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Hello. I’m Domhnall MacAuley and welcome to this BMJ Leader conversation. Today I’m talking to Sanjiv Ahluwalia who is leading one of the new medical schools in the UK. Its quite an adventure. But let me take you back to the beginning. Where did it all start?

Sanjiv Ahluwalia: I started my education as a medical student at Guys and St Thomas’s in central London. I qualified as a junior doctor in 1994 and then went on to become a GP trainee. I subsequently became a GP partner in a practice in Stanmore, where I was for more than 20 years, and I recently moved to another practice in North Finchley.
In parallel I had been working, predominantly in postgraduate medical education, for about 20 years. I took a leap into undergraduate medical education about two and a half years ago and, in my current role, I’ve been working in the East of England at the Anglia Ruskin University. And as you rightly pointed out, it is amongst the newer batch of medical schools that were set up in 2017.

DMacA: Tell us about your current role and the challenges.

SA: My current role is to oversee the development of the School of Medicine at Anglia Ruskin University, to help to develop the curriculum, to ensure that the student experience is a positive one and is relevant to the needs of the NHS in the local area, and also to develop a number of other programs beyond medicine that support and meet the needs of the local population of Essex.

DMacA: It’s not the standard career path to go through general practice and postgraduate general practice to get to that position. That’s a remarkable achievement. What are the skills you needed to learn along the way?

SA: One of them, I think, is perseverance. There remains, I believe, a culture of “What would general practitioners know about education beyond general practice?” Helping colleagues to realize that actually educational principles are transferable across sectors is part of it.
The second is working with colleagues from very differing perspectives and understanding that ‘win-win’ situations, are what one has to be good at creating if one wants to make an impact and really start to change things. Having the ability to create ‘win-win’ scenarios is really important.
Its also really quite important to maintain one’s own values and standards throughout the work one does. Most often people will have similar values to myself in education but occasionally tensions do emerge and it’s really important to be true to yourself if you want to carry on doing this work in the context of a leadership journey. Sometimes it’s also about challenging, being able to challenge in a constructive way, the long held and embedded perspectives that people have. The world is an ever changing place. Expectations are ever changing. And how one engages with that ongoing change process and helping others to come on the journey seems to me to be absolutely crucial.
The final one I would flag is that its really important to be adaptable. in my journey I’ve pretty much found that I need to adapt to a set of very different circumstances literally every few years- as governments change, as policy changes, as the needs of the population change or, as sometimes I describe, to the whim of the latest fad in education. Being able to adapt to those changing buffeting circumstances seems to be an important part of the journey.

DMacA: You’ve spoken about complex systems change, and I know that’s an area that you’re interested in, how do you prepare yourself for that?

SA: People talk about the difference between purpose and vision. I’m a firm believer that anyone who has a crystalline, sharp, clear vision of the future is almost certain to fail. I tend to keep a strong focus on my purpose and try and encourage my team to acknowledge the general direction of travel without getting fixed on a set destination. Because, in my experience, the political and educational landscape keeps changing and with it the vision may very well change as well. So, rather than get frustrated with not achieving a set vision, I prefer to think about achieving an overarching purpose.
The second is being flexible about the nature of change in complex systems and noting that one will require different approaches for different problems even within the same complex system and having the ability to work on parallel activities at the same time but with differing tools. One of the things that I keep in my mind when dealing in complex systems is that it’s about improving the interactions between the parts of a complex system rather than trying to change the structure of a complex system. And this is something that tends to get lost in widespread systems change. Often there is a desire to change structures rather than try and change the way those structures engage with each other and with the system overall. And that is an important lesson that I’ve learned through my time of working in the NHS and beyond.
Finally, it is important to remember that actually looking after yourself and looking after the people that you work with is the most important part of managing in a complex system, because constant change is wearing. It is intellectually challenging and emotionally draining and, therefore, paying significant attention to the needs of colleagues and individuals who are involved in that process is absolutely vital. Otherwise, people will just withdraw from the process of change and that then doesn’t allow a successful outcome to emerge through that process.

DMacA: Now let’s flip the conversation completely, because having talked about systems change, lets talk about the individual again and, in particular, the patient. One of the things you’ve spoken about is the importance of GP education for patient outcomes.

SA: There’s been a long standing focus, particularly in the literature around medical education, on aspects of education such as recruitment, assessment, educational delivery, methods of teaching, methods of learning. And actually there’s very little written in the literature about- ‘to what purpose?’

What is the point of the architecture, the infrastructure, the theoretical pedagogy that exists within education, if not about improving patient outcomes? Much of my work has been to try and demonstrate that clinical education, particularly delivered at the coalface of care, has impact upon on patient outcomes. This is really important to me because when we produce the doctors of the future, or for that matter, the healthcare workforce of the future, we are also doing something else in that process, we’re changing the front end of healthcare. We can now begin to see that, when we have GPs who are trainers, not only do they produce GPs for the future but they are, in real time, making a difference to patient outcomes in patient care as well. Education doesn’t just have the function of creating the future workforce, it also has to function in the ‘here and now’ of improving patient care. And that bit of the conversation, in my experience, tends to get missed. Universities and Deaneries are very focused, and rightly so, on the experience of the students or the experience of the junior doctor in helping them become the professional of the future but, what we ought to remember is that the impact of that educational activity on patient care is just as important. There are multiple reasons why that happens but, at the heart of pretty much everything that I’m trying to achieve, is the belief that by actually improving the experience of the workforce, we’re also doing something else: We’re changing the system in a way that improves the experience of the patients.

DMacA: I guess this also fits in with your interest in peer based education and development.

SA: Yes. There is a lot to be said for learning from each other. Often some of the most important conversations don’t take place between people in a hierarchy, they take place between people who are working or learning at the same level and that is because we bring a similar context. Peers bring a similar context but they also have differing experiences and that is the sweet zone between diversity of thought and a commonality of understanding in the context of the individual. This brings the opportunity to learn in a way that is different to learning that comes from being a part of a hierarchical relationship.

DMacA: Within this context of education, tell me a little about your interest in relational ethics.

SA: A couple of years ago, perhaps a bit longer now, a few of us started to feel slightly uncomfortable that our clinical work, but also our educational work, seen through the lens of the four principles that have been taught since time immemorial within medical schools are perhaps not reflective anymore of the increasingly complex nature of the work that clinicians do and, if there was a need to consider thinking differently about ethics in the context of clinical care. One can take a snapshot in time and apply the four principles to that snapshot in, for example, a consultation or an interaction between a doctor and a patient, but in many aspects of life and general practice in particular, relationships are longitudinal. They take place over time, they take place over space in different venues, and perhaps what’s needed is a more sophisticated understanding of the nature of the relationship and its impact on ethical thinking. And so we spent some time over the last few years thinking about autonomy, patients autonomy and clinician autonomy, and the nature of the relationship between the two, particularly in the context of an ongoing relationship between a doctor and a patient.

That’s the nature of the work that we’ve been trying to undertake. And underpinning it is a belief that we all work in complex systems, with complex lives and many influences when patients and doctors come together and, while those influences are not necessarily visible how they influence decision making and, in particular, the ability to make decisions for oneself, are quite important.

DMacA: Within the context of the consultation, you bring a new dimension to the consultation and please forgive me if I pronounce the word incorrectly, “Hermeneutic”.

SA: That’s an interesting area that we’re currently exploring. My colleague, Doctor Rupal Shah is driving this along with a couple of others. https://bjgp.org/content/70/699/502
Its the belief that helping patients make sense of what they’re experiencing will have a much greater impact upon their ability to make wise decisions for themselves. And one of the risks we see is that, with an ever increasing pressure to measure, to calculate, to follow a guideline, what is happening is that the time to help individual patients make sense of what they’re going through is getting squeezed out. And, because it’s getting squeezed out, patients are leaving our consulting rooms feeling frustrated, incomplete, and unhappy with their consultations. The mushrooming of guidelines, of protocols, of a need to complete templates, and to measure everything, also means that the nature of the way we educate the future workforce is also changing, because we’re having to teach people to get to grips with guidelines and apply them in clinical practice, or learn how to use computers to template data. And so we’re being taken away, I think, from an important aspect of care, which is about helping patients make sense of what they’re going through because that requires quite sophisticated capabilities, reflective practice, advanced communication skills, an understanding about the ethics of medicine. That’s why we introduced the idea that together with all those other skills, they also require an ability to help patients understand, make sense of what that individual is going through. That’s part of the journey of the writing that we’re undertaking.

DMacA: That leads us very nicely into my final question, which is about the paper you wrote in The Lancet, entitled “Different Ways of Knowing.” https://pubmed.ncbi.nlm.nih.gov/32171401/

SA: Thank you for flagging that article, that Rupal Shah and I wrote, about recognising that there are many ways of knowing that extend beyond the measurable and the observable world. Over the last 30 years health care has shifted its lens very much towards measuring and observing what goes on with the human state.

But, actually, there are other ways of knowing as well. There are personal, ethical and aesthetic ways of knowing that exist that we continue to use in clinical practice. For example, someone said to me the other day ‘I actually hardly ever use guidelines in my clinical practice because what I sense from my patients is that they need something else.’ And so that space to be creative with a patient and think differently about what solutions look like requires clinicians to step above and beyond the guideline and seek information that is also biographical, not just biomedical. For me, reinstating the value and importance of different ways of knowing beyond the biomedical is really important.

I think we do also need to acknowledge that that body of thinking actually originated in the 1940s and 1950s in the United States (CARPERS WAYS OF KNOWING) and it originated from nursing. We have a lot to learn from professions outside of medicine about the nature of knowledge, the nature of knowing, and how we then help people through their journeys in life.

DMacA: I love that idea of the biographical, and that really applies to you, because you’ve really broken the mould of our conception of what the GP academic is. It’s been fascinating chatting to. Thank you very much indeed.

Sanjiv Ahluwalia

Sanjiv grew up in London and studied medicine at Guys and St Thomas’ Medical School. He qualified in 1994 and completed his GP training in Barnet in 2000. Sanjiv became involved in postgraduate medical training in 2002, initially as a Training Programme Director. Over the next 20 years he undertook a range of roles – his last role being Regional Postgraduate Dean for London.

Sanjiv is Head of School of Medicine at Anglia Ruskin University since 2022. He is also a practising GP in a surgery in Barnet in North London. He chairs the Primary Care Commissioning Committee for MSE ICB where he is also an associate NED. Sanjiv has several achievements to his name. He became a member of the RCGP in 2000 with a distinction in his membership exams. His research has focused on the relationship between GP education and patient care. He was also heavily involved in the development of community based educational networks (latterly known as
training hubs).

More recently, Sanjiv has led the graduation of the first medical students at ARU and has led the development of the first medical apprenticeship in the UK. Sanjiv has played a role in supporting a multi-professional approach in education and workforce development supporting nursing placements in primary care, extending scope for pharmacists, and implementing new roles such as GP assistants.

Sanjiv became a fellow of the RCGP in 2014 and has been a Clinical Associate Professor at UCL since 2020. He is a member of Medical Schools Council.

In his spare time, he likes to spend time walking with his lovely dog Albie, collects and restores vintage fountain pens, and enjoys visits to European cities.

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.