University of Birmingham

During my career in the NHS, which included serving on three NHS Trust Boards as a Director with a portfolio covering workforce, organisational development and patient involvement, the debate around and attitudes towards the migrant workforce evolved significantly. Just as there was a dawning recognition of the importance of personalised care, there was a slow but definitive shift from viewing migrant workers as a homogenous ‘overseas workforce’ to starting to understand and value the nuance and difference between different groups of workers. At Board level, we started to have discussions about how equitably – even how morally – we were treating the people that worked in our NHS, rather than just taking and using their skills. As Director of Workforce, I recall forming a powerful alliance with a Director of Nursing and the Medical Director. We worked to illustrate to the rest of the Board what a precious resource our overseas workers were, and why we must give voice to their wider life experiences and skills and open ourselves up to really listen.

It was that experience that led me to this blog. In previous years, I have written about the contribution of migrants to the British institution that is the NHS. As we mark the 75^th anniversary of the creation of the NHS, I wanted to capture thoughts from the frontline, with a particular focus on people who started their lives and careers in a different system and have become NHS leaders. In this piece, we hear about the organisation and leadership of health services from two Consultants who started life outside of the NHS. Whilst this is by necessity a snapshot, opening up to authentic voices can contain points of real value. What does the migrant experience add to thoughts about leading healthcare services? What is the learning for the wider healthcare leadership community?

Dr Fabida Aria, Consultant Psychiatrist and Executive Medical Director, Birmingham and Solihull Mental Health NHS Foundation Trust

I came to England in 2002, having lived and worked previously in Oman and India. Migration itself is a huge life event. Living in different cultures has helped me to appreciate and value people in a really holistic way, not just what they do at work. Many of our colleagues have significant backstories, which inevitably influences the type of person that we are, but that we don’t always discuss, and often aren’t asked about. This feels like a missed opportunity.

I want to help create an NHS that gives all health workers the respect and value that they deserve – and this includes being curious about, and open to, learning from their cultures and their own experiences. Working as an Executive Medical Director has really reinforced the importance of being constantly alert and open, not only to what is said, but also what isn’t spoken about; so often that is where valuable learning and surprising insights can be found.

Dr Christiane Shrimpton, Consultant Ophthalmologist and Associate Postgraduate Dean for Appraisal and Revalidation at NHS Education for Scotland

There are many different ways healthcare services can be configured and delivered. Across the world the most successful ones collaborate with their communities and have a strong local focus, often reflecting wider federal arrangements. Coming from Germany, I see many differences but also some similarities about the challenges that healthcare practitioners and leaders face.

The NHS has a very diverse workforce so inevitably staff bring a wide range of perspectives. As clinicians, we need to make the most of the diversity, including the experience of our patients as well as of our staff. An open-minded and curious approach will go a long way to improving communication, and truly collaborating with people about their health and wider wellbeing. We can learn so much from patients and each other – we may have clinical knowledge, but we are not experts about every individual’s life.

Lessons for Leadership

It is striking how both of our contributors focus on diversity and on the importance of being curious about the world. What role do leaders play in that? Some prominent leadership theories focus on models of authentic leadership and of distributed leadership. In practice, this can be about leaders creating spaces where people feel safe in bringing their whole selves to work. Distributed leadership is about recognising that leadership happens at many levels and in many ways, from a quiet word to a colleague of thanks or encouragement to working with patients and service users to change and improve care pathways – it is far more than a job title. Leaders with positional or professional authority, such as Consultants in the NHS, play a central role in creating culture, and the manner in which they lean into that is critical given the highly visible role that they have as role models.

The contribution of the migrant workforce is about so much more than their labour, and it is reductive to simply utilise their skills and not value the whole person. It is a testimony to the welcoming nature of the NHS that increasing numbers of the migrant workforce in the NHS are now becoming senior leaders themselves, but to what extent does the system expect them to ‘fit in’ instead of genuinely welcoming different perspectives? It is also important to acknowledge that the NHS has always aspired to ‘be better’ with regard to leadership and the migrant workforce, which is again both positive and congruent with the inclusive, egalitarian founding principles. Over the years, the debate in the NHS has moved between simplistic equality, moving on to recognise the nuance of diversity, and more recently thinking about inclusivity, although these issues are far from resolved. Engaging our sense of curiosity, facilitating exploratory discussions, encouraging people at all levels to bring their richness to work – these could be some of the core competencies for the NHS leaders of the future.

HSMC and the NHS – a Symbiotic Relationship

One of the things that attracted me to the Health Services Management Centre (HSMC) when I left the NHS was the focus on developing knowledge for a purpose, to apply it to real challenges and to improve practice. Indeed, the work that HMSC does with the NHS Leadership Academy on the Nye Bevan and Elizabeth Garrett Anderson programmes is about developing healthcare leaders to make demonstrable change, to improve the experience of ‘what it’s like to be on the receiving end of me’ as a leader. In my work on NHS Leadership Academy programmes, I have often been humbled by the outward looking, generous and compassionate leadership practice of people who are often so relentlessly busy. Truly, the NHS attracts and brings out the ‘best of us’.

A major part of my personal mission as a ‘practitioner-academic’ is to give voice to the reality of issues around the diversity of leadership in the NHS. I have written articles about the importance of cultural competence in the NHS, and also about non-traditional routes into NHS medical leadership. Leadership remains an evolving field, and in organisations as vast, diverse and complex as the NHS leadership can be found in the most unexpected places. As we have heard from our guest contributors above, the challenge for all of us is to keep our minds, and our ears, open.