an exact director of an organisation. You are responsible for the whole organization, just because you're the medical director doesn't mean your job stops as the medics and nothing else matters. Finance just as much matters for you as anybody else, because you're an executive director of a unit you trust. And that's how it is, is responsibility shared. And we need to understand that, which means that if I'm going to say something, that the nurse director may struggle with, and I could go and discuss it with her and say, this is what I intend to say.

How are we going to get response to that? So getting the team together to make sure there is collaborative responsibility, rather than just saying, so I'll say what I want to, because you can't. You are in an organization which is run by a team. This is how you rebuild credibility in the organization. It's kind of paradoxical, isn't it, that admitting to the failings helps to helps to keep your organization alive? Absolutely. Absolutely. We're all fallible. We're all fallible. Yeah, yeah. As Associate Dean, you are shaping future medical leaders.

What qualities would you say are non-negotiable for tomorrow's healthcare leaders? I think accepting the vulnerability. Accepting this, one of the things that, you know, being vulnerable is perfectly normal. We shouldn't be hiding behind things that we're struggling with. So one of the things you see doctors are, they're often afraid to come forward because of fear of getting something wrong. As long as you run it past people and you've got people around you, Yes, it will develop you as an individual by trying different things, different leadership models, different ways of doing the same thing.

So it, first of all, is accepting vulnerability. And secondly, find yourself a mentor, find yourself somebody who you are attuned to in terms of their style, in terms of their behavior, in terms of their values. And if there's a conflict between values, discuss them, talk about them. Talk about what it makes you feel if somebody is transgressing your values. So this ability to be more open and having an open conversation rather than saying the hiding behind labels. And I think we have a group of doctors that are fantastic.

They are more genuine in their aspirations to improve healthcare systems. Some of them are frustrated in what they can't do. and we're going to find out what it is that they can't do, and how can we make it happen more, I suppose faster for them. Everybody wants change quickly, but sometimes change does take time. It's the ability to explain that this is happening, but not at the pace you are comfortable with. It is happening, let's accept the 1% incremental change every day, rather than expecting 20%, you know, the first day and then 100% in five days, it won't happen.

So this incremental change, accepting that things are different that are moving on. Yeah, I think there is a huge need to improve our appetite for acceptance of what is. I know that I've struggled with control, not being able to control a patient's outcome or not being able to control what happens during the day, whether I get my my letters done or, you know, like, all of these events in the in the day are so I don't know, it can be really tumultuous in a healthcare workday and having acceptance of whatever may come, I'll be okay, I'll do my best and I will manage to succeed in whatever time limits I have.

Having that acceptance is so much more grounding than having a frustration with not being able to control what's going to happen. And I think. In medical school, we have a tendency to train doctors for clinical excellence. And so we do have clinically excellent professionals. But maybe what we also need to be doing is training for moral resilience and values driven leadership, because we're all leaders, you know, we can all work together and be and be leaders and advocates in our own way. Because that's what's what will truly sustain the NHS.

Absolutely true. I think everybody brings leadership skills to the parties. The question is how do you develop them? How do you encourage them to pursue what they want to be doing? And second thing is we've got to be as human beings able to sort of ignore the things that we can't control. You know, you can't control the central driven paradox that will come across. You've got to say, what is the stuff that I can control? Because some of the disquiet amongst the resident doctors now is that exactly what they will be doing was that, A, things aren't happening fast enough.

Mentorship, vulnerability, and future leaders 35:45

Things aren't changing from my perspective in terms of my remuneration for what I do, et cetera, et cetera, is to say, Sometimes you've got to accept that I can't control certain things, that one of the controllables that I control and some of the stress and the distress I give myself is related to that. And I think there's an old Buddhist saying which I quite like the sound of, you know, pain is unavoidable, but suffering is totally avoidable. By thinking about it again and again about something that's not happening, you have no control over.

You're causing more suffering the longer you go on about it. Sometimes it's just got to park it to say, I can't do anything about it. So it's beyond my pay grade, what are we going to call it, you know, that I'm not going to do worry about it. But it's difficult to do. And I'm not saying it's easy, but we've got to be able to start developing human tendency to say this is beyond my control. I remember when I had that Zoom call or Teams call with you. And that was supposed to be our chat for the interview.

And I broke down about about the state of the world. It was in November time. So just after the US elections, actually. And yeah, that was a really vulnerable moment for me. And I'm so grateful to you for the way that you you handled that and you told me about circles of control and I wonder if you could share with our listeners a little bit about that because I felt like that philosophy really grounded me and changed my outlook. The circles of control is an old sort of concept people are talking about but it's something very relevant because if you look at The circle in the middle is what I control.

It's everything that's under my control. For example, what time I get up in the morning, what I have for breakfast and how I feed my child and all that stuff is under my control. The second circle is the circle of what we call influence. So these are the things that I can influence. I can't directly control it. So for example, as resident doctors, I can't control my assessment outcome because that's going to be written by somebody else. but I can influence it by being on the wall, doing the right sort of reflections, etc.

And the third cycle is like, you know, a cycle of what we call concerned but no control. We are concerned about stuff we can't control, we don't control. So say, what difference will it make to my life if ex-president gets in, ex-person does that? Now, that's not being selfish. It's avoiding suffering because the more that pain is there because you are uncomfortable, as you said, by the state of the world, which we all have to be, we've got children coming up, grandchildren for me, to make sure they're brought up in the right environment.

But at the same time, how is that going to affect them directly at the moment? We luckily live in a country where we are privileged, you know, we have a lot of privilege here and we have open speech, we don't have the sort of a strength, the long way to continue. So we've got to be grateful and then enjoy it while we can. Wise words, thank you. You've spoken about black and ethnic minority professionals needing both equal opportunity and support as they climb up through to management and leadership.

What systemic changes would make NHS leadership pathways truly equitable? What's happening now is that there's a programme by NHS England now to identify BME leaders of the future by offering them coaching. And I currently have one such candidate who is a future executive in the making, but who feel that the skill levels aren't quite there, et cetera. So there is a national drive to get that in place. So I think, A, things are changing from the last conversation we had. And that's a new initiative from NHS England, which I am applauding.

That's great because there are a number of people who identify themselves as future leaders from the BME background who feel that they are not quite ready What will it take for them to be ready? So we have a monthly meeting where we discuss issues and we have a coaching session in terms of developing those skills and those areas which they feel they're deficient in. Some of them aren't. It's just they're diffident in the way they present themselves. It's that lack of confidence by virtue of the fact that we put ourselves in a difficult place ourselves.

by sort of seeing ourselves as, I'm BME, I'm such as I'm likely to be struggling. Well, not always. You know, sometimes there are immense strengths that we've got to say, how do we now bring them forward? How do we actually articulate what we stand for? How do we not feel backward in coming forward as particularly in open meetings? You know, we often say, well, I won't ask that question because it may be, seem to be, you know, a daft question. There is no such thing as a daft question. There's no such thing.

And they just ask it. But sometimes that illuminates the whole meetings when you say, Oh, I never thought of that. Yeah, I'm notorious, actually, for in meetings saying, sorry, if this is a silly question. I do it all the time. And I, and I'd kick myself for saying it. It's like, Oh, sorry, I've said that. But it's, it's, I don't know, maybe it's part of being a woman, and you feel like, oh, I need to second guess myself before I put my, put my thoughts out there. or I don't know if it's to do with being conscious of my ethnicity in that space.

I don't know what it is that subconsciously tells me to apologize before putting my voice out there, but it is something that I'm working on and I think that's one of the reasons why I started the podcast, to bring some sort of validity to my own voice. and use it to try and improve things for the NHS, for our healthcare system that I'm passionate about, unapologetically. I think you bring up the concept of intersectionality, that there you are, you know, ethnic person, female, etc. There are numerous intersections that cause us to think differently.

And by automatically apologizing before you start, you put yourself in a weaker position than you would be otherwise. You know, it's like, let's go to a meeting where you're expecting somebody senior to speak up. You know, they say, I'm sorry, I shouldn't be here because I'm not qualified to speak on the subject. Now, where's your attention gone immediately when they've said that? Well, yeah, you're just like, oh, why do you think you're unqualified for this? Well, that's, that's, that's an inquisitive, curious question.

But half of you might say if you're not qualified, I'm not going to listen to you. There's the other side to it. The confident bit is to say, I'm going to ask a question without apology to say, I don't understand this. Can somebody explain? So put the curiosity angle is to change it to say, I'm sorry, I don't quite understand that. Can you explain what you meant by that? And that's a question. And therefore you can put your question in an inquisitive manner rather than being diffident. And I think how we speak to ourselves is so important, you know, it's we, you know, we say, well, I get angry, I get frustrated.

That is self. We got to change the narrative to say, I'm feeling angry. Because naming the feeling, you know, I'm feeling anxious because feelings come and go. Putting it onto the feeling rather than the person. Correct. Taking it away from the person. It's a feeling. I'm having a really anxious feeling because I'm seeing something I shouldn't have seen, or a difficult patient, so I'm feeling a bit nervous, anxious. Feelings will pass. The person will stay. If you're angry, you're angry all day.

When you come home, you're angry with your partner, whereas you passed it. So I think it's just the narrative of how we speak to ourselves is so important. We won't speak to other people like we do to ourselves. Yeah, very true. We've got to be saying, why am I so hard on myself? And again, even when people get things wrong, often the way they talk to themselves is so negative and so self-deprecating. It doesn't really help your self-esteem, etc. I guess the most damaging thing is that the way that one speaks to oneself can also seep into the way that one starts to speak to others, especially in a healthcare work environment where it's really stressful, where you feel depleted, and then your emotions start to take the better of you.

And then you start to treat other people the way that you treat yourself. And that's no way to be. I think sort of there's a quote by Rumi, by a lot of Rumi, because then he said, you know, yesterday, you know, I was clever, so I tried to change the world. Today I'm wise, you know, I'm trying to change myself or something like that. Basically, today I'm wise because I'm going to change myself. So I think the first thing, if we start with ourselves, all about the emotional intelligence, one of the components is to know yourself.

why is this situation discomforting and answering that question for ourselves and being self-aware is hugely important because you know and that makes us more curious you know why am i uncomfortable about this situation and by sitting down and answering it in a proper manner it does not take five minutes to ask the answer that question often will highlight whether the values that you espouse to are being transgressed or the way you're treating yourself is harsher than it should be, but then you come to a right answer.

Again, that's bringing that circle of control back to the smaller circle of yourself or oneself and being able to work on improving oneself means that we can approach our environments and our healthcare system so much more healthily. Yes, very true. So back to when we've been talking about making things equitable for the NHS leadership pathway for black and ethnic, what am I saying? Black and ethnic minorities. I wanted to talk a bit about mentorship versus sponsorship. What does that mean to you?

Can you rephrase the question and what is it that we're getting at in here? Mentorship versus sponsorship? Are you implying that people who are sponsored are in a different place to people who are being mentored? So I mean, when we're trying to get our young leaders up the ladder, sponsorship means using influence to create opportunities. And mentorship is more about taking a young leader under your wing and helping them and motivating them to reach their path.

Circles of control and personal resilience 47:45

What would you say the balance is and trying to get that right for helping our future leaders? I think the balance base is based on opportunity. Particularly, I'm talking about the Midlands now, I don't know about the rest of the country, but I'm sure the rest of the country is no different. Within NHS England, there are training opportunities for doctors, resident doctors to apply for fellowships. So they go out to their training program and do a fellowship where they will develop, for example, we've got one or two trainees developing ways of managing, supporting neurodiverse doctors, neurodivergent doctors.

They meet the senior leadership team and that is England, start developing their leadership skills, and also improve their networking connections. Certainly they have five different people they have to connect to, like heads of school, like different people. So they've developed their leadership skills in that format. So that's a starter for 10, that there are opportunities that people can take up. In a sponsored way, if you use a sponsorship model, they take a year out of training. and do this and some of them will carry on doing it on a less than full-time contract or a portfolio career to say I'll carry on doing that because I enjoyed that and I've got a certain connection with the group that do that.

So there are opportunities. Now mentorship is available to everybody who is in training full stop. You can approach the person that you are closest to at work who you affiliate with say actually can I ask you to be my mentor? Now, they don't have to be in the same specialty either, because they could be in a totally different specialty. But the important thing for us is to say, can I align myself with you? And mentorship means that you share your inverted commas wisdom with the person in front of you.

And then that can develop into a coaching relationship further down the line if there are area skills to be developed. And that's a slightly different relationship. So I think there are opportunities there and I think we've got to make people aware that these opportunities exist, that you don't have to finish your programme and then find what do I do next. So do you yourself recall a time when someone actively opened a door for you and how that might have shaped your career? I think there are many people I think who opened the door for me.

But if I go back to my, you know, before I even became a medic, you know, I came to this country in January. and went to the secondary school and I was offered the opportunity of either going to the upper, you know, lower fifth or the upper sixth form and I chose to do the exam by sitting on my, on in the library. And at the time we were being interviewed for our university placements and the UCCA form it was then. I was interviewed by the new headmaster who basically asked me what I wanted to do.

And he said, you know, I told him I wanted to be a doctor, and he said, some people are born clever, some people work hard, and you're neither. And my chemistry teacher, who was my mentor, when I told him that, he was absolutely furious. He said, how dare he say that? Because he doesn't know what you come through to be where you are. So there is that, you know, his name is Mr. Moore, I still remember, and you've got to be grateful for that individual who had faith in you to say, yes, you can do this.

And that's one of the models. And I think about Mr. Moore. I don't know, obviously it seems long gone, but bless him. So those are the people you remember. Because at a young age, when you're 16, 17, somebody to tell you that you're not going to be good enough. We got to learn the skills as teachers, how do I impart the news that some people aren't suited to medicine. We have a job to do and we explain. Some people aren't suited to a certain specialty, but our job is to do it in a respectful way to explaining why you're trying to do it, not to demoralize them to say, you know, medicine's not for you and all that stuff, because there are always different opportunities that people can explore.

Absolutely. And at 16, 17, you're such an impressionable age. And to write off an individual at that age when they can be anyone, it just seems ridiculous. Yeah, I can't, I can't believe, I can't believe some of the things that people say to, say to children and yeah, just, it really takes a toll. It really, really has an impact. I mean, to this day, you still remember those words. That shows how much of an impact it's had on you. So damaging. But then also such a positive mentor that you had who kind of salvaged your confidence.

He was brilliant. Go ahead anyway. So yeah, that's why we need advocates, we need mentors. Was there a single conversation or a patient story or turning point that changed your understanding of what good leadership looks like? The conversation I was privy to, which again relates to a patient, I think he was the son of somebody who had sadly passed away. And he had requested a copy of the notes of his mother's care in the hospital. We photocopied them, sent him the whole copy. There were several thousand sheets.

And what he had done, he was very meticulous himself. He'd label the pages throughout and looking at the continuity. And there were several pages missing. That wasn't because they weren't in the notes. They were photocopied. The whole thing was photocopied. We gave him the set of notes. He said, they're not even there. So it wasn't as if we were honing it back. And my chief exec, again, was a brilliant person. He said, actually, we're looking at how we're going to sort the notes out, because the notes are not suitable.

They're not fit for purpose. And he said something. He said, how long will that take? The chief exec said it may take a few months, which is correct. It wasn't telling fibs. And his comment was, how many more patients are going to come to harm in those six months? It opened both our eyes to say this has to be done ASAP, it's not a six month project. So we started changing the notes the following week, you know, saying, how did they need to be? So that one question was, how many more patients are going to be damaged in the time that you're going to take to resolve this issue?

I think that's Yeah, it's incredible how what started off being actually quite an intimidating scenario became a tool for positive change. You could easily have handled that in a very defensive manner in a way that a lot of trusts do. But instead, being aggressively accountable and bringing on that change because it's the right thing to do became quite transformational actually. Well, the chief exec was absolutely instrumental in this because he said, this can't work. This has to be number one priority.

And he was led by example. You know, we used to go around the wards checking notes because that's what they had to do. But he led by example purely because what he said, you know, how many more patients are going to be damaged because the notes aren't sorted in the next

Equity, sponsorship, and closing reflections 55:45

six months. That's really inspiring. Leading through crisis takes a toll. How would you say you've protected your own well-being during this time and sustained your sense of purpose and your fire? There were several things. There were professional things like we would, as an exec team, go out for a meal after aborting things. I know it's another few hours away from work, from home, but you would then sort yourself out. You would say, this was a tough meeting, really found that difficult, it was challenging.

And we would support each other, so that we would just have a meal, have something to eat and drink. So when you came home, at least you sorted yourself out. Secondly, I think having mentors like the one I mentioned, my chief exec, my chairman, to have this debriefing session, I found that quite awkward. How do you handle that? And thirdly, coming home, you know, coming home at two young children at a time, you know. to say, at least I'm escaping, although, you know, coming home quite late, but at least you saw them, you know, chance to put them to bed and all that.

So there is that connection. And the third bit was sort of ability to play golf with my friends on the weekend, but go and play golf and forget about work, you know. so there is that personal stuff so obviously to anybody doing that you might say find the solution that works for you whether it's meditation whether it's going to play sport or gym or whatever do something different get up but make sure that you don't take the issues home with you because otherwise and that meeting we had after each board meeting was critical we just dissected it all out put it away and when we came home it was done I really like the fact that you went for a meal after the meeting because it really gives an opportunity for that informal debrief.

And it's a separate space. It's a communal social space, rather than the intensity of the boardroom. And it allows people to maybe feel their emotions more informally. and connect on a more human level than they would otherwise in that kind of almost confrontational space, which can be the boardroom. And I think that allows for more meaningful solutions and more connection than there otherwise would have been if the meeting was the end of that interaction. Yes, true. Well, the thing we just deliberately made it a habit that board meeting would all go as execs.

Yeah. So final question. If you could leave our listeners, a clinician or not, with one principle for building trust in any system, what would that be? Be honest and transparent and leave your values, whatever they are, and understand the conflict that they are, but leave your values. Don't sort of let them be all written by what's in your organisation, because you bring something to the party. And that is critical. Well, that's a beautiful note to end on. Honesty isn't just a value, but a strategy for survival and renewal of our health care systems.

Thank you, Dr. Abrahi, for your candor and your wisdom and another great interview on Safe2Base. Take care.