“Not everything that is faced can be changed, but nothing can be changed until it is faced” [1]. James Baldwin, the Black American writer and civil-rights essayist, captures why the truth about healthcare is heavy — and clarifying.
Those of us in clinical and organisational leadership are used to carrying targets, safety metrics and workforce crises. It is tempting to believe that if we just work harder within the system, we can fix it.
But some truths sit upstream of any dashboard. They are about who our systems were designed around, whose risks are considered acceptable, and whose lives are quietly treated as less valuable. Facing those truths is uncomfortable. It might also be the most important leadership work we do.
The comforting story of “the good doctor”
Medicine trains us to see ourselves as good people doing our best in a difficult world. When things go wrong, we look first to individual failings or resource gaps. The system may be “stressed”, but rarely is it described as unjust.
Global health colleagues have challenged that story for years. They remind us that health systems — including our own — were built through empire, slavery, industrialisation and racial capitalism. The benefits and harms of those histories were not evenly distributed, and they still aren’t.
If you work in the NHS or another well-resourced system in the global North, you work in what some scholars call the imperial core: countries that have long benefited from global extraction and still hold disproportionate power over capital, data and knowledge.
That does not make us villains. But it means our systems are not neutral. They reflect decisions in which some groups have always had more protection and more room for error. Leaders who cling to the “good doctor” story — we are doing our best, leave the politics at the door — risk guarding the status quo.
Listening as a leadership act, not a soft skill
One of the most radical things we can do as leaders is to change who we listen to, and what we treat as “real” knowledge.
Patients, families, nurses, porters, reception staff, junior doctors, migrant colleagues, Black and Brown staff who are routinely overlooked or disciplined more harshly — none are voiceless. They are often unheard.
Global health scholar, Seye Abimbola, describes the “foreign gaze” in academic publishing: work written to impress distant gatekeepers rather than serve the communities being described. A similar gaze shows up in leadership. We make decisions shaped by regulators, reputational risk and political optics, rather than by the lived analysis of those most exposed to harm.
Listening as an ethical practice means:
- Treating repeated patterns of harm — such as disproportionate disciplinary action or worse outcomes — as system messages, not anomalies.
- Believing people the first time they tell us what the system is doing to them, even when it unsettles our sense of fairness.
This is not about “hearing all perspectives equally”. It is about weighting the voices of those historically ignored.
Using privilege without re-centring ourselves
For many of us, the word privilege still triggers a defensive reflex: I work hard. I’m exhausted.
But privilege in healthcare leadership is not about ease. It is about how the system responds to us.
Leaders are more likely to be believed, given the benefit of the doubt, and able to shape agendas. We hold access to rooms, budgets and journals others do not.
The question is not guilt. The question is: what do we do with the power we already have?
In a recent BMJ Global Health editorial, Mark Shrime calls for “prioritarian scholarship” — work that deliberately centres those who are worst off. Leadership can borrow that lens.
Prioritarian leadership would mean:
- Designing decision-making around those most affected. If you change outpatient access, are service users genuinely present — or only their data?
- Shaping metrics that reveal structural harm. Overall improvement can mask widening inequities. A prioritarian lens asks first: what is happening to those at the sharpest edge?
- Taking more personal risk so others can take less. Speaking up about racism or bullying carries different consequences for a junior migrant nurse than for a medical director. Leaders can choose to absorb the fallout.
This is not heroism. It is simply using the insulation we already have to create more safety for those who don’t.
What this means for leadership culture
If we take seriously the idea that we are leading from the imperial core, a few implications follow.
First, we must stop pretending health systems are merely technical machines. They are moral and political projects. Decisions about who waits, who gets seen and who is believed are value-laden, even when wrapped in neutral language.
Second, we need to be honest about how our own careers have been supported by structures that disadvantage others. Many of us trained in institutions easier to access if you were wealthy, white or already connected. Our publication records may owe as much to precarious colleagues’ labour as to our own brilliance. Facing this is not self-flagellation; it is part of redistributing opportunity.
Finally, we must move from statements to practice. Most organisations now have EDI strategies. Fewer have:
- Transparent equity-stratified data — discussed at the highest level.
- Governance structures that give real power, including budget and veto, to staff networks and community representatives.
These are not optional extras. They are core competencies in a world where patients and staff are increasingly unwilling to accept polite inequality as the price of care.
The heavy, beautiful work
The truth about our systems is heavy. It implicates us. It asks us to see that we are not simply rescuers in a broken world, but also beneficiaries of arrangements that harm others.
But there is beauty in that clarity. Once we understand the forces shaping our institutions, we gain new freedom to act differently within them.
Leaders in the imperial core cannot undo centuries of extraction, racism and exploitation. But we can decide what we normalise. We can decide whose voices are amplified, whose risks are reduced, and whose flourishing becomes the measure of success.
That is the invitation: to move beyond being “good doctors” in unjust systems, and instead to become honest, accountable collaborators in changing the conditions that make injustice feel inevitable.
The truth is heavy. Leadership is choosing to carry it — and then doing something with it.
REFERENCES
- James Baldwin, “As Much Truth as One Can Bear,” The New York Times Book Review, 14 January 1962
Author
Dr. Guddi Singh
Guddi is a consultant paediatrician and PhD candidate at King’s College London, researching leadership, health systems and justice. Her work focuses on how values, power and inequality shape care, and how clinicians can lead for more equitable, compassionate systems.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.