Thursday, 28 April 2011

Nurture in the NHS

Last weekend, prompted by the news that graduate medical students would not be eligible for student loans,  I got involved in an interesting Twitter discussion about the relative merits of entering medicine as a postgraduate.

Some people found that having done a first degree, they were better equipped to deal with the pressures and challenges of being a doctor. Maturity was certainly one of the prevailing themes, and there were suggestions that people with more life experience than your average 24 year old make better doctors. This in itself is contentious, and I’m sure that we have all met both ends of the spectrum: children wise beyond their years, and grown ups for whom maturity is what happens to cheese and wine.

This is not what I really want to discuss today. Instead, I would like to focus on what this discussion made me think about the way we nurture our junior doctors in the NHS today.  

The first realisation I had, was that even though I was just 24 when I qualified, having gone straight to medical school, foregoing the opportunity to teach in Africa, I have always enjoyed dealing with graduate medical students and junior doctors. My standard line has always been that with graduate students and doctors, one can focus on the technical aspects of being doctor without having to instill in them the fundamentals of responsibility and professionalism. It has always been my working assumption that having the right attitude at work is something that everyone should just have. In fact, my views have sometimes been as polarised as stating that you either have it or you don’t - it can’t be taught. Nonsense.

Have you ever had a moment when you looked at yourself and thought that you must be someone else? Well that’s what I had. It struck me that among this debate on Twitter, and the attitudes that I took to work with me everyday, was the in-built assumption that when you turned up for work as a doctor, you were expected to be a polished product; that we don’t nurture our young doctors in the way that we should, but rather expect them to be as ‘grown up’ as we are, and to have the insights and maturity that we have.

What made this realisation so personal for me was the memory of a year I spent at one hospital that almost persuaded me to leave medicine completely. Everyday at that hospital was a grind against mediocrity - I was frequently embarrassed to be working there, given the quality of care on offer to patients. Needless to say, I initially tried to change things, but was soon worn down. One of the important lessons for me during that year, was the understanding that there were massive limitations to my approach to medicine and working in a hospital, but I entered that place with ideas, and energy, and all I needed was a little guidance, and a little bit of encouragement. What I got was confrontation and belittlement. Now I know that a lot of that was me, but what I needed at that time was for someone to understand that I was still a work in progress, but that I had potential, and with the right nudging, I would be able to do some good. I’m glad I stuck it out, because in the two years since then, I have received exactly that type of help.

So it has been important for me to realise that my stated preference for working with older junior doctors means that I sometimes forget an important lesson that I should have learned well by now: becoming a doctor can be challenging and stressful, and we only really know what we are going to be like when we start doing it. No one is perfect when they start out, and no one is perfect when they finish, but the challenge for all of us is to help each other get better and better. It doesn’t matter if your house officer has never seen a dead body, or doesn’t have much life experience, because if they work on a firm that allows them to grow and to reflect meaningfully on their experiences, then they will learn from both their failures and their successes. However, this kind of growth is really hard for anyone to go through if they are always having to pretend to be experienced and in control.  

I still think that it is a shame that graduate students will find it harder to study medicine, but what this whole discussion has made me realise is that the culture of the NHS that I know does not recognise that we have a responsibility to nurture our younger colleagues. I hope you will join me in challenging this, by giving junior doctors the space to air their concerns and thoughts, and the support they need to address their strengths and shortcomings with honesty.

Thursday, 21 April 2011

Tell me your name

Having just returned to clinical medicine from a year out on a clinical leadership programme, I have been interested to know what impact, if any, it would have on my experiences and effectiveness as a clinician.

For me the test I have been waiting for has been the acute medical take. As many of you will know, being the medical registrar on call can be a hateful job. Traditionally, I have opined that all routes to disaster arrive at the feet of the medical registrar. The NHS is bad at using the resource of the medical Spr effectively, and at times, I have found myself simultaneously sorting out problems on the obstetric and gynaecology ward, surgical and orthopaedic wards, while all the time trying to run the acute medical take, and providing telephone advice to local GPs. An on call shift in a DGH is one of the most testing experiences one can have, and for the 3 years I have been a registrar, this has been my life for 1 in 6 days and weekends.

At times, the pressure has been huge, and frequently, I have found myself tearing apart at the seams, wondering how I could feel so qualified, and yet at the same time feel so neglected and abused. Such pressure inevitably tells, and although with experience I have been able to identify my triggers better, and manage the pressures more effectively, I have often wondered how we could have arrived at a situation where a doctor is given so much responsibility, and yet offered so little support and guidance. That in itself tells a whole story about the NHS.

One of the unexpected benefits of the Darzi Fellowship was the amount of time spent exploring ourselves. Now I know how that sounds. But imagine being given the chance to understand better how you operate, and how that impacts on other people. Imagine being given the tools to understand issues about yourself that impact on your abilities as a professional and as a person, and imagine being shown how simple it can be to wrestle control over your experiences at work. This is what happened to me, and I never quite believed it could be that simple until I tried it out on call.

This learning is now tried and tested, and what I have learned is blindingly simple. So simple in fact that I am a little embarrassed I didn’t learn it before; but no matter, I am happy to share it with you here.

One of the things I have learned this year is the importance of personal connections, and one of the things I have always loathed about being a medical registrar is that people are happy to overload you with clinical problems (sometimes of their own making) but they are rarely happy to introduce themselves by name, and they are never keen to know yours, unless it is to document in a patient’s notes that you have told them something that they do not agree with.

On my first couple of on call shifts, I did something very simple: every time I dealt with someone new, I introduced myself and asked them what their name was. By lunch time, I was on first name terms with virtually everyone in A and E, and by supper time, we were riffing our way through the medical take.

It is a sad thing when one realises that an impersonal way of working has become the norm. But it is really simple to counter, and it takes no time to sort out. I really enjoyed pausing for a moment to connect with all of these new people that I met, and I think that it made us work better together. It doesn’t really matter what the protocol says, or how the policy is written, it is personal connections that make the world go round, and we ignore that at our peril.

So don’t be upset if you need some clinical advice from me next time I am on call, and I interupt you to find out what your name is. I think that it will help us in the long run.

Sunday, 17 April 2011

Frontline reform - a warning shot

On Thursday, I sat in a ‘teaching session’ in which the manager for the local rehabilitation service, told us how referrals to his service should happen. We work on a local stroke unit, dealing with a range of different needs and disabilities; we don’t choose who our patients are, and we don’t opt out of dealing with patients who have cognitive and physical needs that are too taxing for us. As a new member of the team, and still an outsider, I have been impressed by the professionalism and dedication with which the therapists treat all the patients, but as we sat there being talked to by this manager there were a number of things that struck me.

Many of my gripes centre around the prevailing sense he gave that in accepting our referrals, he was doing us a favour, rather than fulfilling his professional obligations to the patients; but I do not think that it helps us to dwell on this now. Everyday I experience forms of communication that could be improved, many of them by me, and this is not a problem that is easy to solve.

However, what is worth dwelling on is one of the tactics he was using to change the referral pathway for patients requiring rehab (well that’s how it came across). The line that he kept repeating was that commissioning had changed, and as a result of this, we couldn’t offer our patients as much choice as they were used to.

Let me repeat this, we were told by this manager that because of changes in commissioning arrangements, patients could no longer choose where they were treated, and had to fit in with the service that the NHS had set up for them.

‘Hang on a minute’, I thought. But being new, I didn’t confront him, but I did make sure that I went round everyone who had been in that meeting and asked them what impression this manager had left them with.

The main feelings were confusion and irritation. Most of the therapists that I spoke to were dismayed that the patient seemed to be wholly absent from his description of how the system worked, which irritated them. They were also confused about whom they should be referring to this chap’s services, as his message was contradictory and inconsistent.

But what was really telling for me is that they weren’t fooled by the smoke screen of commissioning intentions; they were all quite clear that the new system as they saw it presented no imperative to reduce patient choice. They were very quick to pick up on the idea that there were two things being confused here: a changing commissioning landscape and this managers ambition to select his patient group more carefully, to give him better outcome data, and more leverage in a competitive commissioning world.

This seemed to be an important lesson to me: the idea is that it doesn’t matter how confusing the healthcare reforms have become, or how confusing they continue to be, the patient remains at the heart of the service, and we need to be wary of the cynical opportunism that we saw on Thursday, of hiding beneath the health reforms to make changes that are both unnecessary and not in the patients' interests.

Much of the risk with the Health Bill comes with how people choose to interpret and implement it. We need to be mindful of the competing drivers that may shunt patient care and experience off the top of the list of priorities.

Wednesday, 13 April 2011

Lessons in forgiveness

Last Saturday, in glorious spring sunshine in the Lake District, I read a lovely interview about a lovely man, who plays one of my favourite TV characters: Peter Capaldi is not Malcolm Tucker in real life, but I would certainly be one of the people who would go up to him and ask him to tell me to ‘Fuck off’. In fact, it would make my year.

We all know the kind of intelligence that goes into writing a series like The Thick of It, and Armando Ianucci has been a hero of mine for some years, for being the kind of person who says the kind of things that I wished I had thought of, in a way I wish I could do. Peter Capaldi clearly fits the mould quite well: thoughtful, intelligent, and reflective.

There was one paragraph in his interview that struck me, and I think it is worth quoting it here:

"For a long time I carried this... it's not resentment, it's fear. It was a fear of not being good enough, not being Daniel, or not being Hugh Grant or not being Colin Firth. It took me years to realise it was me bringing that stuff to the table – that when I would get into a situation if I was working with people, I'd blame them. Once I realised that it was a great eye-opener." When did that happen? "Probably not until I was about 40.

Brilliant. Honest. In many ways, it reminds me of what I have been going through this year on the Darzi Fellowship: at intervals, I have been invited to understand some startlingly uncomfortable things about myself, and although it has been hard, it has been hugely empowering and rewarding.  Realising something about yourself that has been evident for years, but somehow hidden from you is both frustrating and uplifting: frustrating that it took you so long to work it out, uplifting that you have gained the insight to do something about it.

And this brings me closer to the point that I want to make today: what Peter Capaldi shows us is that if we choose to, we can learn important lessons throughout out entire lives. We do not necessarily reach a point where we have become the people we are - in fact, who we are is always subject to revision.

I thought of this today, when I caught up late in the afternoon on my Twitter feed (being back on the wards in a hospital with poor mobile reception means that I lag behind Twitter-time now), and caught umpteen references to the vote about Lansley and the reception he got from the Royal College of Nursing.

Now I am many things, but I am not a Tory apologist, and I do not like the healthcare reforms one bit, but I was a little shocked about what I was reading. The nature of the dialogue struck me as trying to exclude meaningful debate. However much concern we have that the listening exercise is a sham, it seems shameful not to engage. What I read told me one thing only: we do not wish to engage in dialogue with the government on where to go with the health reforms.

I would be surpised if this is what the men and women who voted were trying to achieve, but think about where this puts Andrew Lansley: he has realised over the last few weeks, that he has failed spectacularly to convince both the public and the healthcare profession of the need to reform healthcare along the lines of his vision. Whether through integrity or cynicism, he has embarked on a listening exercise, which for us is an opportunity, but when presented with the opportunity to put their views across, he is told that we have no confidence in him. This is not about the RCN - if the BMA was ballsy enough, I’m sure that he would have heard exactly the same.  

But what has this to do with Peter Capaldi? Well, given the nature of the discussion that we are having with Lansley, do you think we are giving him the space and the opportunity to become a better health minister? Are we giving him the space and opportunity to actually listen, or are we drawing a line in the sand, and digging our trenches on one side? One may well argue that this is a fight that he started, but healthcare is something that we care deeply about, and if we discuss what to do about it in the language of confrontation, then it is confrontation that we will have.

Peter Capaldi learned something really important about himself: that his failures were down, in part, to assumptions that he had made about the world, and these assumptions impacted negatively on the impression he created on other people. Whatever Andrew Lansley has done, we bring a lot of ourselves into the debate about healthcare reforms, and it is not always helpful. Whatever the grounds for cynicism, we need to fight it, because no honest and heartfelt debate about healthcare can happen if we are all cynical and belligerent.

Thursday, 7 April 2011

The importance of narrative

So my word of the month has been ‘narrative’. This is wholly derived from Paul Corrigan, with whom I am in danger of developing a twitter crush. There is probably a term to describe the disconnect between the sense in which I feel I know him from his blogging, and the sense in which I don’t know him at all, but I do not know what it is. I suspect this is a thoroughly modern and no doubt unremarkable admission to be making to you.

But the wonder of the modern age is that he has been able to reach me, and teach me something new. I have always understood the importance of language, and often revel in the intellectual masturbation of seeing how ‘eloquent’ I can make a sentence. This is some idiosyncratic measure of complexity of a sentence coupled with unusual turn of phrase.

However, it is Paul Corrigan who has introduced me to the importance of narrative, with the personal learning for me being that a sentence, paragraph or whole document does not stand alone: it only makes sense in terms of what has been said before, and what comes after. And this is crucial.

Of course, Paul is concerned mainly with thinking about the Health Bill at the moment, and this is a good example. The listening exercise can be currently understood in terms of  the government’s need to redress the nature of the dialogue being used about the Bill. They probably believe that the Bill addresses some very real problems with the Health Service, but the nature of the debate recently has only addressed what is wrong with it, and not what it right with it. My personal views on this are not relevant to this current debate, as the point that Paul Corrigan has been making with clarity and consistency for the last few weeks is that the government has lost control of the narrative, and in those circumstances it doesn’t matter what they say, they are never going to be able to get their point across. For example, if everyone is saying ‘there is nothing good in the Health Bill, and the government just wants to privatise the health service’ and the government says ‘we are not privatising the health service, we are just making it more responsive to the patients needs’, no one is going to believe them. However, if the prevailing discussion says something more along the lines of ‘we are not sure what problems the health bill is solving?’ there is still an issue with communication, but it is feasible for the government to say ‘The health bill helps us make the health service more responsive to the needs of the patient by doing x, y and z’, they have some chance of getting their message across.

If the narrative exists on a substrate of distrust, then meaningful dialogue is impossible. The listening exercise is designed to address this prevailing feeling.

And now I have ‘narrative’ on the brain, I am seeing it everywhere. I am doing some revision for some public health exams in June, and the issue of narrative cropped up when I was thinking about environmental risk assessment, and how the evidence shows that the public view risks very differently to the people who assess risks for a living, such as doctors or policy makers. A good example of the difference was seen in the MMR story, where the risk from autism from having the vaccine was more salient than the risk of measles, mumps or rubella from not having the vaccine. Again, the narrative was key here: while we were hearing that the the MMR had been linked with autism, the only response that was being heard from the medical profession was that it isn’t, and in the context of the willingness to believe that the vaccine could be linked with autism, it was impossible to hear any other message getting through.

So my learning this week, is that the content of the message is important, but life is much more complicated than that. One truth that has coming sailing home for me in recent months, is that we have to be cleverer than that if we have a message, and the timing and delivery of any message needs to be judged in the context of the environment and culture in which it is being given. If we imagine for a moment that truth is subjective (and this is not a consistent belief of mine) then we have also to accept that this truth needs to be acknowledged, whether or not, in an empirical sense, it is true. If you are faced with a mother who believes that MMR will harm her child, how can you persuade her it won’t? It certainly won’t be enough to tell her.

If the public believes that the NHS is being cut, it certainly won’t help to tell them that it is not. If the medical profession believes that the Health Bill will be bad for patient care, then the narrative needs to demonstrate how it won’t be.

So having understood this point, all I have to do now is work out how to deal with it. More on that later.

Tuesday, 5 April 2011

Forging new relationships in a messed up world

On Friday, I attended a conference organised by a group of this year’s Darzi Fellows in Clinical Leadership at the Kings Fund; one of the themes of the day was to encourage collaborative working between doctors and managers, and the target audience for this message was a small group of junior doctors, and importantly, an enthusiastic and talented group of graduate management trainees.

There was a strong buzz throughout the day, and workshop groups in the afternoon had some honest and interactive discussions about what unites managers and doctors, and what divides them. I guess the key thing for many people that afternoon, was a clear crystallisation of the idea that there are many more things that unite doctors and managers than divide them, and that at the heart of this, there is a genuine ambition by many people, wherever they work, to provide good patient care. The message from the managers was loud and clear - you do not have to directly deliver patient care for this to be your driving force, and doctors do not have a monopoly on caring.

This experience was overwhelmingly positive, but the day also invited some honest reflection: we can all tell horror stories of the way people have treated us at work, but there was something deeply insidious about the kinds of stories that managers were telling about the way consultants had treated them in the past. It’s not that they were rude (although they clearly were). It’s more that encased in the narrative was the sense that doctors were not just acting out of a sense of professional frustration or indignation, but rather, they were motivated by the sense that, beyond their clinical expertise, the day to day issues with delivering a decent health service were someone else’s problem.

Now these are my words, and this is my interpretation of what managers said on Friday tagged on to my experience of the type of interactions that I have seen pass on countless occasions between consultants and managers.

So the optimism needs to be tempered. And it was tempered even further following a chat with a particularly grounded friend of mine who is a talented orthopaedic surgeon.Her particular gift is her ability to make other people eat their bullshit for breakfast. As I was recounting my experiences of the conference on Friday, she ‘real world-ed me’ and reminded me of how far relationships between managers and clinical staff in some places have broken down, and backed up this sentiment with example after example. While she demonstrated a clear bias, in that in each case the managers were at ‘fault’, her point was well made: the relationship between managers and doctors in many places is poisoned and poisonous, and finding one’s way back from this is going to be difficult in many cases and impossible in others.

But who said it was going to be easy? While it is usually useful to have a well timed reality check, Friday’s conference good precisely because it illustrated a way through this mess. There is no likelihood of all managers and doctors liking each other and wanting to work together, but there is the possibility that some managers and some doctors want to do it, and this was demonstrated on Friday. The slow, steady march to a better healthcare system can begin with connections being forged between managers and doctors who are interested in collaborative working. This won’t be everyone, and there may well be very few to begin with. But once these alliances start to yield results, and once the language of collaboration, rather than confrontation starts to be heard more in hospital corridors, it is possible that some cultural shifts may begin to emerge.

One of the points that I know resonated with a number of people on Friday was when Bruce Keogh remarked that he had only ever achieved success when he was supported by an able manager. He used the term ‘fighting pairs’ and this seemed to strike a chord with many people in the room.

The message they went away with is that they don’t have to change everyone, they just have to connect with someone. If we each find one person from ‘the other side’ in the hospital we work with to connect with, then who knows how much could change.

Cost controls in the new NHS

At a recent event I went to at the Kings Fund, Al Mulley, the Director for Health Care Delivery Science at Dartmouth College made two points that caught my attention.

The first was that the Health Bill does not answer the key challenge that faces healthcare systems around the world, namely that of allocative efficiency. The second point he made was that the method of delivery of healthcare does not matter, what matters is how that system influences the decision making of the professionals who deliver the healthcare. These are related points, but they are worth dealing with in turn.

The principle of allocative efficiency is a relatively simple one: it is a statement that the use of resources is at a level of efficiency which means that you cannot increase one person’s level of benefit (or utility) without decreasing another’s. That is, the system is getting the biggest bang for its buck. Now Al Mulley is suggesting that whatever Lansley’s reasons are for introducing the health bill, they are not going to make the service more efficient in distributing its resources. He didn’t state his reasons for this belief (at least not that I recall) but this viewpoint made me wonder therefore, how do the reforms of the Health Bill seek to control costs?

The answer would seem to be that this becomes the responsibility of GPs; after all, if costs are to be contained, then it will be the work of the people who control most of the budget to make this happen, and we all know who that is. GPs therefore, have been recruited to control costs, but this automatically leads to a second question: how are GPs qualified to control budgets and limiting expenditure?

My answer is that they appear to be amply qualified - afterall, the skill set of the GP is about managing patients over the long term, and living with uncertainty. The perspective of the GP is that the majority of people are OK, and any nasty disease process will reveal itself through a process of watchful waiting. This compares starkly with the viewpoint of hospital physicians, who only see the subset of patients who have become acutely unwell, or have been selected out by the GPs, and therefore investigate and manage their patients aggressively (and expensively).

The two ends of this spectrum translate into two different attitudes to dealing with patients: the watchful waiting of the GP and the aggressive investigation of the hospital physician. This is, of course, a caricature, but bear with me, because we now come on to Al Mulley’s second point which is that what really defines a health system is the decision making that results from the doctors working within it.

My argument today, is that by devolving the budget for healthcare to GPs, we have created a healthcare system that will instill in its doctors the attitude of fiscal control by waiting for pathology to reveal itself. With GPs holding the ring on budgets, the clearest way to maintain financial control is to reduce referral rates. This is a much simpler mechanism than instituting new care pathways to manage chronic disease, and does not rely on the perpetuation of expensive acute hospital trusts. The provision of acute and elective services can be left open to market forces, and will not rely on maintaining the number of acute trusts that we currently have: private organisations will provide most routine care, and the high risk stuff will that no one wants to do will be mopped up by centrally-funded, regional centres. This however, will be worth it, because two thirds of NHS money is spent on staff, and as soon as market forces apply, wage pressures develop.

We all know that market forces are good at controlling costs, but they are not good at delivering equitable health care. The losers in these systems are the sick, the poor and the under educated, and what chance do they have of being heard?

The goal therefore, is not a patient-focused health care service, but a cost-controlled one, and it is possible, just possible that Andrew Lansley has hit upon a brilliantly simple and effective means of carrying this out, and it is not his voters who are likely to lose out from it.

Leadership and Followership - my thoughts

In Spring 2007, I was working as a registrar at a teaching hospital in North West London. Tellingly, this was my first registrar job, and having got an old fashioned training number, I was feeling pretty smug about having avoided the looming fiasco of MTAS. This was not, however, how everyone else in the hospital felt: daily life was taken over by discussing how to navigate the system, and morale had imploded in the face of the realisation that SHOs no longer had the opportunity to try out different specialties by applying for a range of different 6 month posts. There was a real sense that choice and autonomy had been undermined, and it wasn’t clear to anyone that all of this would result in a better overall training experience. I remember having a look at the forum on, and seeing page after page of bitter and scathing diatribe outlining the concordant views of numerous junior doctors, voicing their disdain for the changes to medical training and the application process.

I also remember one lunch time being charged with leading a SHO teaching session on some geriatric issue (I can’t remember whether I was talking to them about falls or dementia or incontinence, but then that’s not really the point of this story): as I came in, conversation revolved around MTAS and its impact on them. Sensing that this was a more popular topic to talk about than the one that I had prepared, I asked the assembled SHOs what actions they had taken to address their concerns. Silence. Nothing.

This was a powerful moment for me: in a room of 10 or so SHOs, at one of London’s most famous teaching hospitals, not one of the talented and intelligent SHOs had had the wherewithal to write to their MP, to email their BMA rep, to discuss their concerns with the educational lead in the hospital, to write to their local newspaper or to write to their favourite national paper. All of their intellectual effort had been directed towards the moaning that they did with each other. Many of them had contributed to the forum on, but that was as focused as their efforts got. I was disappointed, but not surprised that this was the response to the question that I asked, because as a junior doctor I was already well familiar with the prevailing attitudes that circulated among junior doctors in London. I had the sense at the time that their was a prevailing mood that doctors were not really players in the politics of healthcare, certainly not at a junior doctor level. In many ways, it was an extension of the viewpoint that one often hears from junior doctors (in fact, I remember saying it myself), that if they weren’t slumming it in the NHS they would be earning fortunes in the city.  It was my perception at the time, that many were disbelieving of the affront of the government to meddle with junior doctor training programmes, when they were donating their time and effort to the cause of the NHS. The idea that doctors are not public servants, but are pro bono professionals who are donating their skill and time when it could be put to more profitable use elsewhere is an insidious and dangerous viewpoint. But it only captures part of the point.

I was reminded of the story I give above by Paul Corrigan’s excellent blog on the need for followership as well as leadership ( in the BMA. This made me recall a recent conversation with one house officer; I asked him what leadership was. He replied that leadership was getting people to agree with you and then getting them to follow you. Now this particular doctor was one of the current crop of junior doctors who has shown an applied interest in leadership development, by attending relevant programmes, getting involved in quality improvement projects, and showing a great deal of entrepreneurialism in creating changes within a hospital environment. My assumption with such doctors has always been that they are the more enlightened ones, and yet this was a tellingly self-centred approach to leadership and change agency. Since that day, I have been on the lookout for this kind of attitude, and it’s a bit like looking out for tardive dyskinesia on the tube - once you are aware of it, you see it everywhere. And this was just the kind of attitude that Paul Corrigan alluded to in his blog, and represents a challenge for those interested in medical leadership: the goal is not just to create
leaders amongst junior doctors, but to also instill the idea, that doctors do not always need to be at the front of the cavalry charge, but rather that sometimes, the most powerful form of leadership can be to follow someone else’s good idea. Much of the talk that I hear directed towards junior doctors and their role of leadership revolves around how talented they are, and how much insight and expertise they have to offer the system. I have myself bought into this idea, and until recently honestly believed that the NHS was lucky to have me. But this attitude deserves challenge - as members of this health service which puts equity at its heart, all doctors should recognise that we are lucky to be able to work in a health system that allows us to practice in such a financially unfettered way. Few of us know what it is like to have clinical decisions ruled by financial imperatives. With such freedoms, comes the responsibility to play our part in creating success in our organisations. At times, this might involve us driving change, and at others, it might involve us following change. This needs to be emphasised.