Coalition?

As I write this it has been less than two weeks since the UK General Election. I’m still trying to work out who ‘won’. Without being overly political, this has got me thinking. It seemed to me that the result of the election, with no one having a clear majority, presented our political leaders with an opportunity. It was an opportunity to be bold. An opportunity for each leader to say to the other  “We can’t do this on our own, and you can’t do it your own. What say we work together?” 

 

The alliance between the Conservative Party and the DUP is exactly this, but I think missed an opportunity for the larger, main parties to work together for the good of the country as a whole. We are left with a country divide by two-party politics. Parliament is instead set up for confrontational ‘us and them’ debate and the risk of arguments rather than agreements about how to work jointly for the betterment of the people of the UK.

 

This led me to reflect upon the unhelpful ‘us and them’ dynamic that has arisen in some places between commissioners and providers in the NHS. The wider system has pitted us against each other, with our respective regulators insisting upon financial controls totals being met that result in winners and losers. I blogged about this last year when I compared our negotiating to a ‘Title Fight’. (https://drjongriffiths.wordpress.com/2016/09/16/title-fight/) 

 

For some time I have been saying that this is not a helpful approach. It is clear that neither of us can fix the NHS system wide problems on our own. We have to work together. 

 

Our local system is one of a few across the country that is part of the Capped Expenditure Process (CEP). You can read a news report about the CEP here: http://www.bbc.co.uk/news/health-40190597. There is much I could say about the CEP, and hope to be doing so over the coming weeks and months. Not everything is positive. There are, however, some things about the CEP which have resulted in better conversations. One of the fundamental principles underlying the CEP is that we have to all ‘own’ the problem. We collectively need to acknowledge that the amount of money we have to provide care for our population is all that we have, and then together determine how we live within that fixed resource. It is no longer good enough for the hospital to be content if they have balanced their books while the CCG runs into deficit. Instead we are all responsible for achieving financial balance across the system.  

 

What we need locally is a coalition. We need to come together, work together, plan together. We need to put aside our differences and together ensure we are providing the best possible care for the people of the area. This cannot be about organisations looking after themselves, it has to be about organisations looking after the patients. There is no place for one-upmanship. There is no place for individual or organisation protectionism. We simply cannot afford that. If we are to continue to provide the services that the people of our area deserve then we have to put all of this aside and together work out what we need to do.  

 

In Westminster we now appear be led by a coming together of two political parties. Locally in Central Cheshire our health care leadership now needs to consist of a coming together of commissioners and providers across the system. These ideas are not new. I have been blogging about them for a long time. The CEP does seem to have changed things though. It has changed the approach of the regulators, who are now speaking with one voice and giving a consistent message to all parts of the system, and I hope it is beginning to bring about a greater understanding and acceptance between individuals and organisations that their own part of the system is not the only part to be looking out for.

 

Dr Jonathan is a GP in Swanlow Practice in Winsford, Cheshire, and Clinical Chair of NHS Vale ROyal Clinical Commissioning Group.

Follow Jonathan on Twitter @DrJonGriffiths

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You’ve got to be in it to win it

You’ve got to be in it to win it

General Practice is under pressure. I have said this before, as have many others. Just within the last couple of weeks there have been news headlines criticising GP receptionists and leaked letters implying that struggling practices might be allowed to ‘wither and die’. On social media I see GPs venting their frustrations, expressing their concern about where they see things heading and clearly articulating their stress about the job they still love, and yet which is driving them to burn out. As a practising GP I see this. I see the long hours, the increased demands upon us, the lack of resource and I feel the stress. It is not difficult to see how this has arisen. General Practice has been underfunded relative to hospital care in recent years, as has Community Services and Mental Health. At the same time there has been a gradual shift of work that was traditionally undertaken in hospitals moving out into General Practice. Much of this is great for patients – closer to home and with the local GP who knows you. Unfortunately the money has not followed the patient, and GPs have added these extra bits of work to existing services, which are now straining and in danger of collapse. In addition it is widely accepted that demand continues to rise. With this as the backdrop, there are currently talks about service reconfiguration led out over larger geographies, under the remit of Sustainability and Transformation Plans. I have seen lots of GPs expressing dissatisfaction with the STP process, commenting in particular that STPs have no statutory status and no political mandate. I wouldn’t disagree.

I think there are two ways you can respond to this situation. You can be either pessimistic or opportunistic. My fear is that it is easy to be pessimistic and angry. I’m not saying that there is nothing to be pessimistic or angry about, but I would like to question if this is the right approach. 

In my experience, shouting about something doesn’t always get you the outcome you are looking for. It might make you feel better for a while, it might get someone to back off for a while, but in the long term you probably haven’t gained much. There is also the danger that you might ‘cut off your nose to spite your face’. When you are angry and pessimistic, it’s hard to lift your head up and see the opportunities. You can find yourself in a place where you can’t see the wood for the STP trees. Where are you on this?

I think we need to ensure we have the right balance. 

Is there a need to express concern and dissatisfaction, to lobby and protest against things we feel are wrong, or are being ‘done to us’? Absolutely. There are various lobby and supportive groups already in existence that I know of – Resilient GP, GP Survival, GP State of Emergency and possibly others that haven’t seen. These groups do this well. They are highlighting the problems being faced. Raising awareness amongst fellow GPs, the wider NHS and Central Government. They can do this because of their large numbers – they can get media air-time in a way an individual will struggle to do. They can also help individuals who are struggling. I see that in Facebook posts on Resilient GP in particular, with GPs asking for advice and support with difficulties they are facing, essentially crowd-sourcing solutions.

My view of these forums then, is that their existence is good, and helpful. I make a point of reading through the social media posts regularly. I have, however, become slightly concerned that they have become a place of increasing negativity. I understand why, and many I am sure would say ‘for good reason’! The problem with this, however, is as I mentioned earlier- we are in danger of missing out. More than this, we are in danger of fuelling disagreements between GPs and the organisations that seek to represent us and our views. In one recent FaceBook post I could read (in a public forum) about disagreements about whether the Royal College of General Practice was appropriate to represent our views, seemingly pitting them against the Local Medical Committees. I can’t see how this is helpful. I would suggest that both would provide excellent input, and would not wish to suggest that one was more qualified that the other – they have different and complimentary roles. 

Whether you like the existence of STPs or not, they are here, and I would suggest you disengage at your peril. A similar thing happened with the Health and Social Care Act. Lots of people were angry about this, and spent a lot of energy protesting against it. It is still here. I wonder what could have been accomplished had that energy been directed to working with the system rather than against it? 

STPs have large geographies, and it can be hard to feel part of something as large as, for example, the whole of Cheshire and Mersey (our ‘local’ STP is the 2nd largest in the country). What is becoming clear though, is that the majority ‘work’ of the STP will be delivered in local areas. For me, this means that our STP is divided into 3 Local Delivery Systems (LDS), and I am in the Cheshire and Wirral LDS which is further subdivided into 4 local integration programmes, mine being the Central Cheshire Connecting Care programme. This I now start to recognise. Within Central Cheshire we have five Care Communities, and I am sat firmly in Team Winsford. I know what’s going on in Winsford, and I know what’s going on in Connecting Care. This means that I do have a connection with the STP, and this is important. 

I have been concerned about the emphasis on acute trusts in STP planning so far. Concerned that GPs have been overlooked and disenfranchised by the process. I still have some concerns, and don’t think GPs have been properly consulted, but once I understood that our local integration programmes would be the STP plans, then I started to feel better. In fact, locally I think I can see a clear line of sight from STP to Team Winsford and our Primary Care Home. 

You have to be in it to win it, and I suspect this will be true of STPs. I suspect that if any more resources are made available to the NHS they will probably come via STPs. If we as GPs are not engaged in this, we might lose out. We can choose to shout and refuse to engage with a non-mandated process, we can be angry and protest, or we can take a moment to breathe and see what opportunities there might be here. Opportunities to do things differently- think physio first, think community matrons doing home visiting for you, think pharmacists doing your med reviews, think about making your local area an attractive place to work, somewhere you can attract GPs to. All of this could and should be part of STP planning. If we can get our community based services right, we can reduce the demand on our hospital services. This is key plank of our STP, and I’m sure will be in others.

Next time you are tempted to shout in protest about something then, my plea would be that you stop and think for a minute first. Your desire to be upset and cross may be entirely justified. What is happening may not seem fair, and may not be something you would have done or that you agree with. Nevertheless, it may be in your best interests to engage with it, and a constructive, appreciative enquiry, in my experience, can pay dividends. Like I said before…

You’ve got to be in it to win it.

Dr Jonathan is a GP at Swanlow Practice in Winsford, Cheshire, and Chair of NHS Vale Royal Clinical Commissioning Group


Follow him on Twitter @DrJonGriffiths

Tea and Cake

Tea and Cake

This week I will be baking cakes again for ‘Tea and Cake with Jon and Andy‘. I have been doing this for a couple of years now – putting aside an hour for any CCG staff member to come along and ask me anything. I bring cake, Andy brings his tea-pot.We do this every couple of months and it has been well received.

 

I get asked what this is about, and why I do it. There are a number of reasons.

 

To give permission to talk to me. Now, on one hand I think this is daft, because I’m telling you now that you can come and talk to me anytime, but I appreciate it’s not quite as straightforward as this. I’m not always available – I’m in surgery for 2 days every week and then have meetings filling my diary. Some days you can only really speak to me if you have scheduled the time into my calendar! The tea and cake sessions essentially do that for you. There is also something about members of staff having the confidence to go and say hello to the Chair. Again, I think I am approachable, but someone recently told their colleagues that they thought I was ‘scary’. Clearly I need to work on my approach-ability! The tea and cake sessions signal that it’s OK to come and say hello – in fact it is positively encouraged. I hope that through these sessions people will then see that I am not scary after all.This links to the next reason:

 

To make people realise I am human too. I am very happy to talk about non-work related topics in these sessions. I talk about my pastimes and hobbies, about the cakes I have made (or that my daughter has helped me make), and about anything that people want to hear about. These sessions are great as they give us a brief moment to lift our heads from the busy day and chat. I hope people can see that I am nothing special and also get a sense of who I am and what motivates me. Understanding me as I lead the organisation is important to me.

 

To give opportunity to ask awkward questions. And by this I don’t just mean questions that are difficult to answer, but also ones where there is no other forum to ask them. Meetings usually have tight agendas, and we try to stick to them – what if you want to ask something different, that perhaps only you want to know? We make it very clear that you can ask anything during a tea and cake session.

 

To say thank you. The cakes are always home made. Usually by me although sometimes my 13 year old daughter helps. People are always surprised and grateful for this. It is a little thing – but it is my way of saying thank you, and of saying that I value their work and contribution.

 

When I first started working as a junior doctor 22 years ago, my registrar used to encourage me into action after any break we had by saying,

“Come on Jonathan, it’s time to save lives and stamp out disease”

It is a line that has stayed with me throughout my career. I sometimes ask our CCG staff if they feel they are saving lives and stamping out disease, because I genuinely think that they are. It is a tough time to be an NHS manager. We don’t have enough money, and people frequently raise the issue of money being spent on managers rather than front line staff. I think this is understandable, but unfortunate, and I am not sure that people who say this really understand the value of the management taking place in CCGs.

 

I do know, because I see it, that CCG staff in Central Cheshire are hard working, dedicated and doing their best to improve the health of people locally. They talk to clinicians working at the CCG, they hear the patient stories at Governing Body and other meetings, they frequently live in the area and so are patients themselves, or have family members who are. They care passionately about the people of Central Cheshire and are working to ensure that quality healthcare is available for them. They are running projects to commission new and better pathways, they are monitoring the quality of local services, they are making sure the local hospital is paid for the work done, they are holding the trust to account for it’s performance targets.

 

They don’t get much, if any, recognition.

 

My tea and cake sessions are, in part, to recognise this. They are to say thank you, to point out that I value them, to answer any questions they have, and to hopefully inspire them to continue.

 

This blog is therefore to do the same. It is to publicly thank the CCG staff for their work, and to make sure they know they can come and eat cake with me in these sessions.

 

I could have written this blog about the front line staff working across Central Cheshire, and I hope that none of them feel I have overlooked them or missed them out – there is no slight intended. I know that they are all working hard as well, and that the people of this area are receiving the very best care. I could have written this blog about the staff I work with in practice at Swanlow. I see their hard work in clinics, admin and reception. I know they do an excellent job too.

 

This time though, this blog is about CCG staff – often forgotten and maligned, but doing essential work to ensure services are available for us all.

 

Thank you.

 

Dr Jonathan is a GP at Swanlow Practice in Winsford, Cheshire, and Chair of NHS Vale Royal Clinical Commissioning Group.

 

Follow Jonathan on Twitter @DrJonGriffiths

 

Photograph is of cakes made for the May 2016 Tea and Cake session.

Virtually Fractured Clinic

Virtually Fractured Clinic

One of the first blogs I wrote was about the relative of a friend of mine attending fracture clinic. I called the blog “Wait, wait, wait…“. In it I detail the experience of attending the clinic, the inconvenience and wasting of time encountered. Imagine my delight, therefore, when I heard that our local orthopaedic surgeons were keen to introduce a ‘Virtual Fracture Clinic’. Let me tell you about it.

Currently, if you attend A&E and they suspect you have a fracture, then you are treated and sent home with an appointment to attend fracture clinic for follow up. With the Virtual Fracture Clinic, rather than having to return for the follow up, you get a phone call from the orthopaedic doctors, who review your X-rays, ask how you are, provide advice and can often avoid the need for further attendance. Some people will need to be called back for assessment, but many not. Brilliant. This makes things so much better for patients, avoiding unnecessary attendances while maintaining the quality of the service. 

This clinic is a win-win. It’s better for patients, and it’s cheaper for the NHS. As a commissioner of a cash-strapped CCG this is music to my ears. As far as I’m concerned this clinic should be put into place immediately. 

There is a problem though. It might be a win-win, but it’s not a win-win-win. Good for patients, good for the overall NHS budget, but not good for the hospital bank balance. The clinic loses the hospital money as their are fewer out patient attendances. The hospital are the ones who can put this clinic in place, and they have so far not done so. 

This is what happens when you have a system built around individual organisations in their silos all looking out for their own organisational needs rather than the needs of the larger system. The hospital are being instructed to ensure they achieve financial sustainability, and this has become a greater driver than the need for system sustainability. This is what is playing out with our local Virtual Fracture Clinic. It is resulting in fracture lines appearing between the clinicians at the hospital and their management who appear to be blocking the development of the clinic. It is also resulting in fracture lines building between commissioners and hospital managers. 

This is a wholly unsatisfactory and unacceptable. For there to be drivers in the system that prevent the development of something that would improve the long term stability of the local health economy and, many would say even more importantly, be better for patients, then what is going on here? How can this be right? 

We need to take action. We need to push, hard, for clinics and schemes like this to be implemented. Canterbury, New Zealand chose to implement and fund any scheme that saved patient’s time. They recognised that this was a key way in which to improve and integrate their system. Locally, in Central Cheshire we seem to be a way off this.

The system needs to change. The system needs to recognise it is a system. Organisations need to recognise they are just one part of the system, and that we can achieve so much more together, but only by collectively doing the right things for patients, and the system itself. 

We have an opportunity here to do the right thing. Let’s not lose it. Let’s put aside our individual needs and put the patient first.

Fracture clinics are there to ensure healing. Let’s make this project the start of making our local health economy better.

Dr Jonathan is a GP at Swanlow Practice in Winsford, Cheshire, and Chair of NHS Vale Royal Clinical Commissioning Group.


Follow Jonathan on Twitter @DrJonGriffiths


Image courtesy of stockdevil at FreeDigitalPhotos.net

The Post Boat

The Post Boat

When I was 11 years old my family had the unexpected opportunity to have a holiday of a lifetime. Friends of ours were living in The Bahamas at the time, and we were invited to stay with them. We arranged a 10 day break during the Easter holidays. The trip would be our first and last overseas holiday as a family, and involved our first journeys by aeroplane. You can’t fly direct to Marsh Harbour where our friends lived, so we had flights from Heathrow to Nassau, and a connecting flight onwards. All very exciting.

The outward journey went well, we arrived safely and had a wonderful time. Part way through the 10 days our hosts checked with my parents about our return flight time. My mum explained that she had been rather taken with their descriptions in the past of how people sometimes used the Post Boat to hop from island to island rather than flying. We had therefore got a flight arranged back from Nassau to Heathrow, but thought we would just jump on the Post Boat for the short trip from Abaco Island back to Nassau. 

There was a stunned silence. “The post boat takes at least a week to make that journey,” we were informed. Ah. Our flight back to the UK was in less than a week. There was no way we could use the Post Boat, it was just going to take too long. To make matters worse, it soon became apparent that there were no available commercial flights either. We were stuck on the island, which me and my brother thought was great, but was somewhat stress-inducing for my parents!

It can be pretty stressful when plans fall apart. Sometimes it can be because planning has been poor, sometimes our planning was based on poor or inadequate information, and sometimes the planning might have been fine, but other circumstances beyond our control come into play.

We have known for a while that our local health economy was heading for financial difficulty. I recently blogged about that in a post I called Glass Half Empty. Our plan for some time has been to collaborate and work with local providers to integrate and transform our local system. We have known there wasn’t enough money. We have known we couldn’t carry on with the current levels of activity. We had a plan. It has become apparent that our plan is like the Post Boat – it is going to take time, and our flight is leaving now. The Post Boat still seems like the better way to do it. A better journey, a better or at least the same end point, cheaper and smoother. We’ve run out of time though.

In 1982 my parents had to charter a 6-seater plane to get us back to Nassau. The picture with this blog is of my family standing by the plane (I’m the older child). I dread to think how much that cost. It wasn’t what we wanted. It was stressful and expensive, but it was quick. There were longer-term implications I am sure in terms of our family finances. 

Our CCGs need to find the equivalent of chartering a light aircraft. We have to save money now, and our integration programme is going to take too long. We have developed a Financial Recovery Plan. It has all kinds of things in it, some of which sound really good for  both our CCG bank balance and for patients (I particularly like the idea of the Virtual Fracture Clinic), but many of the schemes are going to be about cutting or reducing services. We will have to look at how many cycles of IVF we can afford to fund. We will have to consider our prescribing, and are looking st promoting self care, and reducing prescriptions for Over The Counter medicines (in other words, please don’t ask for prescriptions for paracetamol or calpol from me, as refusal can often offend). We will have to consider referral thresholds for procedures like hip and knee replacement (so, for example, you might not be able to be referred unless your BMI is below a certain value and only if you are a non-smoker, and you might have to complete a 6 month lifestyle class first). We will have to consider all kinds of things that are unpalatable, unacceptable to some people, and certainly unpopular. 

The Kings Fund recently published a blog from Ruth Robertson about public perceptions of NHS finances. It’s worth a read and gives us an idea of how the public are likely to react to these initiatives. The key message for me is that we need to very quickly present these plans and schemes to the people of the Central Cheshire area. I believe that an informed and engaged public will understand and be tolerant of our actions. What we need to try and avoid at all costs is just cutting services without explaining why. I am disappointed that there is not a higher profile national conversation going on about this, as we are not the only area to be struggling with money. I have said before, and will say again now that I think the government and NHS England have a responsibility to be informing the public of the implications of austerity on the NHS. 

34 years ago, we missed the Post Boat. This year we are realising that the integration boat has already sailed. We still need to do the integration work but it is not going to solve our immediate financial problem. 

This blog is a warning. A warning to fellow commissioners who might still be on the Post Boat – are you sure it’s going to get you there in time? A warning to providers that the money is running out, and that drastic commissioning actions are about to be taken. And most of all, a warning to the public that NHS services as you know them are about to change. You may not like that. You may well blame me for them, and I can understand that, but the most important thing is that you understand why we are taking the actions we are. We want to do this with you, not to you, and the first step in that is letting you know what’s going on.

We’ve missed the boat, let’s make sure we all get on the same plane. 

Dr Jonathan is a GP at Swanlow Practice in Winsford, Cheshire, and Chair of NHS Vale Royal Clinical Commissioning Group.


Follow Jonathan on Twitter @DrJonGriffiths

Trust

Trust

I’m writing this on June 24th. I woke up this morning to the news that the UK had voted to leave the European Union. Anyone who follows my social media feeds will know that I voted to remain, and I am feeling pretty confused, upset and very worried about what this might mean for the future of this country. Clearly not everyone will share my views (over half the country it would seem!), and I am not sure I want to do a blog about the referendum, but one thing did occur to me that seemed worthy of comment.
Trust. 
Or rather, the lack of it.
I could not help but notice that the majority of senior politicians from all parties (with a few notable exceptions) were strongly advocating that we should remain in the European Union. In addition, leading experts in finance and economics were highlighting what they saw as the risks of a leave vote. It seemed to me that many of our elected representatives were not listened to, were not trusted. During the referendum campaign Michael Gove famously said that “the people of this country have had enough of experts”, and it would seem that this resonated, and was possibly true. This is a scary thought. That we are electing individuals to make decisions on our behalf, and then not trusting them to do that with our best interests at heart, and also that non-elected experts are not being believed. 
As a doctor I have also experienced this. Think only of the MMR vaccine – I have had patents clearly not prepared to trust my advice about its safety and benefit. I have also had many conversations with patient about changing drugs where they will not believe or trust me when I tell them  that a cheaper drug is not necessarily a worse drug.
Where there is lack of trust, things start going wrong. Where there is lack of trust we become fearful. Where there is lack of trust we pull up the drawbridge and start building walls. Where there is lack of trust we look inwards instead of out towards others.
Stephen Covey has written a book entirely about how he sees the power of trust aiding businesses, speeding up negotiations and smoothing the way for good things to happen. My job as a commissioner relies on collaboration and cross-organisational working. My job as a GP relies on collaboration and cross-organisational working. We can’t do that effectively  without trusting each other. Working on relationships and developing trust is vitally important. It is so often overlooked, and so often seen as the ‘soft and fluffy’ stuff rather than the difficult and important stuff. I once heard Chris Ham of the Kings Fund say that “The soft stuff is the hard stuff.” This is undoubtedly true, and not only is it hard, it is important. I would say that nothing is more important. 

Without trust, we struggle to build relationships. Without relationships, we struggle to do anything. 

This short blog, therefore, is about the need to build relationships, and the need to trust each other. If we instead decide to throw up walls and barricade ourselves behind them, we can look forward to a life of isolation and fear. I mentioned Stephen Covey earlier. His father wrote the very famous book 7 Habits of Highly Effective People. If you have never read it, I would recommend it. In the book Covey talks about the need to achieve independence,  but that a greater goal beyond that was interdependence. We can achieve so much more together. I’m not sure people really get that. We are so wrapped up in the need to stand up on our own two feet that we forget that there is only so much we can do as an individual, and (deliberately repeating myself) so much more we can do together.


My message today, as the UK embarks upon a new and more distant relationship with our European neighbours is that we should spend time on our relationships. That we should work on understanding each other, warts and all. And that we should work on mutual trust, because that, ultimately, is what makes things happen.

Follow Jonathan on Twitter @DrJonGriffiths

The Queen, Ernest Shackleton and Elizabeth Garrett Anderson

The Queen, Ernest Shackleton and Elizabeth Garrett Anderson

The Central Cheshire CCGs have worked with the North West Leadership Academy and AQuA to put on a Clinical Leadership Development Programme. I was fortunate enough to be asked to provide an introduction, and thought I would pull my thoughts together into a blog for you.
I started with an intro about myself and our local health issues, the financial challenge and the need for clinical leaders. I’m not going to replicate that bit here, but I then talked about three people who have recently had significant anniversaries, and considered some leadership lessons from them. From the photos, everyone recognised The Queen, a few recognised Ernest Shackleton (but all had heard of him), but only one or two recognised Elizabeth Garrett Anderson (and only they had heard of her).
The Queen



Little introduction is required. HM Queen Elizabeth II had her 90th birthday this month and must be one of the most famous people in the world. She has lived her life in the public domain more so than any previous British monarch, and the Information Age has been responsible for this.
It is worth remembering that she never thought she would be Queen. Her father was never expected to be King until his brother abdicated. Nevertheless, she did not shy from the role and took it on. This in itself bears consideration – just when you are at your lowest, grieving your father’s death, is when you are thrust into your role as Queen. She is unable to have anything significant happen to herself or her family without it being splashed across the world’s media. Just think on that for a moment – if your children’s marriage breaks down, or if your daughter-in-law tragically dies in a road traffic accident, how do you manage that? You manage it in relative obscurity, you can deal with it as you choose, quietly if you prefer. The Queen has no such choice. In fact, you will probably remember the criticism she received following the death of Diana. 
When you lead, you open yourself up. When you lead, you will be subject to criticism. 
Something else. By my count The Queen has undertaken at least 114 international state visits during her 64 years on the throne. That’s a lot of small talk. It’s a lot of smiling, shaking hands, waving and talking about the weather. I think it’s a lot more than just small talk though. It’s about representing your country, advocating, smoothing things over, relationship building and relationship maintenance. These are all essential attributes of leaders. You need to spend time collaborating and working with others. External networking is key. I think the Queen is probably pretty good at that. 
I will move on now, but first leaving you with this quote from Her Majesty.
“I know of no single formula for success. But over the years I have observed that some attributes of leadership are universal and are often about finding ways of encouraging people to combine their efforts, their talents, their enthusiasm and their inspiration to work together.” ~ HM Queen Elizabeth II

Ernest Shackleton
This year marks marks the 100 year anniversary of the rescue of Shackleton’s crew in the Antarctic. I’m hoping you are already familiar with the story, but will give a brief description as I understand it. Shackleton wanted to be the first person to cross Antartica from coast to coast. You may have heard of the advert he allegedly placed in the newspaper when looking for men to join him – “Men wanted for hazardous journey, small wages, bitter cold, long months of complete darkness, constant danger, safe return doubtful, honour and recognition in case of success.” ~ Ernest Shackleton. Unfortunately there is no evidence that Shackleton actually placed such an advert, but it does give you an idea of the challenges he faced.
Things did not go well for the expedition. The ship, Endurance, became trapped in the ice. Shackleton hoped that the spring thaw would release them and enable them to continue, but instead the movement of the ice as it started to thaw damaged the ship, which eventually sank. The crew had already abandoned the ship by then, and were camping on the ice. It was hoped that the ice flows would drift them towards land, but this did not happen, and eventually they took to the life boats and endured an open sea voyage to Elephant Island – an uninhabited rock far from any shipping lanes, with no hope of rescue. After establishing a camp here, Shackleton and a handful of men set off on a further open sea voyage in one of the life boats to South Georgia. Here they completed a hazardous land crossing of the island to eventually reach a whaling station, and organise a rescue trip for the remainder of the men.
My re-telling does not really do proper justice to the scale of what was achieved and endured. I would suggest you do you own research if this has piqued your interest. 
Shackleton was known as an unusual leader for his time. Someone willing to do any job, adopting a person-centred approach to leadership. During one of the sea crossings he gave up his gloves to one of his men, resulting in Shackleton himself suffering frostbite.
Shackleton was calm in adversity, did not overreact, and was known for his ‘calm and reflective demeanour’. I cannot emphasise enough how important this is for a leader. To be seen as someone who will always be measured, confident and calm. Leaders who are reactive and display their stress and mood-swings are very difficult to work with. Shackleton demonstrated a key leadership trait in my view. A mantra I try to follow when I lead, particularly when doing so publicly, is to lead with ‘confidence and joy’. Not always easy when you are not feeling joyful!
A quote from Shackleton before we think about Garrett Anderson:
“Difficulties are just things to overcome, after all.” ~ Ernest Shackleton
Elizabeth Garrett Anderson



Elizabeth Garrett Anderson was a remarkable woman. 
She was born on 9th June 1836, so would have been 180 last week. I will quote from Wikipedia:
“Elizabeth Garrett Anderson, LSA, MD (9 June 1836 – 17 December 1917), was an English physician and suffragette, the first Englishwoman to qualify as a physician and surgeon in Britain, the co-founder of the first hospital staffed by women, the first dean of a British medical school, the first female doctor of medicine in France, the first woman in Britain to be elected to a school board and the first female mayor and magistrate in Britain.”
Wow. If you’ve never heard of her before, now’s the time to remember her name and what she achieved. She endured continual opposition to her quest to become a doctor. After applying to various medical schools, and being rejected by them all, she worked and trained as a nurse. From what I can gather she essentially just went along to the medical student teaching, learning about anatomy and medicine. She eventually became a member of The Society of Apothecaries, which at the time was a route to becoming a physician. She then became a member of the BMA, and set up consulting rooms in London. While business was initially slow, with people being suspicious of a female doctor, the outbreak of cholera meant that patients soon became less picky about who their doctor was. Her practice and reputation then grew, and the rest, as they say, is history.
It should be noted that as soon as admitting her, The Society of Apothecaries immediately changed their admission rules, closing the loophole that allowed her to join, and thus preventing any other women from joining. The BMA likewise immediately voted to refuse membership to any other women.
How must this have felt, and how did Garrett Anderson deal with this. I can only presume with significant personal resilience and great tenacity. She clearly had a vision of what she wanted to achieve, and continued to pursue this in the face of opposition. Another great leadership lesson. 
A quote from her sums up her approach I think:
“I think he will probably come round in time. I mean to renew the subject pretty often.” ~ Elizabeth Garrett Anderson
Lessons

So, what have we learned. I think a few simple things, which I will sum up in a list of words. They are characteristics shared by leaders. We can see them in the lives of these individuals. We can learn a lot just by observing and taking note of what we see.
Vision.

Resilience.

Collaboration.

Tenacity.

Persuasion.

People-centred.

I wonder, can you see these traits in the people you look up to as leaders? Can you see those traits in yourself? We can all learn, we can all change. Examine yourself – do you need to move to develop any of these? The good news is, you can.

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