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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 December 8; 335(7631): 1213.
PMCID: PMC2128654
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Please can we have some courageous leadership

David M Lewis, general practitioner, Severn Valley Medical Practice, Worcester

Before I became an NHS general practitioner I had an enjoyable 20 year career as a medical officer in the Royal Air Force. I feel privileged to have experienced these two very different working environments.

In the RAF I learnt about the military concept of leadership. Since joining the NHS I have heard this word used a lot. At the age of 30, proud to be a newly promoted squadron leader, I found myself in my first senior medical officer (SMO) post. This was not through any special ability on my part; leadership still comes young in the British military. I had worked with some impressive role models, but there was no particular training for the SMO role. At last I was “The Boss”—I “had my own train-set.” I took command of a joint RAF/army medical centre in Northern Ireland, when things were still quite ugly there. I felt enthusiastic and energetic.

My first steps were faltering. The RAF medical branch has always been forward thinking and was an early adopter of the concepts of protocols and guidelines. In my gaucheness, I realised that being an SMO could be easy. I simply had to condense all of my ideas into written protocols and guidelines. I tapped away at my keyboard with unalloyed excitement. After a few months, I had assembled quite a few protocols and guidelines. My early experiences of this experiment were reinforcing. When something went wrong in my medical centre, I discovered that the miscreant had not followed the appropriate protocol, and my superiors accepted this as a valid excuse. The young medical assistant was punished and there was tacit approval of my polished administrative skills (for a doctor, that is).

My medical centre was singing along. One day a new medical assistant, 18 years old, was posted in. Later I grew to respect her as a solid performer and an old head on young shoulders. The practice manager put her through her “induction programme” (I had written the protocol). She looked a bit distracted and bewildered. I suspect that her mum had cried when told she was posted to troubled Northern Ireland, just as mine had. At one point, she was sat down in the staff room and a folder labelled “Protocols & Guidelines” was thrust into her hands. I noticed that this folder had grown into something slightly larger than War and Peace. I watched, obscured by various members of the team on their coffee break. The practice manager said: “These are the Boss’s protocols and guidelines,” and raised his right eyebrow. Diligently, the newcomer thumbed through protocols 1-8, reading intently. Then she threw back her head and yawned, a long deep yawn. She skimmed through protocols 9-20, and then closed the book. She didn’t look at protocols 21-80 at all.

The next day I sneaked into the medical centre early and put the “Protocols & Guidelines” folder in the bin. I had reflected and realised this was cowardly leadership. Instead, I summoned my courage and went to the commanding officer, who was a rather fierce helicopter pilot. I suggested that we should close the medical centre for half a day every week for staff training (except to emergencies, of course). I had to defend my corner on this. I explained that my staff were, in the main, quite young and inexperienced, and had a lot to learn. With his reluctant approval I introduced this immediately. Together as a team, we talked about many things: emergency situations that frightened us. Together we walked through various scenarios. I was proud of that team. In every medical centre I commanded subsequently, I insisted on a weekly half-day of team training.

A few years later, I was SMO elsewhere when something went wrong again. I squared my shoulders and apologised to the commanding officer. I told him this was my fault; I hadn’t trained my team well enough. I even politely refused to name the individual who had committed the error. I felt even more proud that day. I had learnt courageous leadership!

I often think of this during my work as an NHS GP. I am deluged by advice, protocols, and guidelines. They tumble forth from the National Institute for Health and Clinical Excellence, eGuidelines, National Service Frameworks, our primary care trust, the Department of Health, the BMA, our local hospital, the Choose and Book administrator, the “Joint Societies,” and uncle Tom Cobley. I have no hope of reading even 10% of it. I have never met a colleague who has looked me in the eye and asserted he or she keeps up with it. Electronic communication has compounded the problem. “Vital” guidance, badly written in impenetrable English, can be despatched to a thousand addressees with the twitch of a terminal phalanx. From my own experience, I recognise it for what it is: cowardly leadership. The courageous leader not only writes down the wisdom, but accepts responsibility for its assimilation and implementation. Please can we have some courageous leadership?

The courageous leader not only writes down the wisdom, but accepts responsibility for its assimilation and implementation

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