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Hello, I’m Domhnall MacAuley and welcome to this BMJ Leader conversation. Today we’re in the UK and I’m talking to Sue Holden. You’ve had the most fascinating career. But, you didn’t start off in the health service, tell us where it all began.

Sue Holden:  My very first job was working on the markets, selling material. At school, I wasn’t the most academic of people. I loved sport, any sport. I managed to scrape through, three GCSEs, and two CSE Grade one, so I got the minimum that you need to do anything.

I went to the job centre, which a lot of people might not know about. People used to go to the job centre and they would have a list and say, well, this might suit. The following afternoon they were interviewing at the library for a library assistant. I said I like books, so that’s where I went and I was offered the job, and that’s what I started doing.

DMacA: You were a librarian, but you didn’t think that was for life?

SH: In the library, there was a lady called Mildred, who worked in the reference section. I’d been there for about two years, and she said, “You don’t want to be doing this. While it’s fine, this isn’t what you want to do, what do you want to do?” I said, “I don’t know, I hadn’t really thought about it.” She said, “Well, what are the things that you like? You are great with people. You get on well with the old ladies”. She said, “ Why don’t you think about nursing?”  And, I said, “Oh, I don’t know. My next door neighbour is a nurse in theatre, and I’m not sure.”

My mum had done some auxiliary nursing when I was little. I didn’t really remember and she spoke very well of it, but it hadn’t really entered my head as a career because I didn’t think I would have a career. I needed a job, I didn’t think about it as a career.

I remember the interview. One of the questions was, “Why should we train you to be a nurse if you’re just going to go off and have babies?” And, at the time, I thought, well, that’s nothing to do with you. And, I said it. “I don’t know why I’ve been asked the question. I don’t think that’s anything to do with being a nurse.” And, the guy that interviewed me, Mr Dorgu who was the head of education, said, “Okay, we’ll put you on the training. If you’re prepared to speak up to me, you’ll speak up to others.”

DMacA: When you were doing your nurse training, you were going to change the world even then?

SH: Oh, absolutely. And I have this real sense of right and wrong, that you should always be trying to improve things. And I had a particular experience working on an orthopaedic ward in the main hospital and, basically, I spoke up. That’s what it would be called now but it wasn’t then, it was called complaining. But I didn’t do it in a very political way. I had seen care that I didn’t agree with and tried to change it. I spoke to the matron. Nothing happened. And so I wrote a long letter, a six page letter, and then went on my three week break.

My first day back into work was spent in the office of the Chief Nursing Officer, who said, how dare I write a letter like that?. That I didn’t know what I was talking about and I didn’t understand how hospitals worked, I didn’t understand the constraints. There was a whole list of why nots. But then what emerged was that the ward sister had been moved off the ward and had been taken off training, and there had been some significant changes. I felt quite justified. But at the end of it, he said, “Well, you’ll never work in the main hospital again for the rest of your training” And I didn’t, I worked at peripheral hospitals. That was my first real experience of power being used inappropriately. And, it made me cross.

DMacA: You then went on to study midwifery where you made a big impression, but that wasn’t without its challenges either.

SH: At the end of my nurse training, and this is very un-PC but I’m not apologizing for it, I genuinely thought I only had two routes to go. Either I could go into midwifery or go into mental health nursing, because in both of those placements, I felt you had more autonomy of practice. I didn’t realize that’s what it was at the time because I said to myself, I just don’t want to be told what to do by doctors. Those two branches seemed to have more opportunity to influence. Because I didn’t smoke and drink lots of tea, which was the norm in mental health wards at that time, I went into midwifery. It was life changing in the sense that I still feel awe and wonder at new life and the privilege to be part of a new life experience is pretty amazing.

I then applied to become the delivery suite leader, and it wasn’t without controversy because, from the perspective of the midwives, they looked at this young whippersnapper who had five years experience – how does she think she can come in here today and tell us what to do – to the extent that they raised a complaint when I was appointed. It was around their perception that a lack of years equated with lack of experience. So that was another big learning experience for me.

It’s what you do with your learning. It’s what you do in terms of reflection and how you test out your thinking and how you acquire new understanding. It’s not just going with what’s always happened. I didn’t appreciate the enormity of the job at the time. I just thought I could change things.

DMacA: As time went on, you were very senior and you had a clash with management that changed the direction of your career.

SH: I did. I always maintained that, if you are to be credible with clinicians, you have to have a currency of practice. So, I carried a case load of high risk women. I’d set up an after birth service in about 1996 because I recognized that what was written in the notes of a woman’s experience was a physiological note, it wasn’t their experience. Because when women went home and you asked them about what had happened, their experience was very different from what had been written in their birth notification. One is a factual, medical, physiological account of what happened. Her story didn’t figure. And that was really quite impactful because it led me to understand that we’re trained very much to focus around the physical signs of a pathology and record the physical. What we’re not trained is to recognize the interplay that has with an individual’s emotions, and their previous experience, and their worries and fears.

I’d gone in early one morning and was with one of my ladies who had gone into spontaneous labour. She previously had a stillbirth. She was progressing really nicely and she wanted an epidural. We were in the process of getting it started. But, every Monday morning there was a management meeting and I chose to stay with the lady. And that wasn’t well received, because it was felt that I wasn’t fulfilling my management responsibilities. And it wasn’t the first time that I had had a different perspective and, I made the decision that I needed to leave.

When I reflect back, and I’ve done quite a lot of reflection, working through what my triggers are, it’s a values clash. When I was younger, I tended to move away rather than work through them because I didn’t have the skills. I didn’t have an understanding of the politics. I didn’t have a recognition of the other person’s perspective. So, I found myself without a job, but had just finished  my master’s course in health professional education, which I thoroughly enjoyed, and I was already doing some lecturing in midwifery at the local university. I saw a job advertised, as Research and Development Lead, and I thought I’ve just done my masters and just done my research and I’ll be all right. So I applied for it. It was a really tough interview.  I was interviewed by two men, both with a strong background in research, but it was in randomized controlled trials and they were both doctors. There was a nurse on the panel.

I talked about the shock I’d had that we invest so much in people’s education and development in health. And it is one of the absolute advantages, you know, when you talk about the ancillary benefits, the education opportunities are there. But, you do your dissertation, put all that work in, and it’s usually about something that you care about and that’s work related. And then it sits on the shelf. I wanted to see Nursing research used in practice.

DMacA: So this brought you into a new world in education and research. And then you moved in a number of stages through management, through quality improvement. Take us quickly through some of those steps and what you learned from them.

SH: I’d been doing the role for about 15 months, 16 months. And then the regional director, a man called Jim Easton, was setting up an organization called the Learning Alliance. It was at the time when there was a lot of discussion around continuous improvement.  The Institute for Health Improvement had a big presence in the UK and I bumped into the person that was leading that in North and Yorkshire region, a lady called Maxine Connor, who was quite inspirational. She saw the benefits in creating a very flexible approach to work, virtual team based, and working across a large geography.

We tested out some of the early team space stuff and we were able to be involved in the development of some of the improvement leaders guides. I got to know people like Helen Bevan, Jean Penny, Hugh Rogers, all very influential at that time and thinking differently. And it was a bit like I had been given a sweetie box because suddenly I had all these different tools and approaches to consider how you progressed and improved things.

And because of this, I also had the privilege of working with a lady called Kath Rounce from Middlesex University, and we set up the first professional doctorate (DProf) in health. At the time, doing higher qualifications through experience wasn’t really done, it was always programmatic. I’d always felt very strongly, and I talked about it quite a lot in my other role, that we need to be more willing to accept that experiential learning has equal value to academic learning, if not more. So, it gave me an insight into how you can influence and how you work with very senior individuals, and the way that they think, that more strategic perspective, that broader picture.

DMacA: You said something very interesting there, which was that you learned to deal with and understand senior executives but, now, towards the end of your career, you are one of those senior executives.

SH: And I don’t feel it. I think that’s one of the things that we do that needs to stop. I strongly feel that we can create an aura or we can lay our perspective on senior executives, but they are people first. We are, everybody, is a person first. And the humanity of the individual often gets veneered with the authority and the title. I’ve always felt, and always strive to be, authentic. And that means that if I’m having a bad day, you’ll know I’m having a bad day. And it’s not that I’m having a go at you. We all have them. I’m not perfect. Neither is everybody else. But I do expect certain standards, because I always believe that you shouldn’t ever ask people to do things you’re not prepared to do yourself. And I think there’s some fundamental ethics in how you lead that you need to own.

DMacA:  I’d like to ask another question because, while you come across as a very kind and understanding leader, but leaders sometimes have to give pretty tough messages, how do you do that?

SH:  You do it in a kind way. And I think what I’ve learned is that, in sharing something of me, in being clear what my standards are, and what my values are, and what my motivations are, you’re able to engage with individuals on the things that matter to them. And I genuinely believe there is no reason why anybody should ever have to leave under a cloud, because people have skills and abilities, and it’s our responsibility to find the right fit. But if you genuinely want to make things better for patients, that has a common binding purpose, you will find a way through it and you do it in a respectful way, and you do it in a way where you honour the investment that person has already made. Because these jobs are really tough.

You know, I think anybody that is appointed into a chief executive role now, the number of demands placed on them, it’s not just a job, it touches their life outside of work. The time they spend, the visibility because of the media, their privacy is often diminished. And we all need private space.

You have to be able to give tough messages. So, there’s a balance. But those tough messages are always easier if they’re coming from a basis of values, of wanting to do the right thing, and being willing to be humble when you get it wrong.

DMacA: What I’m really interested in, from a leadership perspective, is something that you previously said, which is that you have to understand your own motivation. Tell me a little bit about that.

SH:  I don’t think you can discount the fact that I have had a very privileged opportunity to observe many organizations at senior leadership level. Most people develop their career and perhaps have one or maybe two roles at the very senior level. I feel the wider perspective I have been able to experience gives me is a very broad canvas of understanding that people come into these roles for very different reasons.

Sometimes we overlay our judgment on how we think, and why we think, they might be doing what they’re doing without really getting underneath the reasons and what their motivation is. That then means that, when you try and support individuals, if you have over laid your own understanding and not checked it out, you’re going to get it wrong and it won’t work. So, one of the things that I have been able to develop, because of that breadth of experience across many organizations and I’ve worked with a lot of different leaders, is that leaders are not ‘one size’. They absolutely are not. And, more importantly, what I have learned is that organizations need different leaders at different times.

One of the misnomers, I think, is failure. When an organization reacts and responds to what’s happening externally, it changes and not everybody can change with it. That doesn’t mean they failed. I hate the word failure in the sense of an individual has failed. There isn’t any individual that fails. What happens is that that leadership style doesn’t fit any longer. And that might be because the organization needs a different style or set of skills to what the leader currently has, or the leader themselves can’t adapt to that. But it doesn’t mean the skills that they had before are suddenly useless.

The NHS fails leaders and it fails them because it believes that the same person is going to be the right person. When things start to be challenged, it’s an easy option to get rid of the leader and they go under a cloud. And it’s unhelpful, it’s disrespectful, and it’s not compassionate. Because with the size of the organization, we’ve got to be able to support people into the roles where their skills fit.

That’s a really big thing for me, that you need to respect the gifts that people have and recognize that they might not be yours, you might not like them, but they still have talents and skills and need to be used and directed where they will have most benefit.

DMacA: I just love that philosophy of recognizing the gifts that people have and their talents. Thank you very much for sharing your philosophy on leadership. That’s what really came across today. It’s been an absolute pleasure talking to you. Thank you very much indeed.

 

Sue Holden

Sue Holden is Chief Executive of Aqua, an NHS improvement organisation. Starting her career as a librarian, she trained as a nurse, then as a midwife, and she has worked in the NHS for over 40 years. She became Executive Director in a Teaching Trust before becoming an Improvement Director for NHSI in 2015. She then worked 5 years with Trusts in Quality and Financial Special Measures, and from 2019 – 2022 as NHSE, National Director for Intensive Support. Sue believes in the importance of supporting individuals, organisations, and systems to improve.

Professor Domhnall MacAuley

Domhnall MacAuley currently serves on the International Editorial Board for BMJ Leader.

Declaration of interests

We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.