Posts Tagged ‘Leadership’

Leadership in the NHS: leaving the comfort zone

By Bob Mathers - 28th February 2010 1:29 pm

As classical scholars know, the god of the doorway is Januarius. At his annual reappearance, most of us begin to look to the year ahead with renewed optimism and ambition.

We are infected by a touching desire to take charge of our co-workers. But no sooner are we back at work than the door of reality slams in our face. Power struggles reignite and the sausage factory mentality reasserts itself.

Even if we’re hard enough to survive, it won’t make us better leaders. As Lily Tomlin said: “The trouble with the rat race is that even if you win, you’re still a rat.” What is it about leadership that is so perennially fascinating, enticing and difficult? If you Google the word, you’ll get at least 1.7 gazillion references.

In the film running through our heads, leadership features as an activity beyond the grasp of mere mortals. It usually stars guys like Gandhi, Churchill or Kennedy. It’s an aspiration, not an occupation. In real life, the likelihood is that we will have worked under many more bad leaders than good ones. A bad leader is a ‘loser’. They will have lost any plot that was going, our loyalty and respect and most opportunities to have achieved anything worthwhile. So how do we tackle it?

Let’s first separate ‘leadership behaviour’ from the idea of leader. We are all capable of behaving like a leader because we work mainly within our comfort zone. This gives us the sure-footedness and confidence to fuel those resolutions each year.

We know the territory and have experience to fall back on. Behaviours might be:

•     communicating to create a bond and describe a better future i.e. vision;

•     encouraging others to perform beyond their previous best i.e. motivation;

•     subtly directing people through difficulties or crises without getting too involved yourself i.e. influence.

Leadership behaviour is related to the jobs we do. But the world changes and pushes us every day. In accepting the consequences we sometimes have to leave our comfort zone and operate from positions of less certainty. Are there clues? Look at any leader we respect, to whom we give ready allegiance, who shows us a good example. They have an integrity which inspires us to follow them.

Study their kind of ordinary, day-to-day, low-key leadership style. Chances are it will involve:

•        Trust (do others believe what I tell them?);

•        Purpose (is there a point or a value to this?);

•        Communicating (can I describe this vision?);

•        Responsibility (am I right to get involved and take this on?); and

•        Risk-taking (have I spent enough time thinking about this?).

The challenge of leadership is not always about ‘big’ or ‘important’. It’s more about continuity, holding things together. Every doctor is a potential leader - of individuals, teams or services. Fulfilling the role means balancing responsibility for serving the immediate needs of patients with bringing through the next generation of practitioners.

In between is the small matter of working within the organisation - those who set out the protocols, organise the resources, pay the salaries and so on. That’s the real challenge, not the status and position of the comfort-zoned day job.

This is the first article in a three-part series on leadership.

Bob Mathers provides non-clinical training for health professionals. Email him on bobmathers@btinternet.com.

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The clinical director’s survival guide

By Katherine Teale - 10th December 2009 1:12 pm

Being a clinical director is like being the manager of the England Football Team (minus the huge pay packet) - everyone thinks they could do a better job until they find themselves in the hot seat. 

Having been a clinical director for two years now, these are some of the hard lessons I’ve learned. 

The first thing to remember is that it’s your fault - even if you weren’t in the hospital. Get used to saying sorry.

Learn the four essential rules of email:

1. To avoid extra apologising (see above) always check your facts thoroughly before sending an angry email. Better still, don’t send angry emails.

2. Never say anything in an email that you wouldn’t mind everyone in the hospital reading - because there’s a fair chance that they will.

3. The chance of an email achieving its purpose is inversely proportional to the number of people copied in. Some things are best discussed face-to-face. The only emails not copied in to 50 other people are thanking you for something which has gone well (very rare). Emails pointing out some gross failure on your part are always copied into half the hospital.

4. To avoid email overload, some emails may safely be deleted immediately - these include any which contain the words “it’s unacceptable” (translation “ I  personally don’t like it but can’t actually come up with any coherent reasons”), or “it’s a disaster waiting to happen” (ditto), or any mention of the word “status” (they’ve obviously lost the plot completely). 

Then comes mobile phone etiquette. If answering calls on the rare occasions when you’re not at work, always say you’re “off-site”. Never admit to being “at home” - clinical directors aren’t supposed to have them - nor is being “on holiday” considered an acceptable excuse for being uncontactable. Try to give the impression that you’re at an important meeting at PCT headquarters. 

Learn to accept that it’s virtually impossible to change other peoples’ behaviour, however irrational. You can only change your reaction to it. The following responses, though tempting, are not recommended: screaming, weeping, physical assault, or any combination of the above. The only sure-fire way of persuading colleagues to change their behaviour (i.e. holding a gun to the head) is unfortunately frowned on by HR.

Be grateful that you still do your day-job at least part of the time, and so have a get-out clause. Giving anaesthetics is great - I know what I’m doing (more or less), get instant results, and people are occasionally grateful. How different from the daily grind of the full-time manager, who has no relief from the tyranny of meetings, angry emails and conflicting targets.

Overall I’ve learned that most colleagues, from support workers to consultants and managers, are decent, hardworking folk who try their best most of the time. When people behave in an apparently irrational way, it is not (always) simply to annoy you, but generally due to some underlying problem which is nothing whatever to do with the matter in hand. Understanding this can save you a lot of aggravation. 

Finally, there are two areas of personal development which are essential to the survival of all successful clinical directors: firstly, a good sense of humour; and, secondly, friends outside work. You’ll need both in spades.

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Us women have nothing to lose but our guilt

By Katherine Teale - 19th October 2009 10:43 am

I am sitting in Costa enjoying a quick cappuccino and doing what I do best - feeling guilty. I’m feeling guilty because it’s 4pm on a workday and I’m not at work. And I’m feeling guilty because I’m not with my daughter.

The fact is that being a female doctor is all about feeling guilty. Apparently we’re a ‘demographic time bomb’ because we all want to go part-time, added to which we don’t go into clinical leadership roles, and we reduce the standing of the profession. If I find this all a bit hard to take, it’s some consolation to know that I’m not alone (although that’s part of the problem, obviously) - medicine is now full of guilt-ridden women. 

Medical school intake is now 56% female, up from 24% in 1961. We were discussing this during my orthopaedic list this week (percentage of female surgeons in theatre 0%). I have to admit it doesn’t seem obvious to me why I should be responsible for reducing the status of medicine more than, say, Harold Shipman.

In my experience, medicine has become a much pleasanter profession to work in as the proportion of women has increased. When I started anaesthetics, in 1988, only two of the 12 trainees were female. In theatres, there were separate changing rooms for the female and male theatre staff, a palatially proportioned facility for the male doctors, but no changing room at all for the women doctors. 

The two of us had to use the cleaners’ changing room, which was the size of a small cupboard. Now, trusts are even having to provide special rooms for female doctors to express breast milk!

As to being part-time, I have to confess that when I first came back from maternity leave I worked a three-day week. But over the years it’s gradually crept back up to full time, mainly because of my pathetic inability to say “no”. I would be the first to admit there is a problem with part-time work and it’s this: once you’ve experienced life with less work, it becomes addictive. The less you do, the less you want to do.

Where once the odd half day off seemed like an unimaginable luxury, soon a four day week becomes an intolerable imposition on your time, and three days a week is only barely acceptable. I think the best arrangement would be to work just sufficient hours to break up the routine of lunches, tennis matches, manicures and whatever else non-working mothers fill their day with - perhaps about 15 hours a week.

Surely it’s not beyond the wit of the manpower (womanpower?) planners to factor all this in. We would still earn more than most of the population, and with current levels of unemployment the more jobs there are to go round the better.

So male doctors are going to find themselves in the minority - the good news for them is that there will always be plenty of jobs available in the fields to which they are perhaps more naturally suited (plumbing, car maintenance, etc).

Meanwhile, I’m going to stop feeling guilty every time I steal half an hour for myself, practise saying “no” when the trust piles on more work, and dream about the day when the poor old men have to get changed in the cleaning cupboard.

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Breaking down the barriers to female medical leadership

By Mike Broad - 16th October 2009 6:12 pm

A new report, called Women Doctors: Making a Difference, identifies the barriers preventing female doctors from reaching senior positions and sets out how to address them.

It’s been produced by the National Working Group on Women in Medicine, which was set up in the wake of the Chief Medical Officer’s annual report in 2006. Sir Liam Donaldson’s report identified a shortage of women in leadership roles in the medical profession despite outnumbering men as medical undergraduates.

Donaldson expressed support for the report’s recommendations and said the Department of Health would consider each of them. Here’s a summary of the key recommendations:

1. Improve access to mentoring and career advice

In the next round of contract negotiation there should be an explicit facility for appropriately trained and skilled doctors (usually consultants) to undertake mentoring or career counselling as a programmed activity within their job plan.

To facilitate accessing mentoring or career management support, the future commissioners of medical education should maintain a register of all doctors who are skilled and are willing to undertake these tasks and make it more accessible to other doctors.

2. Encouraging women in leadership

Appointments to NHS, academic and clinical committees and boards should be advertised widely and have a transparent and democratic process rather than simply an appointment by nomination.

Committees should be encouraged to develop their ways of working to enable greater participation by doctors who are parents or carers.

There should be increased access for women to the committees and boards of major medical institutions, including the medical schools, postgraduate deaneries, medical royal colleges, NHS trusts and other NHS bodies. The Equality and Human Rights Commission should consider auditing the appointments process for all such posts.

3. Improve access to part-time working and flexible training

The postgraduate deaneries should maintain a list of doctors wishing to train part time in a slot‑share arrangement.

NHS Employers should develop guidance for meeting the costs of continuing professional development, including for those who are working less than full time.

The development of credentialling should be expedited, and there should be full recognition by the medical Royal Colleges that time alone does not indicate competence to practise independently.

The aspirational quota for part-time training should be abandoned in favour of a needs-assessed availability by strategic health authorities (SHAs). The newly formed Centre for Workforce Intelligence should be commissioned by each SHA to provide this needs assessment on a regional basis, and provision should be made to meet it.

4. Ensure that the arrangements for revalidation are clear and explicit

The GMC and the appropriate medical royal colleges should ensure that they have a clear set of re-licensing and recertification standards and assessment processes in place for doctors who have taken time out of training or the profession to return to work.

Responsible officers should coordinate refresher training for those who have taken time out of training to meet these standards. There should be funding for this within the NHS budget.

Trusts should offer ‘back-to-work’ and ‘taster’ sessions where those who have taken a career break can shadow working doctors to re-familiarise the doctor with procedures and work patterns, so that they are confident on return.

5. Women should be encouraged to apply for the Clinical Excellence Awards

The Advisory Committee for Clinical Excellence Awards (ACCEA) should provide greater feedback to applicants and advice as to where additional development might be necessary, and develop a network of mentors.

Selection panels should be gender balanced wherever possible; due consideration should be given to part time applicants, and ACCEA’s processes should be monitored for gender equality.

6. Ensure that the medical workforce planning apparatus takes account of the increasing number of women in the medical profession

NHS Medical Education England (NHS MEE) and the Centre for Workforce Intelligence should ensure that workforce models for the future clearly delineate the effect of a rising number of women in the workforce so that appropriate advice for the workforce planning apparatus can be given.

7. Improve access to childcare

The Conference of Postgraduate Medical Deans and the Department of Health should consider whether the model such as that in place in the North Western Deanery, which commissions a lead employer for all specialty trainees in the deanery, would be a practical and desirable model in the new education commissioner/provider landscape. The additional benefit of better facilitating access to government assistance for maternity benefits and childcare of this model is clear.

Postgraduate deaneries or their lead employers should plan ahead for the childcare needs of their trainees and facilitate arrangements between a trainee and the trusts during their rotation for access to childcare provision.

Trusts should appoint a childcare coordinator within their human resources department if they have not yet done so. Childcare coordinators should develop internet resources to act as both an information resource and message boards on local childcare options, including emergency cover.

Hospital-based childcare should move to extended opening hours.

The DoH should explore the costs and benefits of doctors who are parents paying for full-time or part-time childcare as a value-for-money solution for enabling doctors to progress their careers. On the basis of this analysis the DoH should submit a case to the Treasury to allow doctors to pay for childcare from their gross earnings. In addition, it should establish whether any central funding might be available for childcare assistance.

8. Improve support for carers

All postgraduate deaneries or their nominated lead employers and NHS trusts should have a lead person responsible for supporting carers.

9. Strenuous efforts should be made to ensure that these recommendations are enacted through the identification of champions

Trusts should identify a non-executive director to have responsibility at a local level for improving working patterns, giving advice and handling complaints. The director should work closely with a lead consultant for workforce planning.

Read the full report.

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Women need more support to become leaders

By Mike Broad - 14th October 2009 4:11 pm

The career prospects of women doctors would be significantly improved by better access to part-time training and child care, a report claims.

The report, called Women Doctors: Making a Difference, identifies the barriers preventing female doctors from reaching senior positions and sets out how to address them.

To improve access to part-time working, it urges deaneries to maintain a list of doctors wishing to train part-time in slot share arrangements, and for strategic health authorities to drop quotas and base provision on needs assessment.

And, controversially, it calls for the development of credentialing - or training modules - to be speeded up.

To improve childcare provision, the report calls for all trusts to appoint childcare coordinators to improve the information and options available to doctors. 

Another factor highlighted is the lack of mentoring and career advice for female doctors. A programmed activity should potentially be made available within the consultant contract for senior doctors to provide mentoring and counselling, it recommends.

The report, by the CMO’s National Working Group on Women in Medicine, also calls for a clear set of standards and assessment processes for revalidating women who have taken time out of training or the profession. It also urges more women to apply for Clinical Excellence Awards.

Baroness Deech, chair of the working group, said that with more women entering the profession than men it was time to look at the “obstacles to the full exercise of every doctor’s potential”.

She said: “Our report focuses very much on the implementation of change. In order to achieve continuity of patient care and the best use of every doctor, the reforms must be tackled.”

Commenting on the report, chair of the BMA’s equal opportunities committee, Professor Bhupinder Sandhu, said: “We’ve come a long way in the last decade and that is extremely positive but our journey is by no means over.

“Women doctors are still often left behind and this is apparent in academia, surgery and leadership roles. Young female doctors need role models so that they can see that it is possible to be a successful doctor and have a family.

“While the report makes specific recommendations, there also needs to be a change of attitude and culture to enable female doctors to reach their full potential in medicine. This change of attitude is important among female and male doctors.”

CMO Sir Liam Donaldson expressed support for the report’s recommendations and said the Department of Health would consider each of them. He identified a shortage of women in leadership roles in the profession in his 2006 annual report and set up the working group.

Professor Jane Dacre, chair of the Royal College of Physicians’ women and medicine working group, said: “Women should be encouraged to take on leadership roles and medical workforce planning must be responsive to the greater proportion of female doctors coming into the profession and their preferences for different styles of working.”

Read the full report.

Read our feature: Will women have what it takes to lead the profession?

Read more on credentialing.  

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Will women have what it takes to lead the profession?

By Mike Broad - 18th June 2009 2:54 pm

There’s much to celebrate on the advancement of women within the medical profession.

It wasn’t so long ago that women faced considerable, and at times seemingly insurmountable, barriers to both entering the profession and advancing. Now they’re afforded the same career opportunities as men and, research suggests, there are no delays to career progression if they work full-time.

There are, however, potential implications for women becoming the majority of doctors within 10 years, as predicted by the Royal College of Physicians’ report Women and medicine: the future. Many more doctors will want career breaks, to work part time, and work within certain specialties. For starters, it will demand more consultants and for NHS work to be organised differently. The NHS needs to take note and plan for it.

There’s less to celebrate when it comes to developing the next generation of medical and academic leaders. Paradoxically, we could find that as the proportion of women increases the leadership talent pool dries up.

It was a salient point made by Professor Dame Carol Black back in 2004 but quickly became lost in the media frenzy. Female dominated professions have a tendency to lose their influence. 

But, let’s be clear about what level of leadership we’re talking about.

There should be no shortage of leaders at clinical service levels. With the investment in the NHS, the prospects for a woman to achieve a consultant post are high.

They form the majority of entrants now embarking on specialist training in the majority of specialties. And women already represent 47% of the very small number of early appointed UK-trained consultants aged between 30 and 34, according to the Royal College of Physicians’ report.

Furthermore, a paper by Oxford’s UK Medical Careers Research Group suggests that women doctors who work full-time have similar career progression to men, even if they’ve had children. This contrasts sharply with other professions such as law or accountancy.

Working part-time is clearly compatible with holding an NHS consultant post in many specialties. And, what’s more, the overall numbers of male doctors are also increasing so there should be plenty of leadership candidates at a local, clinical level.   

The real problem lies with elite roles, such as clinical and medical directors, presidents of royal colleges and leading societies, medical school and deanery leads, even chief executives.

Data is thin apparently but what does exist suggests at these rarified levels women are in short supply.

Women and medicine: the future suggests that women are in the minority on royal college councils, and there is yet to be a female president of a royal surgical college. In 2007, only 12% of all clinical professors on university contracts were women. In 2006, six medical schools had no female professors. And just two out of 34 medical school deans were women.

The picture is no better in primary care with very few women chairing the professional executive committees of PCTs.

It’s in part due to a legacy of male dominance – with women accounting for less than 20% of the entire pool of consultants over 55.

But, it’s also due to the requirements of getting into that elite role. Landing one of these jobs is difficult. It demands single-minded determination and involves long work hours, either attending many meetings and events, or building up a portfolio of research in addition to clinical responsibilities, or both. It’s not for those who want to spend a lot of time with their family.

Unless current trends change, women doctors will continue to work part-time in large numbers; take more time off than male counterparts and focus on particular specialties.

The report suggests that it’s unlikely that most women will make it to the top in proportion to their increased entry into the profession. Senior echelons will be made up of ‘best of the rest’ and the quality of leadership - both medically and academically - could be compromised.  

But, Professor Bhupinder Sandhu, co-chair of the BMA’s equal opportunities committee, disagrees. She doesn’t believe there will be a shortage of female leaders in future and the trends that have seen a dramatic rise in female leadership in her health community in Bristol will play out across the country.

She believes that the quality of leadership among recent luminaries has been high – and points to the Department of Health’s Professor Sally Davies, Professor Parveen Kumar, co-author of Clinical Medicine and former BMA president, Dame Deirdre Hine, chairman of the RSM, and Professor Shelia Hollis, Professor Dame Janet Husband and Professor Dame Carol Black, all former presidents of royal colleges.

“Many other potential women leaders already exist but are held back by the culture and ethos that has historically existed. This is slowly changing and will continue to do so,” she says.

A working group convened by Chief Medical Officer Sir Liam Donaldson, and chaired by Baroness Ruth Deech, to discuss problems faced by women in medicine is due to report before the end of the year. It’s anticipated that it will provide a range of recommendations to improve the availability of part-time training and working, and encouraging leadership development.  

Dr Helen Goodyear, president of the Medical Women’s Federation, believes women doctors need more encouragement to put themselves forward for leadership roles.

She says: “Role models are few and there will be a need for mentorship as well as resolution of the gender pay gap for women to succeed in these areas.”

 

RCP report’s recommendations for accommodating more female doctors  

1. The organisational implications of changing workforce patterns and preferences with respect to working hours and specialty choices should be urgently examined so that the effective delivery and continuity of patient care is not compromised.

2. The economic impact of changing work patterns and their interaction with policy initiatives already under way needs to be evaluated.

3. Critical information gaps must be filled with some urgency to gain timely, rigorous and systematic insights into the implications of the new workforce trends.

4. The scope and detailed coverage of workforce planning needs to be extended and its analytic methods upgraded to take full account of the demographic shifts now under way.

5. Individual doctors at each stage in their career - and especially at the point of selecting their preferred specialty - should be provided with far more extensive information, guidance, and feedback on their career choices and aspirations.

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NHS needs to prepare for more female doctors

By Mike Broad - 3rd June 2009 10:02 am

Women will become the majority of doctors within ten years presenting current challenges for workforce planning, Royal College of Physicians’ research shows.

The RCP’s two-year review, examining the changing gender balance in medicine, reveals that women are more likely to work part-time and focus on particular specialties.

A 15-year follow up of doctors after graduation suggests that, on average, taking into account career breaks and part-time working, women prove 60% of a full time equivalent doctor against 80% for men.

Women also prefer specialist fields that offer more predictable working hours and a relatively greater amount of patient interaction.

Women currently make up 40% of all doctors, representing 42% of GPs and 28% of consultants. On present trends, women will make up the majority of GPs by 2013 and the majority of the medical work force some time after 2017.

However, only 8% of consultant surgeons are women.

While women already account for 47% of UK-trained consultants aged 30 to 34, there are also very few women doctors on NHS trust boards as medical directors. In 2006, none of the six medical schools had female professors and just two of 34 medical school deans were women.

Professor Jane Dacre, chair of the working group, said: “This research has shown that women doctors will soon be in the majority and are now reaching consultant status in greater numbers. It is likely to lead to an increase in part-time working. Also, women on average make different specialty choices from men.

“The combination of these changes in the medical workforce will need to be examined to ensure the continued delivery of high quality care, and the best use of the considerable talent available in today’s medical profession.”

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Masters degree in medical leadership launched

By Mike Broad - 28th May 2009 4:14 pm

A new masters degree in medical leadership has been launched for aspiring clinical and medical directors, and chief executives.

The degree, run by the Royal College of Physicians, Birkbeck College and the London School of Hygiene and Tropical Medicine, has been designed to specifically meet the needs of medical practitioners.

It aims to give senior doctors an appreciation of organisational management and leadership. The MSc consists of nine modules, which can be completed in two years.

Professor Ian Gilmore, president of the RCP, said: “The responsibility for planning and transforming the delivery of health services for a large organisation is a complex one, and one in which doctors should be fully involved.

“With this in mind we have developed this programme to help prepare the next generation of medical leaders, and encourage doctors from a wide variety of backgrounds to apply.”

Applicants need to enrol by the end of July 2009.

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Coming to terms with being a consultant

By Dr Anita Houghton - 26th May 2009 12:20 pm

NHS consultants are no strangers to change, so the implementation of the 48 hour week should not come as any great shock to the system. After all, we’ve handled regular restructurings, wholesale changes in the way out-patient appointments are booked, skill-sharing with other professions, less junior support and more on call, to name but a few.

And yet, how often do we reflect on the effects of all this change on our day to day working? How often do we stop and think about how we’ve adapted over the years, and how often do we try to anticipate what a new development is going to require of us personally?

Looking back, it’s interesting to ponder on what the changes have meant for the average hospital consultant; and here you find some paradoxes. On the one hand, consultants are encouraged more and more to contribute to the management of their service, simply maintaining a good clinical service is not enough. On the other hand, consultants arguably have less authority than ever before. Ask a consultant ten, fifteen years ago who their line manager was and they would probably have laughed at you. And that’s only the ones who knew what ‘line manager’ actually meant. More recently appointed consultants are quite accustomed to seeing one of their colleagues as their boss.

In clinical work there has been a trend away from independent working towards team work, and not only medical teamwork, but multidisciplinary team work. Yet, for the most part, the buck for clinical decisions still stops at the consultant. Because of changes in clinical training, and because juniors work fewer hours, they do less and less of the low level tasks. This means that consultants, while managing more at the top end, are also clerking patients and ordering investigations. More paradoxes.

The way consultants are expected to relate to patients has also changed. The expression ‘person-centred’ may have as many meanings as the people who use it, but one thing is certain - it is no longer enough simply to provide a scientifically sound diagnosis and treatment.

So the modern NHS consultant needs to be not only different from the old version, but considerably more. If you have been a consultant in both the old and the new orders, how have you coped with these changes in expectation? Have you moved easily with the times, adapting your style, and if so, what changes have you made, specifically?

Alternatively, have you dug your heels in, or drawn a circle around yourself within which you hope to continue operating in the way you always have? Whichever route you have taken, and most people will have struck some kind of a balance between the two extremes, how has that been for you? 

One thing that doesn’t seem to have changed at all is the expectation that doctors think of themselves as tough people who, in all circumstances, cope. But change is difficult, and if kindness and support in that change is not forthcoming from the system, then doctors have to provide that for themselves. If you have been in the system for a while, operating in a way that seems to be required of you, it’s very tough to find yourself suddenly in the wrong.

Give yourself a little compassion. And if you are managing someone like that, try to understand that their rigidity and lack of cooperation is purely a defence. Underneath that defence lies a repository of sadness for what has been lost, and fear of what is to come. These feelings need to be dealt with before anyone can change.

The next article in this series on management will examine what is required of a modern NHS consultant. 

Anita Houghton provides career and management coaching for doctors and other professionals, and is author of Finding Square Holes, a self-help book for career development, available at www.workinglives.co.uk/articles.htm 

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MMC reasoning reveals need for new leadership

By Lindsay Cooke, co-chair of Remedy - 25th May 2009 10:53 am

Remedy has been handed the outcome of a Freedom of Information request made by a junior doctor in January 2007, just as MMC/MTAS was about to go thermo-nuclear.

Disclosure was furiously resisted by the DoH and reading the email exchange - which is detailed on the Remedy website - one can see why.

They reveal that MMC had as little to do with improving doctor training and patient care as I have with lap-dancing.

It was a dumbing down exercise designed to impose a job culture on a profession, flush out some of the ‘awkward squad’ (senior SHOs who might not be sufficiently biddable for the government’s taste) and - and what an ‘and’ - open the door to a sub consultant grade which would ultimately allow for the culling through natural wastage of potentially the most vocal and powerful awkward squad of all - consultants. That’s my analysis, by the way, and I write this in a personal capacity. Call me paranoid if you like, but it’s not paranoia if they’re really out to get you.

So, what now? The government has succeeded in replacing an organic, evolutionary training system with something unproven and deeply unpopular.

It would appear that your institutions either colluded or were hoodwinked. The elephant is not just in the room but is monopolising the sofa and has cornered the remote control. You’ve been shafted, and grassroots doctors are catching the flak every day in tick box training, rota gaps, insecurity, general demoralisation - never mind WTD coming over the horizon at a gallop.

I’ve spent enough time with doctors in the last two years to know that you see yourselves as special and different. I think you are too. You’re the best and the brightest, and it should not be beyond you to take a long, hard, collective look at the professional, economic, political and social realities you now face, take a deep breath, scream if you need to, and then start coming up with some positive proposals - if only for the benefit of the poor bloody infantry of this process, the patients. I’m one of them which is why I have the temerity to deliver this ’Mummy lecture’ as my children call it when I go off on one. I’d trust you lot over any politician, and so would over 90% of the population.

Remedy can’t and shouldn’t lead this process - indeed, the only kind of leadership I’ll have any truck with is ‘leadership with’ not ‘leadership over’. It can, however, act as honest broker. Arguably, it’s the only organisation that can as it’s the only organisation untainted by MMC.

The challenge for the profession is whether your ivory tower dwellers or those with their heads buried in the sand will have the humility to accept the invitation - and if they do not, whether a new leadership, of ideas and values, creativity and commitment to a great tradition of public service, will emerge.

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