AUTHORS: Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov
In this series the Medspire team interviews doctors about their career, their specialty, the choices they have made and their advice for doctors and medical students.
Today, the subject is Mrs Celia Ingham Clark, medical director for clinical effectiveness at NHS England. Mrs Ingham Clark has recently been involved in important work tackling sepsis and saving lives. In 2013, she was awarded an MBE for services to the NHS.
A podcast of this interview is available here:
How did you get to where you are today?
I trained in medicine at Cambridge and London. I then decided I wanted to become a surgeon, so I followed the standard surgical training pathway, which at that time included three years full-time in research.
While I was doing the research job, I had the capacity to do some other things at the same time. I got involved with the junior doctors committee of the BMA, and became their deputy chair for education for a year.
That was really interesting, because it was at the time when we were first concerned about the hours of work of junior doctors, and I began to see that if you took an interest in the management side of things, you could make a difference for the people around you.
I completed my surgical training, got a job as a consultant at the Whittington Hospital in London. By coincidence, the post of director of medical education became free at the same time, and I was appointed to this role as well. So I was able to pursue my educational interests, improving things for junior doctors in particular.
After a few years, I realised that, actually, improving things for patients was what most of us are all about. I couldn't do much more of that through the educational route, so I switched across into the mainstream medical leadership-medical management route. I became a clinical director, then a medical director of the trust.
Originally this was an acute trust, and then we changed to become an integrated care organisation, so I was also medical director for the local community services and social care services. I also had the opportunity to take on a role for colorectal surgery nationally, in a clinical leadership role.
I then moved on from the trust after I'd been medical director for eight years, and took on a role at London region, leading on quality and on the introduction of revalidation for doctors.
After that, I was able to gain a national role in NHS England, originally with a focus on reducing premature mortality - focusing on diseases which cause people to die young - and then it broadened out to include clinical effectiveness.
Then, when NHS Improvement and NHS England merged about 18 months ago, I got a broader job, which covers both professional leadership and clinical effectiveness, and that's the role I'm in now. I'm effectively one of three or four deputies to Steve Powis, who is the national medical director.
What made you decide to go into general surgery?
I was one of the students who liked almost every specialty. I really wasn't sure what I wanted to do.
Then I went on my elective to Zululand in South Africa. This was back in the days of apartheid, and the level of care that was available for people in Zululand was much lower than the level of care available for people who lived in the white areas of South Africa.
In particular, there were very few medicines, so if people came in with basic medical problems, we couldn't do very much at all. I don't think we even had a blood pressure machine, but if people came in with basic surgical problems, we were able to do something about it, and in some cases make them better with operations.
I started to appreciate the immediacy of being able to work out what's wrong with someone and fix it yourself. I quite liked that immediacy, and that's really what led me into a career in surgery. It was general and colorectal surgery, based on the people I worked for who I admired as consultants. I tended to go down the route of the people I admired, which many of us do.
What makes a great surgeon?
A great surgeon has to be able to work hard, to make difficult decisions with incomplete information, and act quickly. So some of what you have to do as a surgeon is about being direct when you need to be, because you will save someone's life in an emergency situation.
You also need to have very good communication skills, primarily with patients, because you're asking them to put their trust in you at a time when they're putting themselves into a situation which is potentially very dangerous and scary for them.
So you've got to be able to explain things well, pick up on the cues from patients and from their families, and try to give them explanations to help them make decisions about their treatment. You've got to have very good technical skills, because it is a technical specialty.
And you've got to work effectively as part of a team, because a surgeon doesn't do things effectively on their own, but with the anaesthetist, the theatre team, the ward team, and the critical care team. So it's quite demanding from that point of view, but also extremely satisfying to be able to make people better.
What advice can you offer to those who are interested in going into surgery - particularly women?
You've got to look at what the job involves for senior people. There is no doubt, if you do surgery, most surgical specialties have still got a significant emergency component and will continue to do so. So you've got to work out if the lifestyle will work for you.
For example, when my children were very young, if I was on call for emergencies, I always had to make sure that either my husband or somebody else was in the house to cover, in case I got one of those emergency phone calls and had to drop everything and go straight to the hospital.
I couldn't be left alone with the children by myself when I was on for emergency duty. There are quite a few specialties like that, but then there are other specialties that are not. So you've got to think about that.
If you really enjoy the technical aspects of things, then procedure-based specialties are very rewarding - whether that's a surgical specialty, or something like anaesthetics or interventional radiology, which are also quite technically based. There are a breadth of opportunities.
Also, with surgery, you don't have to choose your subspecialty very early on. So if you choose general surgery, you don't really need to decide for sure whether you want to be, say, an upper GI surgeon, a colorectal surgeon or an endocrine surgeon until you're quite a long way down the training ladder - you can keep your choices open for quite some time.
I don't think there's anything I'd say specifically to women rather than men in terms of going into surgery, because both have to think about their parental responsibilities if they're going to have a family, and to think about caring responsibilities for elderly relatives.
And if you're with a partner who is also medical, you've got to work out how you're going to do the geography so that you can actually see one another occasionally, because it's really difficult when training jobs are in different parts of the country. So you've got to go into surgery with your eyes open, but it is a very rewarding specialty.
Tell us about your leadership journey, and what made you become involved in leadership?
I don't think I set out with the intention of becoming a senior medical leader. I set out with the intention of becoming a consultant. Early on in my career, I tried to do things to make things better for my patients.
Then I saw that perhaps there was an opportunity to make things better for a broader group of patients. For example, when I was a new consultant, I spotted that we were admitting people to treat them for things like perianal abscesses.
These were largely fit, young people. They had a very unsatisfactory patient pathway - they would tend to go to the back of the queue for emergency theatre because it was a quick procedure and they were young, so they 'didn't mind waiting'.
Sometimes, they'd wait one or two nights in hospital, before they got their operation, and were starved for much of that time. So I worked out a pathway to try to improve things, implemented it in my firm with my patients, and got my colleagues in the hospital to agree to do it as well. It looked like it was working.
We did a randomised control trial, which was easier to do in those days. We showed that it worked, and we were able to spread it more widely. I thought: ‘That's making a difference, not just for my patients, for others’.
And from then on, a lot of what I did in my career was about identifying good ways to do things - not always things I thought of, Quite often, it was things other people had done - and then trying to systematise that to make a better deal for patients.
All of us in medicine want to make a better deal for patients, and so it was relatively easy to get people to work alongside me, in order to do this. That's really been the theme underlying my leadership journey.
With your first leadership role, what new challenges did you face, and what new skills were required?
I didn't make an abrupt switch from clinical to leadership. It was a gradual transition. So when I was first a medical director, I was still doing half the time as a clinical surgeon. Then it just gradually moved across, because in surgery, you've got to continue to do plenty of procedures to keep your skills up.
What I found most difficult as a leader was having those difficult conversations with consultant colleagues, because I struggled to understand why some people weren't necessarily wanting to come alongside me to make better things for patients.
If consultants were not engaging, or making a bigger fuss about something than I could understand, I found that quite hard to start off with. Leadership is actually quite similar to teaching. It's not something that you necessarily can do that you're born with.
It's something that you can learn, and you can learn the tricks and skills to enable you to do it better. For example, if there was a dispute with a consultant, I learnt that if you tell them how this makes you feel, they can't really dispute that. If you say, 'I think you're wrong’, they can dispute that.
But if you say: 'It makes me feel very uncomfortable to hear that what you're proposing doesn't seem to be the best way of treating patients’, then they have to acknowledge that this is your feeling.
Everybody has a valid point of view, and quite often the people who were perceived to be difficult actually held very high standards themselves for patient care, and were 'being difficult' because they felt that what the management was proposing wasn't the best thing for patients.
How is NHS England structured?
NHS England and NHS Improvement are coming together as a single organisation now, and it is a huge organisation. They've got a regional office in each of the seven NHS regions, and then they've got central directorates, which include medicine, nursing, improvement, operations and several others.
The medical directorate is only one of those, and we're headed up by Steve Powis, the national medical director. We try to ensure that we have clinical advice for all the policy work that we do, because the combination of a good clinician and a good manager is the best way to actually develop a good policy and then implement it.
When I say ‘clinical’, I don't just mean ‘medical’. The allied health professionals and pharmacists, dentists and clinical scientists have got just as valid a say as the doctors. We try to ensure that we've got access to good clinical advice across the board, but with a focus on the topics that are our priority areas.
For example, we've currently got a priority on maternity transformation, on mental health, on diabetes, and prevention of diabetes. We make sure that we've got clinical advice in that space. That clinical advice comes from people who we appoint part-time as national clinical directors or national specialty advisers.
Or it comes from the doctors or other clinicians who chair the clinical reference groups in specialised commissioning, or from the clinical leads in the ‘Getting It Right First Time’ programme (the GIRFT programme).
What does the medical director for clinical effectiveness role involve?
The specific things that I do in relation to that role are particularly around providing clinical leadership on the national clinical audit programme. We commission a programme of about 40 national clinical audits - for example, cardiac disease, respiratory disease, mental health - and we have to interact with the audit providers.
We have to make sure that they provide audits that are up to scratch, and we have to look to make sure that the system implements the recommendations that come out of those audits. I co-chair a group that looks at any national recommendations that come out from those national clinical audits.
We try to make sure that the relevant policy team picks it up and works with it, and that may be somebody within NHS England, or in one of the royal colleges.
For example, there was a recent recommendation from the maternity side, which said that ED, general practice, and medical specialties need to be more aware of the things that can go wrong with women who are pregnant.
There wasn't any point in going out via the Royal College of Obstetricians and Gynaecologists to try to make that happen, because it was everyone else that we needed to get to. So I contacted the Academy of Medical Royal Colleges - which is the overarching umbrella for all the colleges - and asked them if they could do something with the relevant colleges to try to get messages out.
So a lot of what I'm doing is building links with others. I also lead on the interface with the National Institute for Care and Excellence (NICE), so that we can actually look to see what they're doing, provide them some steer on topics that are really important that we'd like them to produce guidance on, and make sure that we're aligned in what we're trying to do to improve care for patients. Those are the main things in that space.
The other aspect, which is important in terms of commissioning, is that I'm the clinician who sits on the joint pricing executive, which is the group in the finance directorate that actually works out how the commissioning of services will work each year in the NHS.
I help provide advice on whether we should provide any additional incentives to get provider trusts in particular, or GPs in particular, to do one particular thing better.
For example, you may be aware of the Quality Outcomes Framework in primary care QOF), and there tend to be things put in QOF that we want GPs or their practices to do more of, and that they'll get paid more to do, such as measuring blood pressure in everybody who needs to have that done.
What are your current priorities as medical director for clinical effectiveness?
The biggest priority is a strategic one, which is moving forward on the way we do the national clinical audits. We're working very closely with NHS Digital on this.
At the moment, the national clinical audits are very good, and they're perceived to be very good on an international basis, but the data that they present in their reports tends to be about 18 months old.
Therefore, if you go to a trust and say: 'Look, you're an outlier on this audit’, sometimes, you get a pushback which says: 'Well, yes, that's old data, we're not like that now’. People want more immediate feedback on their data, and they want to be able to use that data for quality improvement.
So we're talking with NHS Digital about how we can change things so that going forward, where possible, we can collect the data effectively in real time through the routine data collections through hospitals and general practice.
We then pass that data to people who have an interest in the various specific topics to analyse it and re-present it back out to the system quickly - ideally, within three months. There's a really good example of how this is done, because that's basically what we've done during COVID.
A lot of data in COVID was collected, processed quickly, and got back out quickly, particularly on ITU, for example, to enable trusts to improve their performance. So we'd like to move to that sort of situation overall. It is extremely difficult to get from an existing system to that different and new system, but we think it's the right way to go.
Tell us about your work tackling sepsis and saving lives
On sepsis, my action was only about bringing people together who had an interest in that space. When I first became the medical director for reducing premature mortality, we had to work in train on cardiac, respiratory and cancer, but we didn't have anything in train on acute infections.
What is fascinating is, when you look into it, about 40% of everybody who comes into hospital as an emergency admission has some sort of infection as their primary problem, and the extreme end of infection is sepsis.
So I brought together people who had an interest in that space - people from the front line, from pharmacy, from Health Education England, Public Health England, the colleges, and the Department of Health.
I said: 'What are we going to do about sepsis?' There's also a very good charity in that space, the UK Sepsis Trust, and we brought them in as well, because they've done a brilliant job on public messaging. We looked to see what we could do, and made sure that what we were all doing was aligned. I think what's made the biggest difference - the messaging out there.
So in most hospitals and most GP surgeries now, there's a poster up, saying: 'Could this be sepsis? Look out for sepsis’. It's a much more prominent thing. We also link that up with NEWS2, National Early Warning Score, in order to identify people who are acutely unwell.
NEWS2 does not automatically mean sepsis, but it means someone is acutely unwell. If you know they're acutely unwell, one of the common reasons for that is sepsis. So it's actually sped up the process of identifying and treating people who are acutely unwell, and particularly those with sepsis.
From what we can see, the mortality from sepsis has fallen over the last five years. I can't guarantee that’s because of what I did, because there were lots of other factors in the frame, and certainly the charity, the UK Sepsis Trust played an extremely important role.
But it's nice to make a difference for patients in that way, and we've got more to do on that. For example, we're now joining that up with the work on antimicrobial resistance, because we don't want people to be given antibiotics inappropriately, but we do want them to be given timely appropriate antibiotics - so there's a fine balance there.
Tell us about your interest in quality improvement.
Quality improvement is a way of thinking in medicine, and everybody, from medical student onwards, has the opportunity to be involved in that - you can influence the environment around you.
When I was a consultant, I ran a special study module for final year students in day-case surgery. It was only a four-week module, but I tried to make sure that we had running projects, so that when students came in they could hit the ground running and get something useful out of it.
One of the most successful projects that we did was that the students, for two weeks, asked every patient in the day surgery unit how they wanted to go to theatre. Were they happy to go on a trolley?
Would they prefer to go in a wheelchair, or would they prefer to walk?
The vast majority of patients said they'd prefer to walk, and so we changed the system for our hospital so that the patients walked to the theatre. They had more autonomy, they felt more in control of things, and it was very effective.
The student got a poster at a national conference out of it, we got a paper in a journal out of it, and it was quality improvement on the ground, in real time. And that student was able to make a huge difference for patients in the broader sense.
A lot of places now enable patients to walk to theatre - and not just day surgery patients. I'm sure we weren't the only people to initiate that. But you build the evidence, you build the culture, and you show people that by actually doing the thing yourself, you believe in it, and will also pick up if there's something wrong with it.
So what's wrong with asking people to walk to theatre? The problem was we didn't have the trolley at the theatre end to take them back, so we had to put in a system for the porters to bring the trolley down while the patient was on the operating table, because they couldn't walk back straight after a GA. So you have to learn from what you do.
What makes a great quality improvement project?
It's the same with any other type of evaluation. You need to be very clear what your aim is, and not be distracted from that, and you need to not be overambitious. So ‘Should we let people walk to theatre?’ is not too big a project - you can't change the world in one go.
You have to know what your ambition is, you have to get the people you're working with to agree to work with you to achieve that ambition, and then you've got to set out what the necessary steps are for you to get there. You have to be prepared to iterate.
One of the common techniques that's used for quality improvement is using ‘PDSA’ cycles. These ‘Plan, Do, Study, Act’ cycles are where you make a tiny change, see what it does, make another tiny change, see what it does, and just gradually improve until you've got a better process going forward. Those are the principles that are important on quality improvement projects.
What makes a good leader?
First of all, you have to be aware of others' views and others' opinions all the time. It is not about you deciding for yourself that this is the way to do things. It's about listening, looking and learning all the time.
You have to set a vision. You have to be able to bring people with you, because if you can't, it's extremely frustrating, and you have to be prepared to change tack. Not massively, but a bit - if you hear from other people, or get feedback from the work that you're doing that you need to change tack.
You can't be too dogmatic about exactly what it was you were going for, and you have to respect everybody's opinion. Just because you're the named leader, or you've got the title, it doesn't give you the right to think that you're better than anybody else, or to disregard anybody else's point of view.
Everybody has a valid viewpoint, and they will often give you very useful information, which enables you to improve the work that you're doing.
Reflecting on your career, have there been any role models within leadership who have shaped you as a leader?
Probably the most prominent among my role models would be Dame Clare Marx, who is now the chairman at the GMC. I first met Clare when we were both trainees and doing an ATLS course together.
At that stage, she was probably four years ahead of me, and I was very impressed that she was forging a career in orthopaedics, because that was even more uncommon then than it is now. She was very determined in the work that she did with the Royal College of Surgeons of England.
She actually became president of the Royal College of Surgeons of England, and did a very good job there, and brought other women senior surgeons alongside her. Now she's moved on to the work that she's doing with the GMC.
It’s a different approach to what the GMC had before. It is more about listening - more keen to actually listen to patients and doctors, and improve care for patients through what they do. So she's always been a very determined and extremely well-spoken person as well. I have to respect that. So she was a role model for me.
What advice would you give medical students and doctors who are interested in taking on leadership roles?
Every doctor has to be a leader at some level. So it's not: ‘Shall I become a leader or not?’ It's: ‘What shall I do as a leader?’ By the time you're a registrar, you have to be able to lead the on-call team.
Even at foundation doctor level, you've got to work with the ward team, and to decide what things you're going to ask other people to do, and what things you're going to do, and how you're going to organise it. So all doctors have to be leaders.
I think you have to listen to people all the time. My style of leadership, naturally, is someone who is collaborative and facilitative, so I'm supporting other people to get a good job done. I think that's exactly the sort of leadership style that the NHS largely needs at the moment.
If the building is on fire, you need the directive leader who says: 'Do this, do that’, a little bit like in the middle of a cardiac arrest. But actually, for most of what we do it's: ‘What shall we do? This is what we're trying to get to.
Do we agree this is what we're trying to get to? So how do you think we can best get there?’ is the approach. You've got to be prepared to learn throughout your career, and that's one of the privileges of being a doctor. You never, ever know it all.
One of my children is now a Foundation Year 1 doctor, and is astonished at the things I don't know. I'm not surprised. It's an awfully long time since I was an undergraduate student, and an awful lot of drugs have been discovered or developed since then that I've never heard of.
But I'm learning from my son, and that's interesting and helpful, and it helps me to be a better leader. I’m not just learning from him. I’m learning from a lot of the people who I work with. We have the national medical director's clinical fellows who work with us in some of the national arm's length bodies, and I'm always learning from people in that space.
When I was a consultant in practice, I always learnt from the students and the trainees that I worked with. So it's a little bit like that ‘reverse mentoring’ you hear about now, to make sure that you're entirely au fait with the right way to approach inclusion in a general sense.
That's important as well, because the attitude to inclusion is so much more positive now than it was 20 years ago, and people like me have to learn better how we can make sure we're inclusive in the work that we do.
So it's learning from others, learning from people who are coming behind you, and bringing those people on after you as well. We've got to create the leaders of the future. So things like doing this is one way that I can give back to the system, because I want readers to realise that they too can be leaders, and that it's a really fascinating and interesting aspect of medicine.
Why is there often a conflict between clinicians and management?
There's much less than there used to be. There's a better understanding of the different roles that clinicians and managers have, because it would be very difficult to run the health service without the managers.
We need people who know how to write business cases, how to create a plan to get something done, how to follow that plan through, and how to bid for the money effectively. The managers look to the clinicians to give them a steer on what are the things that are most likely to improve quality of care for patients.
Now clinicians will come up with loads of things and, of course, every clinician will favour the things in their own specialty or subspecialty. The managers can't be that artisan.
They actually have to start making decisions about: ‘Do we spend this money on more endoscopes, or do we spend this money on something new in the children's ward?’ So there will always be people who are disappointed, because the thing that they want to happen isn't prioritised.
The way one deals with that is not to just go off in a ‘grump’ about the managers. It's to be a good follower, to actually listen and recognise when something else is being prioritised, and then do what you can to make the case for the things that you want going forwards.
What are some of your proudest achievements?
The collaborative work that I led on sepsis made me feel good. When I was medical director at the Whittington, the work I did developing relationships with consultants was really important. When some external people came in to measure how we did on what was called the ‘medical engagement scale’, we were one of the best hospitals that they looked at, which made me feel good.
We had the lowest hospital standardised mortality in the country for a couple of years when I was medical director, and we got a 'good' from CQC. So those sorts of achievements were fantastic. Of course, I'm really proud of my children, because everybody tends to be proud of their children, and I'm delighted that one of them is a doctor.
I've always really enjoyed providing feedback and giving advice to juniors. My son and his fiancée came to see us a few weeks ago, and the fiancée, who is also a Foundation Year 1 doctor, passed me a little card.
I said: 'Why are you giving me a card?' She said: 'It's not from me, it's from someone else’. It was a nice little written card, and it said: 'You won't remember who I am, but I was one of your medical students in 2003.
I'm now an ST7 in surgery, and I've only gone into surgery because of the role model that you were, and you encouraged me, and you helped me do well’. It was a female student from an ethnic minority background, who had listened to me and watched me when she was a student, and was now on the verge of becoming a consultant surgeon. So that felt pretty good.
What are some important lessons that you've learnt and have shaped you as a surgeon and a leader?
As a surgeon, I have to be well organised. So getting today's work done today is always worth doing, but you have to balance that with making sure you've got a work-life balance.
There's actually some good research that shows people who do an extra half an hour to an hour's work each day, on top of what they're due to do, are actually very effective and get a lot done. But once you do more than about an hour over what you're scheduled to do, your efficiency falls off really quickly.
So I never feel too bad when I walk away after 7:00pm and do something completely different. That balance is really important. Building a network of people around you, who you can call on to help you, is important, and you can only do that if you offer to help other people as well.
Helping one another is really important, and I'm fortunate that I've now got a great network which spreads very widely, and there's all sorts of people I can ask for help when I've got something difficult to do.
Then ‘walking the talk’. People know that I deliver on what I say I'm going to do. I'm reliable, I get things done on time, and if I can't get something done, I will go back and say 'Look, I'm really sorry, I'm stuck on this.
Can we find another way, or can we get some more help?' Being reliable and delivering is important. It's no good me going around saying: 'It's really important everyone is a great leader, do this, do that, do the other’. I've got to demonstrate that I'm doing it in my own work as well.
How can medical students and junior doctors excel in their careers?
As a medical student or junior doctor, you're already in a position where you're excelling. Inevitably, you are someone who is intelligent, able to pass exams and capable of working hard. So what you need to do is decide how you want to shape your career.
What do you want to spend your time doing? Which specialty is the one that's most interesting to you and also enables you to have a work-life balance as things go forward?
Look at the actual day-to-day work of people who are young consultants ahead of you, because the chances are that you will be doing that sort of work, or possibly doing the work that the registrars currently do when you're a senior doctor, because the hierarchy is going.
It's a much flatter career structure going forward. So you've got to enjoy the work that you do - but again, it's about listening and continuing to learn, and enjoying it. People talk about the ‘joy of work’, and it sounds a bit cheesy.
But actually, most of us get out of bed in the morning and, even if we're tired, or know we've got a really nasty thing to do in the day ahead, there is huge pleasure in working with the teams that we're embedded in, in our working lives, in the NHS, because the positive culture in the NHS is so strong.
We all know that we're in this to try and make a better deal for patients, and to help one another to do that, and that makes it a really privileged place to work.
Do you have any habits that allow you to excel?
It's about working hard and having a decent work-life balance. It's making sure you get the job done, and if you're the sort of person that struggles to get the job done, team up with somebody who is a ‘completer finisher’ that does those details.
Increasingly, we recognise colleagues among us who have got degrees of dyslexia, so, for example, won't be able to edit a piece of writing to a standard that is adequate for publication.
So rather than beating them up, you make sure that they're teamed up with somebody who can do that editing so that, collectively, you produce something that's fit for purpose. Helping one another past our shortcomings is really important.
What is your favourite book?
It's quite an old one. It's written by Anthony Trollope, and it's called The Way We Live Now. It was written at the end of the 19th century, and describes the political situation, and newcomers trying to find their way in the political environment in London.
It could have been written about the situation that we're in, in this country, or perhaps even more in the US nowadays, in terms of people who upset the status quo, or fail to upset the status quo. So it's a really fascinating book, and that's the one that I'd recommend.
Medspire podcasts are produced by Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov, both full-time junior doctors. They aim to inspire the next generation of doctors and scientists by exploring the career journeys of leading clinicians and researchers.