Healthcare professionals would benefit from more investment in leadership programmes that enable them to directly see and understand how the upper layers of the NHS function. My experience as a Darzi Fellow helped me realise that cultivating the next generation of clinical leaders is essential if the NHS is to survive present and future challenges. The Darzi Fellowship is unlike any of my previous NHS roles. From the outset, I was invited to senior management meetings and allowed to observe how they dealt with resolving challenges whilst facing pressure from staff and grappling with the effects of funding decisions made at government level.
Darzi Fellowships were established in 2009 to cultivate future clinical leaders from multi-professional backgrounds. The 12-month fellowship involves undertaking a bespoke PgCert Leadership in Health alongside a “challenge” to develop a fellow’s leadership knowledge and skills through undertaking an improvement initiative under the mentorship of a senior clinical leader. I became a Darzi Fellow in September 2024; my challenge involves improving retention and wellbeing of SAS doctors and consultants within a London NHS trust.
A paradigm shift in thinking
The combination of academic (PgCert) and practical (challenge work) of learning how to become an effective future clinical leader has catalysed a paradigm shift in how I view organisations as large and diverse as the NHS and the challenges it faces. Through working on several projects associated with my challenge, I gained a clearer understanding of the differing obstacles frontline clinicians and medical leaders face in trying to ensure our health service survives one of the most turbulent periods since its founding.
A rare opportunity to observe and understand
The Darzi Fellowship gives me the opportunity to observe, analyse and comprehend the complexity of problems affecting the NHS – a rare position in which to be considering the typically hectic nature of clinical work. I have the freedom to understand and the chance to think creatively about how to undertake my challenge work. I am also in a privileged and psychologically safe position that enables me to ask probing questions of senior leaders, whilst remaining outside the hierarchy and not worrying about whether raising thorny issues will negatively affect my career. Many of us probably know a colleague whose honest attempts to raise concerns about an issue adversely affecting patient care or staff wellbeing was either met with a wall of silence or resulted in some form of backlash. Moreover, the NHS has a poor track record when it comes to treating whistleblowers fairly. As one example, the case of Dr Chris Day comes to mind. Despite recent endeavours to encourage a culture of openness and an announcement by the Department of Health and Social Care that NHS managers who muzzle whistleblowers face losing their jobs, we still have a long way to go to create a culture of transparency.
As a Darzi Fellow I am also developing the skill of asking powerful questions, which Vogt, Brown and Isaacs describe as those that are thought provoking, welcome creative thinking and new possibilities, or stimulate a reflective dialogue. This may include enquiring why the Trust does things in a certain way and querying the rationale behind the culture whilst suggesting alternate ways of doing things that could lead to better outcomes from the point of view of doctors’ wellbeing, retention, and career development. I am also fortunate that my Darzi mentor is a supportive, approachable, and encouraging senior medical leader who recently became the Trust’s Chief Medical Officer.
Understanding systems leadership
I now understand the importance of creating networks both vertically, horizontally, and across organisations, as Goss describes in Systems Leadership: A view from the bridge. My challenge work involves working with frontline doctors and senior leaders within my trust, as well as colleagues in another trust (or a combination of these). Learning to navigate multiple stakeholders, and knowing when, how and where to push, is a skill I began learning when leading multi-disciplinary teams as a clinician, and which I have honed further as a Darzi Fellow.
I also developed a broader view of how organisations operate. Goss notes “As with all systems, the more of it you can see, the more likely you are to understand the linkages and connections”. She further explains that junior staff struggle to comprehend how their entire system functions by lacking access to the ‘balcony view’ reserved for senior managers. In their book The Practice of Adaptive Leadership, Heifetz, Grashow and Linsky explain how diagnosing a system requires moving from the dance floor to the balcony as the distance allows you to see what is happening from a different vantage point, one which provides a broader view of the terrain. A combination of perspectives from multiple viewpoints gives clarity to an organisation’s inner workings and challenges. (Alongside my fellowship, I continue working clinically one day a week to ensure I also get a view of the dancefloor). Such valuable insights are not typically offered through traditional training pathways. Even when I worked as an acting consultant (in a different trust) I had a limited understanding of how decisions affecting frontline staff were made behind the scenes. In this regard, a few months as a Darzi Fellow has proven more illuminating than a decade as a clinician. Goss notes that staff who lack access to the ‘balcony view’ available to senior managers struggle to comprehend how the system functions in its entirety.
Tackling ‘wicked’ problems
A remit as broad as improving retention and wellbeing across a large trust has no simple solution. I have learnt to be more patient as diagnosing and responding to the dynamic nature of an intricate system seems more complex than treating individual patients. Some systems cannot be cured – longstanding problems cannot be surmounted merely by sufficient resources or will. This is an example of what Grint describes as a ‘wicked’ problem, namely those lacking ideal answers or which can only be solved through a patchwork of inelegant solutions. Grappling more effectively with a ‘wicked problem’ requires deep understanding of an organisation’s culture and the ability to consider and craft imperfect solutions in real time. Unlike clinical practice where we strive for perfection, there may be no gold standard treatment for large organisations.
Recommendations and future direction
I believe it is important for healthcare professionals interested in developing leadership skills to have the chance to view their organisation from the balcony, whilst being mentored
by senior leaders. Arguably, senior leaders may also benefit from spending more time on the ‘dance floor’ to better understand the challenges on the frontline. Knowing how both frontline clinicians and senior leaders operate is key to resolving the challenges each group faces, and thus being able to understand and diffuse tensions between both groups. Unfortunately, with budget cuts affecting the NHS, the Darzi Fellowship will not be funded next year. Other healthcare leadership programmes doubtless face similar fates. (It is also necessary to improve the evaluation of such programmes which has hitherto been of low quality). Leaders are not born ready, they develop and come into their own with the right support. The NHS needs a new generation of leaders to succeed those currently in post. Without programmes to foster these, or at the very least a culture that enables meaningful leadership development for those who feel confined to ‘the dancefloor’, who will be left at the rudder?
Acknowledgements
Thank you to Dr RM who is involved in teaching the PgCert at LSBU kindly looked through an early draft of this article and provided feedback
Author
Dr Tomasz Pierscionek
Tomasz is an SAS doctor (psychiatry) and Darzi Fellow at West London NHS Trust
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.