May 2019 - Dr Darragh Hamilton, Scottish Clinical Leadership Fellow

Clinical leadership is very in vogue, isn’t it? This is the notion that by engaging and empowering clinicians through leadership endeavours, we can build a better NHS and improve patient care. For the past ten months I’ve stepped away from clinical practice and have worked as a Scottish Clinical Leadership Fellow (SCLF), splitting my time between NHS Education for Scotland and the Health Workforce Directorate of the Scottish Government. The SCLF programme is open to CT/ST2 trainees in Scotland of any speciality and has been in existence for eight years now, expanding more or less every year since it began. And so, with ten months under my belt and an ST4 post secured for August, I am reflecting on what I’ve done, what I’ve learned and how I’ve changed.

Perhaps the most eye-opening learning for me has been in observing how the NHS works from a very different perspective than the one I’m used to. It feels a bit like when Dorothy gets to Oz and looks behind the curtain at the wizard pulling the levers. The NHS has its own invisible curtain that separates “us” on the shop floor from “them” or “management” who run the show. The curtain behind which trainees seldom get to glance. The same curtain that I shake an angry fist at when aggrieved by rota gaps, late rotas and poor parking facilities.

It was because of frustrations like this that I applied for the leadership fellowship. I was fed up of feeling angry and powerless to do anything that might make anything better. And I believe that if you want to change something, you should try to understand it. Ultimately, I wanted to be useful - to my patients, to the teams I work with, and the systems I work in. I wanted to be efficient. I wanted to know how to make things around me more efficient because working in the NHS is hard enough without all the unnecessary extras that making it harder. I didn’t identify with the leadership bit of the job title – I certainly had no goals to move into NHS management - but I decided I wouldn’t let that bother me and go for it anyway.

So, what have I done with this year? In working between an NHS board and the Scottish Government, I’ve seen how the two operate and watched with fascination the interplay between the them. I’ve been able to trace backwards from my first-hand experience of rota gaps to the source of the gaps in the first place and grappled with the exact numbers of doctors we have in Scotland compared with how many we need and where we need them to be. I’ve endured the cognitive dissonance between the need for safe staffing and introducing more flexibility in training. I’ve sat with uncomfortable truths while oscillating between despondency and unbridled optimism at a rate that would alarm any psychiatrist. I’ve really struggled with the jargon. And not just the acronyms but the frightening regularly with which people tend to speak for a long time, and at the end I have no idea what they’ve actually said. I have been deeply moved at the bravery of people to speak their mind, to be vulnerable, and to tell the truth to huge audiences with uncertain consequences. I have been inspired by the tenacity and vision of others to steer huge organisations from disaster and to do so with compassion and grace.  I have been relieved to hear that, like me, even those I most admire don’t think of themselves as leaders, but as people with a job to do. I have soul searched and in doing so I have met my inner imposter but am working on replacing her with a kinder one. I was encouraged to find out that many other women in leadership positions are doing the same.

In the main this year I have been focussing on work around physician wellbeing on a regional and national scale. I have had the privilege of being the latest in a long line of clinicians (many of them psychiatrists) who have been trying for some years now to develop a health programme in Scotland for sick doctors akin to what already exists in England, Ireland and Wales. This required a literature review on the mental health of the profession; the prevalence, the triggers, and the suicides. The process of doing that almost felt like bearing witness to the trauma and tragedy first hand, which brought an unexpected emotional labour to the work and I feel humbly changed as a result.

In putting numbers to recruitment challenges in psychiatry through the lens of the workforce directorate in the government, I became curious see the other side of the coin. At a meeting of the Royal College of Psychiatrists in Scotland Teaching and Recruitment Group (STARG) I heard about the efforts of the Choose Psychiatry campaign and the admirable work being done by members throughout Scotland to raise the profile of psychiatry. Keen to get on the bandwagon, I took on the organisation of a national conference for core psychiatry trainees and foundation doctors on career options in psychiatry. This came about through a personal interest I have understanding the relative gap between Scotland’s usually well filled core psychiatry training and usually underfilled higher training. By asking trainees what they want from their careers and giving some steer, we can start to understand and even close this gap.

While at the College, I found a sense of community that has made me thoughtful of the role of the College in my career and I am reminded of the empowering words of Dr Kate Lovett at the Psychiatric Trainee Committee’s Supported and Valued Conference earlier this year when she said that the College isn’t some building in London, the College is its members.

Among the many opportunities and benefits that came with the programme, there were also unexpected challenges. I knew I would miss patient contact, but I did not expect to miss it this much. Working in wards and clinics for the past five years meant that I was used to measuring the graft of my day by patients seen and jobs done. It was difficult to go from that to working at a desk and through meetings. I had to find new ways of measuring my graft and my worth.

It has also been a year of surprises and revelations. I am now embarrassed at how shocked I was to realise that people I would have previously considered “management” genuinely care about NHS staff. I’ve also been surprised at how out of touch others have been. Ultimately, we are in it together and despite what our instincts might tell us, we want the same thing. We just come at it from different perspectives. We all have our blind spots and prejudices even if we’d rather not admit it. As clinicians we often feel like we are railing against the system, but I think we need to start believing that we are the system, even if only in the eyes of those lower down the pecking order from us. We each have our spheres of influence, within which we have the power to act kindly.

As a final thought, I think it is time for clinicians to start having conversations that challenge and redefine the traditional view of leadership. There is overwhelming evidence that having people from underrepresented and minority backgrounds - women, ethnic minorities, LGBT+ community, disabled people - in leadership positions makes for more successful businesses. But we don’t put ourselves forward for these roles because we don’t think we fit the mould. Most of us don’t identify with the outdated archetypes that usually spring to mind when we think of leaders (middle aged white men) which means lots of us miss out on opportunities that would ultimately diversify, enrich and progress our NHS.

But we can change this. We can change the NHS because we are the NHS. Bold clinical leadership at all levels can be the vehicle that gets us there.