I am sharing my experiences of leadership and the journey of a healthcare entrepreneur. I hope that this will inspire others into following the same journey and create opportunities for all!

The Maslow Foundation aims to ensure social inclusion, using the voice of lived experience to create services that meet their ambitions and I am proud to be Chair of Trustees creating hope, joy and meaning in our lives. Our services include creating safe spaces to ensure meaningful conversations, being able to connect individuals into wider services with a model of trauma stabilisation and connection. We are pleased to be offering housing to those who cause harm from domestic violence and enabling their partners to remain in their local community. This has revealed the challenges with employment and our move to creating an entrepreneurial laboratory and microbusiness support. We are champion the Child Impact Assessment to support mothers who may be sent to prison and their children to inform judges and provide a robust plan for the family. To support the charitable sector I have launched Urban Nest Housing Solutions to access housing with safety at our heart.

Nurture Health and Care Ltd has been co-founded by myself and my team to nurture workforces across the public sector. This is built on a model of Psychological Safety and recognises the need for connection, sense making and action. By creating sense making structures through our supervision model or decision making groups in our investigation team, we can enable people to make sense of risk and uncertainty. We are proud to be offering services to the NHS for investigations and the Prison and Probation Ombudsman/NHS England for clinical reviews. In addition, we are providing sexual offence examiners to sexual assault referral centres, with a unique workforce strategy which includes the accredited Sexual Assault Nurse Examiner programme (SANE) and our inspection ready governance delivery. We use our four ways of knowing to help provide understanding, equality of voice and values based decision making to create new insight for our services. We provide post graduate preceptorship programmes and enjoy the contribution of our Nurse Ambassadors and run a Nurture Ripple and Cultural Architect Programme generating psychological safety to embrace the ambition and creativity of our workforce enabling success.

I am interested in how language can represent culture and be measurable through artificial intelligence and have set up a new organisation, the Centre of Artificial Intelligence Interface (CAII), with the launch of our new website and first product which acts to create different perspectives as a basis of decision making: https://www.3friends.ai/ and looks how ethical AI solutions can contribute to healthcare.

As a Trustee for Survivors In Transition, I continue to support my passion of providing services to those who have experienced sexual violence and am lucky to work alongside Fiona Ellis, who as CEO has created a values based innovative organisation to provide therapeutic interventions.

I am also exploring setting up a microgrant funding system to create financial support, coaching and an incubator of change recognising how passion, entrepreneurialism and the agency of people can support change in our services. I look forward to sharing this journey.

Alexis Hutson (https://www.alexishutson.com/) facilitated the Faculty of Medical Leadership and Management course – Tomorrows Strategic Leader which I attended and highly recommend. She was an excellent resource and identified the concept of ‘Taking a Thought for a Walk’ which I have named this blog after. Simon Bennett (http://www.simonbennettcoaching.com/) is my personal coach and I advocate this support, It enables us to explore the journey that we are all undertaking in a psychologically safe space.

I believe that without aiming for the impossible, miracles cannot happen and through authentic leadership, we can enable every person to be able to reach their own potential.

The concept of work-life balance implies that work is bad and life is good; it suggests that work and life are two different entities that need to be strictly separated and kept at a constant value.

I believe there is a misconception that less work equals more happiness.

Work is seen as a mechanism for financial support and to be difficult, whereas our home environment are believed to inspire joy and happiness and feel easy.

In my experience, work-life balance is more like a rollercoaster than a constant and our challenges are as likely to be in our own homes as in our working environments.

Joy and happiness can be experienced through all our interactions which include work.

Dr Steve Suckling and his blog: https://themaslow.foundation/towards-the-innovation-paradox/, has interesting insights into the concept of life, a good life or a better life and that is a more appropriate journey to consider aligning to.

Our work needs to be more than just be a job. Whether we are artists, educators, healthcare professionals, managers, scientists or even entrepreneurs, many of us find genuine joy in our work. Some days, we may feel this is strenuous and tiring while other days, it is productive and creative but all occupations, team work, making a difference and showing skill can all enable us to feel pride and success.

There is also work in our home lives, with children, household tasks and wider demands, which may inspire however can be hard and exhausting. Embracing the chaotic nature of life is to accept that some periods of your life will be filled with ‘work’, while other points may be more ‘soul nourishing’.

What we all need is time to feed our soul!

Reading may be the space to find joy, which can be a rare treat but could be built into our days. Walking might be our sanctuary and should be placed as a priority. Spending time with friends and family can all feed our soul. For me making a difference to some-one is rejuvenating, which can be saying thank you at a supermarket or part of my working routine but makes me smile.

One of our human flaws, is that when something joyful happens, we feel a flood of positive thoughts and feelings. However when it happens for a second or third time, that same event loses its magic. In a working day, where routine abounds, we need to notice the good and work on how do we keep noticing!!!

Understanding our energy resources is a more useful concept than work-life balance

Rather than identifying a work-life balance maybe we could consider energy as a concept and to identify our own energy production activities and dedicate time to these. We also need to understand the support we need when energy draining experiences occur.

When we have joy and energy creation, this is transferable so can give us resilience to survive the difficult or enable the capacity to grow.

When we are supported and lifted up by our community, we can be inspired.

When we are being pushed down and constrained, we feel apathy and not being ‘good enough’.

What is impossible to achieve is the perfect family with the perfect job, within the perfect company, living in the perfect location, with enough money and resources to create a perfect life.

By changing our mindset to identifying whether we are passive recipients of life, enjoy a good life or want to have a better life is for us to choose.

Through feeding our souls every day, enjoying the journey that is appearing and finding ways to be resilient when needed, this ensures that we all experience joy, happiness and laughter which we can notice. When darker times occur, we should have strategies at hand to move forward through sadness, anxiety and tiredness.

We need to analyse all our commitments as an employee, partner, parent, carer, friend, leisure and soul feeding opportunities and factor these in our healthy lives.

Unlocking Energy with Purpose

By having a sense of purpose, this has been shown to increase our energy levels and the East has some interesting concepts which we can learn from to consider as part of our approach to a Healthy Life.

Ikigai is the Japanese art of living and although there is no direct translation, it has been defined as:

“essential to happiness in this life are something to do, something to love, and something to hope for.”

“Our ikigai is different for all of us, but one thing we have in common is that we are all searching for meaning.”

“There is a passion inside you, a unique talent that gives meaning to your days and drives you to share the best of yourself until the very end. If you don’t know what your ikigai is yet, your mission is to discover it.

“Your reason for being gives you a reason to live”

Ikigai is not related to work or money but what gives us meaning. This is for us to decide but could be ever changing and a journey of discovery. Alongside work, it can be family, a dream or simply an experience that you create. It is often found in the ordinary not the extraordinary. It can be multiple ideas and is rarely a destination but the path we follow.

Here are some websites that look at the concept of Ikigai:

Ikigai: The Japanese Secret to a Long and Happy Life (Book Review)

https://www.linkedin.com/pulse/10-rules-ikigai-japanese-secrets-long-happy-life-shiv-yadav/

As leaders how can we create these energy generating environments

As an employer or as a leader, our responsibility is to support everyone to be the creator of their own life canvas and provide healthy work and healthy life opportunities which feed the soul as well as demand energy.

We never want to find our workforce working excessive hours which can do harm or working in environments that are unsafe however choice should underpin decisions and where stressors are abundant, we find new opportunities to distract and give alternatives.

Remote working has diminished the separation of home and work, however our natural world would have been a blended environment, so identifying and fulfilling our own needs is more important that setting hours at work.

My priorities are:

• Creating purpose which connects us generating shared meaning and joy.
• Ensuring we take time to enjoy and celebrate our journey, without the pressure of speed to achieve and noticing the world around us.
• Through tough times, working with people to manage those demands, understanding the energy deficit which is occurring and ensuring some energy credits are available.
• Build our teams that enable inclusion, with positive psychology, psychological safety and understanding, whilst recognising and noticing peoples true potential.
• Share our successes and seeking to ensure social value and flexibility to meet the needs of our workforce and enjoy the experience of giving back.
• Reconnecting with nature through walking, spending meetings in inspiring places alongside sustainability and ensuring we have a minimal impact on the planet
• Celebrating contribution, being grateful and giving thanks

Ikigai is one idea which I found interesting to bring energy creation to transform our workplace culture for the better. By searching and learning together we can all aspire to be part of something that wants to do something better every day. To do this as leaders, we need to find time to feed our own soul and that of those we serve.

Todays blog looks at Power and Influence and how this impacts on evidence based medicine (EBM).

I believe that discussing how power interacts with EBM is uncomfortable, as it suggests inequality which I think makes this a particular challenge for those of us who believe in Equity and Fairness.

My personal experience which has spanned roles on Boards, being a doctor and being a nurse, alongside being a patient and a family member supporting others, enables me to really understand how power, status and ‘being a patient’ are important considerations.

As a doctor, my ideas seem to have more validity and carry more weight, however as a nurse, communication is easier with people and leads to different conversations. As a patient, I may not identify as a healthcare professional as feel this might lead to consequence, but I do use this when supporting family members and have leveraged this to direct outcomes.

It is critical therefore that we understand how power, relationships and communication underpin shared decision making and therefore form a core component of EBM and that power, finance and resources, feeling safe and knowledge are intimately related.

What does power look like?

The ‘actors’ can be at an individual, team or organisational level, a placed based system or even a global community.

In life, the decisions we make create winners, losers, positive and negative outcomes.

How this is shaped is through our knowledge and experience, our situational awareness and the predictability of the decision including how much control we have over our actions. Resources and infrastructure all inform our ability to move forward.

We all have power in a situation to act, to be inactive or to be a counter power and act as resistance.

Interactions can also be blocked. If A knows B and B knows C, but A does not know C, both A and C require B to mediate. B occupies a ‘structural hole’. They may act as a bridge overcoming the gap, exploit this gap creating competitive advantage, or block the gap completely.

Hierarchies and complex systems have ‘structural holes’ which can be overcome in fully distributed networks, where all nodes are effectively connected to all other nodes, enabling shared understanding.

Mismatched structures and resources, knowledge ownership and status or having different value sets leads to differences of opinion which creates tension. How we manage these tensions will ensure success or failure for collaboration.

Problems arise when powerful actors, have a blind pursuit of relative advantage and neglect structural order and rules particularly when they have access to wider resources.

By understanding these dynamics, we can influence how our world changes.

• You can enable agency of others, creating the capacity to achieve goals.
• Through sharing of knowledge, you can enable facts to be discovered, and create the mechanism for this to be available and others to create change.
• By role modelling, you can influence how we all behave.

Looking across our health and social eco-system, we know hierarchies exist, with many structural holes and power, finance, safety and knowledge interact which impact on the achievement of EBM.

Power and our Patient Relationship

Healthcare interactions are characterised by socially prescribed roles which have status creating an imbalance of power and influencing our behaviour. This includes both professional roles and the role of ‘Patient’.

In a consultation, the professional is perceived to have higher status, greater familiarity with the system, greater academic knowledge of disease processes, and more extensive access to further information and resources. They typically control the agenda and the use of time and direct the outcomes offered.

The Inverse Care Law

Because of the impact of social determinants of health, such as poverty, social exclusion, education and other structural inequalities, individuals most in need of healthcare are least likely to seek it or receive it.

Patients, in order to gain access services, have to continually reframe their symptoms and concerns to fit organisational categories and some are better at this than others.

Even when patients have greater knowledge about their condition than the person treating them, the power dynamic is such that the professional views tend to trump the patient’s perspective. This is particularly true when the patient does not follow the rules expected of them and may be perceived as a ‘heart sink’ patient or a problem.  

Power imbalances suppress the patient’s voice.

We need to create mechanisms to amplify our patients voices and include the role of those with ‘lived experience’ to co-produce EBM.

Peer support is founded on a non-coercive, human rights-based approach that focuses on building relationships purposefully sharing their own experiences, and through the mutual sharing and commonality of experience, embodying hopefulness. They maintain equality with, and work alongside, others facing similar experiences underpinned by mutuality and reciprocity, widely recognised as core principles, with the central focus being on building trusting relationships rather than intervention.

By acknowledging these power dynamics and building a new skill mix, we can ensure that the patient voice and their families and carers are represented and this will be key to successful personalised care.

This requires fit for purpose systems, along with appropriate allocation of resources across the landscape of health and social care. Part of the transformation needed is to recognise concepts such as psychological safety, so that we can share our perspectives and the knowledge gained, including those with lived experience. This knowledge then should be perceived as ‘valuable and credible’ as part of our evaluation.

Power and Team Dynamics

When we undertake roles in organisations, we form teams and become leaders, followers or resistant power holders who have the capacity to action but also influence other’s attitudes and behaviours.

Understanding the power we hold is critical to building success in our organisations enabling people to flourish and the health and social eco-system to thrive.

Power can be related to our job title or as part of a role as gate keeper to resources however this is a simplistic view with social assets such as knowledge, information, expertise, respect, friendship, social approval, decision-making opportunities and cultural considerations all being key in understanding how power unfolds in our teams.

Power and politics go hand-in-hand so understanding the context that surrounds our teams is important and understanding whether there is a single source of power, distributed power or a power struggle will enable us to identify strategies for success.

Individuals or teams, who are content with the status quo, feel safe and are satisfied will be empowered to lead, follow, advocate and challenge effectively. Where conflict occurs and tension arises, people become more focused on negative aspects of team dynamics leading to paranoia, anxiety and harm performance.

We need to be able to consider the dark side of power in teams alongside the benefits of leveraging our power.

Power dispersal which elicits differences in perspectives and interests between members and is critical for inclusion and distributed wisdom, can also have negative outcomes if there is confusion of goals and ambitions, or lack of structure to facilitate decision making.

We also need to identify our ‘structural holes’ in our teams and bridge these to ensure that we communicate effectively across whole teams.

At times, power struggles are overt, and can be explicitly seen but often they are more subtle with disagreements about goals and outcomes, personality or value clashes, and conflicts over team logistics, such as meeting times or task allocation.

In order to gain more power, individuals, teams or organisations, may both try to pull others down or to bring oneself up. They may engage in behind-the-scenes coalition formation, purposely withholding information from each other, or gossiping about one another. They may explicitly refuse activities or more implicitly ignore them or take credit for others work.

Power struggles are notoriously difficult to clearly identify and resolve and divert energy away from our true purpose.

Conflicts can only ever help performance when the real issues are brought to the table and discussed. This requires trust which is often absent. Power, therefore, is a sensitive topic, which people find difficult to openly talk about, making their eventual resolution very problematic and the chance of escalation likely.

Power struggles are contagious and create a wave of negative behaviour.

By understanding the mechanisms and levers by which power can harm teams, we can seek to remove the deleterious effects of power for team outcomes. Without understanding the dynamics of power, you create the unintended consequence of perceived unfairness and of toxic cultures.

In order to create safe systems in which EBM can be delivered, we need to create teams, that build on psychological safety, understand how power feels within that team and have organisations that ensure inclusion including that of our patients, families and staff.

The Power of Organisations in Health and Social Care

It is well known that socio-economic factors play a huge role in determining people’s long-term health, and contribute significantly to inequalities and therefore working collaboratively at an eco-system level is essential to improve outcomes but we have paid little attention to the power holders across our environment including Integrated Care Systems although we will be aware of models such as: Mendelows Matrix to analyse stakeholders.

Anchor institutions are large organisations that have a significant stake in a local area. They have sizeable assets that can be used to support their local community’s health and wellbeing and tackle inequalities, through procurement, employment, training, professional development, and buildings and land use. These anchor organisations are therefore critical power holders in our communities.

The Kings Fund has identified that the NHS is a significant stakeholder in terms of its role as an anchor institution with local authorities holding significant infrastructure. Wider, place based assets include commercial organisations, voluntary sectors and other stakeholders such as housing and education all participate in the health and social care eco-system.

Currently, many organisations are in crisis but hold power and at the same time are ‘stuck’ in reactive management.

We need to support all our organisations, including our anchor organisations, to provide psychological safety, active open-mindedness, distributed power models, collaboration and focus on improvement over time, rather than comparison.

The challenge is that our current model of health and social care is built on competition for finance and workforce resources, alongside regulatory oversight, reputation concerns and achievement of outcomes which leads to tension.

What we can achieve by understanding our power

No one can gift us power.

We may be promoted, elected or admired and be senior in roles, however if we do not own or understand our power and influence, this will dissipate and lead to a lack of achievement in the opportunities which present.

Organisations may be assumed to hold power, but if we are not responsible with this or understand how we impact on others, we create unintended consequence and systems fail to achieve their potential.

Authentic power does not come from an external source or important title. True power is generated from within.

Understanding and role modelling Psychological Safety, allows connection and empathy to be shown.

Wisdom allows an understanding of facts, procedures, perspectives and emotional responses and through participation, we generate distributed understanding and transform.

Owning our power leads to increased confidence and an understanding of our role in current situations and how we can help in the achievement of objectives.

Understanding power allows us to connect and maintain relationships and address our ‘structural holes’. It enables negotiation and adjustment.

When we understand our values and those of others, we create visibility and credibility enabling advocacy for ourselves and others.

The admission that we don’t have all the answers, rather than making us powerless is a power move.

Addressing culture that rewards busyness, and moving to one that creates opportunities to discuss topics allows creativity to be born.

Ensuring we all have an open mind and create learning journeys leads to growth and mobilisation of power.

Through this understanding of power and influence, our model of EBM will be created that meets the next generation of health and social care outcomes for everyone.

Because justice and fairness sit at the heart of my personal values, I find it important to explore how these principles influence the way we think about healthcare.

Co-operation has been central to human survival, shaping the social norms that guide our everyday lives. From these norms emerge the frameworks through which societies define justice. Social justice reflects the relationship between individuals and society, raising questions about how opportunities, resources, and rewards should be distributed.

However, our understanding of fairness and justice is not fixed. It is socially constructed and shaped by culture, experience, and context. As a result, people hold different views about what fairness looks like in practice, making its application within health and care far from straightforward.

Research suggests that a preference for fairness is a fundamental human impulse. When we perceive situations as unfair, we often experience strong negative emotional responses, while fairness tends to generate positive feelings. From these reactions we begin to construct our sense of what justice means.

For some, fairness is linked to effort and reward, the belief that individuals should benefit from their hard work. This perspective can unintentionally lead to assumptions that those unable to work are less deserving. Others view fairness through the lens of equal process, emphasising consistent rules and procedures applied to everyone, as seen in tax systems, employment practices, and equality policies.

Fairness also serves a psychological function. It provides a sense of safety and predictability, helping us feel that the world operates according to understandable rules. In this way, fairness can be protective: it allows us to believe that outcomes are controllable rather than random.

Yet this belief can have unintended consequences. When negative events occur, there can be a tendency to assume the individual must somehow be responsible for the outcome. This “victim-blaming” response is often rooted in unconscious bias. Recognising this tendency in ourselves is important so that we can challenge the cognitive distortions that reinforce it. Equally, individuals who experience harm may internalise blame, carrying feelings of shame or guilt that are not theirs to hold.

These dynamics are frequently present within healthcare settings and can contribute to the patterns of disproportionality we continue to see. Addressing them requires open conversation about our assumptions, emotions, and biases. Only by acknowledging and challenging these internal narratives can we begin to move towards a more just and equitable approach to care.

Justice for Patients: Personalised Care and Population Health

We know that the burdens of ill health are unevenly distributed both within and across populations, and that the benefits of health care are not always available to those who need them.

A Community-Powered NHS

Achieving greater justice in health and social care requires more than simply avoiding discrimination. It also requires the fair distribution of effective treatments and a deliberate response to the barriers created by the social determinants of health. This includes ensuring that diversity is reflected in how services are designed and delivered.

While the care of the individual patient must remain our foremost professional responsibility, justice in healthcare also requires us to balance individual needs with equity at a population level. Navigating this tension is one of the central challenges of modern healthcare.

To move towards a more just system:

• Clinical education must extend beyond history taking, examination, diagnosis, and treatment to include the development of clinical judgement, ethical reasoning, and shared decision-making with patients.
• Policy makers should adopt broader, interdisciplinary approaches that incorporate lived experience, psychological understanding, negotiation around evidence, and strategies to minimise harm, including the risks of overdiagnosis.
• Health systems must support the co-creation of shared understanding between professionals, patients, and communities. By recognising both individual and population needs, services can better address the social determinants of health and move beyond a purely traditional medical model.

Justice for our Staff

The Equality Act and wider workforce legislation provide important protections within our labour markets. However, differential attainment and a lack of representation remain persistent challenges across many sectors. The concept of social justice asks us to look beyond legal compliance and consider how systems and cultures can actively promote fairness and opportunity.

Recent national work on leadership in health and social care highlights the importance of building collaborative and inclusive environments that support people to thrive.
https://www.gov.uk/government/publications/health-and-social-care-review-leadership-for-a-collaborative-and-inclusive-future/leadership-for-a-collaborative-and-inclusive-future

Across the NHS and wider social care system, we must work collectively to improve the experience of work for everyone. This requires a sustained commitment to equality, diversity, and inclusion, reinforced through leadership behaviours that role model psychological safety within trauma-informed organisations.

Workplace wellbeing must also be prioritised. Creating environments where people feel supported, valued, and able to grow is essential to sustaining a healthy workforce.

Mentoring and coaching opportunities should be available for individuals and teams to support development and help people realise their ambitions.

Ultimately, the goal is to create workplaces where people can genuinely say: “I feel free to be my authentic self at work.”

Justice for our Organisations

How do justice and fairness operate within the complex landscape of organisations that contribute to health and social care systems?

Many organisations, including those within the public sector, function within structures influenced by market principles. Businesses traditionally operate within competitive environments, and even statutory organisations often incorporate elements of competition, whether to secure contracts, demonstrate value, or position themselves as leading providers of services.

Within this context, justice is often expressed through legal mechanisms, particularly when organisations fail to meet their statutory or regulatory obligations.

Competition can bring benefits. It can generate comparative information, encourage organisations to improve standards, drive innovation, and sometimes reduce costs. In these ways, competition can act as a stimulus for improvement.

However, competition can also shape behaviours such as self-enhancement and self-preservation. While it does not always lead to overt conflict, it can create conditions where organisational priorities risk becoming inward-looking, potentially undermining shared goals.

For health and social care systems that depend on collective responsibility and shared outcomes, this creates an important tension. Moving from competition towards genuine collaboration therefore represents a significant cultural shift — one that requires trust, transparency, and a shared commitment to improving outcomes for the populations we serve.

Seeing the Individuals in our Boards as People

We often talk about Boards as if they are single, rational entities capable of absorbing pressure without consequence. In reality, Boards are made up of individuals who, like everyone else, experience emotional responses, unconscious bias, and moments where they may feel either threatened or protective. Recognising this human dimension is essential if we are to achieve meaningful transformation.

At times, I believe our Boards are displaying responses that resemble organisational trauma. Under sustained pressure, systems can shift into patterns similar to fight, flight, freeze, or compliance. This may present as defensiveness, narrow or “tunnel” thinking, reduced creativity, and difficulty forming trusting connections — all responses that can limit our ability to work collaboratively across the health and social care landscape.

If collaboration is to become the norm rather than the aspiration, we need to rethink how decisions are made.

Too often, the system is governed by rigid questions such as:

• Is this decision legal?
• Is this decision evidence-based?
• What is the correct process to follow?

These questions are important, but when applied too narrowly they can reduce complex problems to simple rule-following. Health and social care challenges rarely fit neatly within black-and-white frameworks.

Instead, we need to move towards a culture that values judgement alongside rules. This means creating space for conversation, shared understanding, and reflection, recognising that complex problems often have multiple possible solutions. Through dialogue, curiosity, and collective sense-making, organisations can move beyond compliance towards collaboration.

Beware of the Unintended Consequence of Regulation

Despite the importance of external scrutiny, recognising that organisations cannot “mark their own homework”. Our current regulatory frameworks are struggling to keep pace with the complexity of modern health and social care systems. Much of the existing approach relies on proxy measures, binary judgements, and models of reward and punishment that are poorly suited to the realities of complex, adaptive systems.

Regulation should evolve to reflect this complexity. Inspectors and regulatory bodies would benefit from greater understanding of organisational psychology, psychological safety, and trauma-informed approaches to inspection. Rather than focusing primarily on comparison and benchmarking, regulation could place greater emphasis on understanding context and measuring meaningful progression over time.

At present, regulatory bodies are constrained by statutory and legislative frameworks that prioritise rigid measurement and benchmarking as the primary tools of assurance. This can limit the ability to take a more nuanced, system-aware view of organisational performance.

Informally, many leaders report that even when organisations receive “good” or “outstanding” ratings, inspections are rarely experienced as supportive or developmental processes. The effort required to demonstrate compliance can feel disproportionate, with time spent evidencing processes rather than strengthening culture or improving patient care.

History has also shown that regulatory oversight does not always identify emerging risks. Major patient safety failures, including the maternity scandals we are currently grappling with, were not detected early through existing regulatory mechanisms.

Concerns are also frequently raised about variability in inspections, perceived lack of objectivity, and the emotional impact on those involved. Some leaders worry that organisations serving areas of greater deprivation, or with more diverse workforces, may experience poorer inspection outcomes. When this occurs, regulatory processes can feel unfair and risk being perceived as unjust.

Although inspectors often demonstrate awareness of the systemic challenges organisations face, regulatory actions can sometimes have unintended consequences. Organisations may experience further workforce depletion, staff burnout, closure of services such as community beds, and an increased focus on procedural compliance rather than meaningful improvement. In addition, there is limited independent appeal, and disagreement with findings can sometimes be interpreted as defensiveness rather than constructive challenge. Without stronger system-level oversight, regulatory interventions in one part of a pathway can inadvertently create risks elsewhere.

External scrutiny remains essential. However, we need to reconsider how it is designed and delivered. Regulation should be independent and robust while also enabling organisations to feel supported in improvement. Rather than standing apart, regulators and organisations may need to work more closely together, developing shared understanding of risk and managing consequences at a whole-system level.

Justice in Evaluation

We therefore need to reconsider how we measure outcomes and evaluate progress across evidence-based medicine, workforce strategy, and the regulatory and commissioning infrastructure that shapes our systems.

A number of methodologies already exist that support a whole-system approach to evaluation.

One example is logic modelling, which provides a structured way of representing how different components of a programme interact to achieve intended outcomes. Logic models are designed to:

• Assess the assumptions underlying how a programme is expected to achieve change
• Identify cause-and-effect relationships
• Develop a deeper understanding of how interventions are intended to deliver results
• Build shared understanding among stakeholders

Importantly, outcomes should be identified early in the design process rather than retrospectively aligned with predetermined or funded activities.

Another approach is Realist Evaluation, often framed through a Context–Mechanism–Outcome (CMO) model. Realist methodology is based on the principle that the same intervention will not work equally well in all settings or for all people. Instead, it seeks to understand what works, for whom, under what circumstances, and why. The concept of realist evaluation was first developed by Pawson and Tilley.

Realist approaches recognise that programmes operate within complex social systems. Factors such as culture, socioeconomic conditions, organisational norms, and community context, although not always directly observable, can significantly influence whether an intervention succeeds. Social systems such as families, schools, and economic structures interact with one another, creating dynamic environments where people, information, and resources continually flow between systems.

Within these open and adaptive systems, causation is rarely linear. Outcomes often arise from the interaction of multiple social factors and interventions occurring simultaneously.

For this reason, realist approaches are particularly valuable when evaluating complex interventions, such as community-based public health programmes or integrated care initiatives. They help explain why outcomes may differ across populations and settings, and they offer insight into how interventions can be adapted to work more effectively in different contexts.

By broadening our perspective and being willing to unlearn some of our current approaches to assurance and evaluation, we can begin to develop health and social care systems that are better equipped to respond to contemporary challenges.

At the heart of this shift lies a fundamental question: how do we create fairness and justice within the systems we design and operate? Exploring this question is essential if we are to build a more responsive, equitable, and compassionate health and social care landscape.

In moving from our traditional model of evidence based medicine (EBM) to Personalised Medicine (PM) and ensuring that greater participation and inclusion is built into our service designs, we are going to have to move away from the conventional statistical analysis to a new way of generating measures to identify best practice.

We know that our current lens has led to bias and created systemic disadvantage, so we need to shift to expand our quantitative approach to include qualitative research methodology.

Importantly, we are missing the process of looking back and ‘marking our homework’ so we can check our assumptions and ensure our direction of travel is positive. We have lost this capability with ‘in the moment’ decision making.

This shift from outcomes and meta-analysis to triangulation through mixed methodologies, using a diverse perspective to interpret and create insight is needed.

Our traditional model of evaluation is based upon: Input – Intervention – Outcome and we need to move to: Experience – Conversation – Understanding but what new measurements are needed to demonstrate success.

As we drown in information, how should evidence be generated and disseminated?

How can evidence generate evidence-based policy that is flexible to changing context?

How can we educate our front line workforce on the best options and be confident in using their intuition and judgement?

What are the current research methods that are available?

I have become more familiar methodologies and reviewed recently both quantitive research and qualitative research and concepts such as blended methodologies.

The qualitative method of inquiry examines the ‘how’ and ‘why’ of decision making, rather than the ‘ ‘what,’where, ‘ and ‘when.’ Unlike quantitative methods, the objective of qualitative inquiry is to explore, narrate, and explain the phenomena making sense of complexity and does not test a hypothesis but discovers emerging themes.

Narrative research

Narrative research focuses on exploring the life of an individual telling their stories of individual experiences. Data collection include interviews, field notes, letters, photographs, diaries, and documents collected from one or more individuals. Data analysis involves the analysis of the stories or experiences and developing themes to gain greater insight.

Phenomenological research

Phenomenology defines the ‘essence’ of an individual’s experiences regarding a certain phenomenon. Data collection is through Interviews with individuals, examining documents and observations. Data analysis involves the researcher interpreting the phenomenon, based on their judgement, rather than simply describing it.  

Grounded Theory Research

Grounded theory comes from the ability to induce a theory grounded in the reality of study participants. Data collection involves recording interviews from many individuals until data saturation. Data analysis includes analysing data through ‘open coding,’ ‘axial coding,’ and ‘selective coding.’ Open coding is the first level of abstraction, and refers to the creation of a broad initial range of categories, axial coding is the procedure of understanding connections between the open codes, whereas selective coding relates to the process of connecting the axial codes to formulate a theory. Results of the grounded theory analysis are supplemented with a visual representation of major constructs usually in the form of flow charts or framework diagrams. Quotations from the participants are used in a supportive capacity to substantiate the findings.

Ethnographic research

Ethnography is used for understanding culture-specific knowledge and behaviours. Ethnography focuses on narrating and interpreting the behaviours of a culture-sharing group. To understand the cultural patterns, researchers observe the individuals or group of individuals for a prolonged period of time. Ethnographers collect data by observation, interviews, audio-video records, and document reviews. A written report includes a detailed description of the culture sharing group.

Historical research

Historical research creates insights from the past and involves interpreting past events in the light of the present. The data is collected from primary and secondary sources such as diaries, first hand information, and writings. The secondary sources are textbooks, newspapers, second or third-hand accounts of historical events and medical/legal documents. The written report describes ‘what happened’, ‘how it happened’, ‘why it happened’, and its significance and implications to current clinical practice.

Case study research

Case study research focuses on the description and in-depth analysis of the case or issues illustrated by the case. Observations, one to one interviews and documents are used for collecting the data, and the analysis is done through the description of the case. From this, themes and cross-case themes are derived and a written case report constructed.

Lens of Philosophy

If our data, regardless of qualitative or quantitative origins, is only interpreted through the lens of a scientist, it is likely that we will continue to attempt to build rules and fail to take account of the complexity of the problem. Through the lens of philosophy, we can build on our concepts, explore possibilities, embed time and consider domains of spirituality, connection and allow other alternatives to be revealed.

Our current position

Evidence-based medicine currently is defined as the optimal integration of the best research evidence.

NICE has published evidence across:

• Conditions and Disease
• Health and Social Care Delivery
• Health Protection
• Lifestyle and Wellbeing
• Population Groups
• Settings

Although, NICE is increasingly widening the perspective of their stakeholder engagement and including qualitative research they still prioritise:

• Systematic Review and Meta-analysis
• Economic Evaluation in Health Care
• Quasi-experimental Evaluation of Health Care Programs and Policies
• Randomised evaluations

As healthcare professionals it is important we consider the following challenges of evidence based medicine.

Publication bias

Publications tend to publish statistically significant results which are positive proving the hypothesis which generally is that the intervention works. Many trials are never published and those with negative findings, even if significant are left unseen.

Small trials are often considered not worthy of publication as their results are not statistically relevant and yet often these ‘hint’ at important findings. An example includes the delay in adoption of thrombolytic treatment for acute myocardial infarction where as early as the 1950s, small trials showed reductions in mortality rates, but we had to wait for a trial which involved the enrolment of 48,000 patients before it became national best practice.

Poor quality research

Researchers may use the wrong methodologies, collate data incorrectly, use surrogate outcomes, misinterpret results and often came to unjustified conclusions.

Discredited Trials

Discredited trails often continue to be cited as best practice as papers remain accessible. If a busy health practitioner does a quick ‘google’ search, the discredited paper may be the first to appear, with no identification of its flaws.

Under reporting of harms

Harm outcomes are often incompletely reported.

Conflicts of interest

Conflicts of interests are widespread amongst academic institutions and researchers and associated with pro industry conclusions. Ghost authorship where there is a failure to declare conflict of interest or publish an advertisement with the appearance of a robust publication can mislead.

Trials stopped early for benefit

A significant number of trials stop earlier than planned due to apparent benefits that overestimate their true effectiveness. These trials receive great media attention and then affect clinical practice.

Statistical heterogeneity (how different we are)

As pharmacokinetic and pharmacodynamic mechanisms are fairly similar across all humans, patients appear to be relatively homogeneous (the same) in drug response. However, heterogeneity (differences) still occur, even if they are more likely to be due to the wider eco-system of social determinants of health and behaviours rather than variations in biochemical mechanisms.

When dealing with outcomes, EBM assumes that the “reality” of the drug or intervention response as statistically homogeneous (the same); so we all react in the same way thus an average response represents individuals well.

However we see heterogeneity (differences) in trials:

1) between-patient variability (the differences between patients)

2) patient-by-intervention interaction (the extent to which the intervention response differs between patients) 

3) within-patient error (the variability that the same intervention given to the same person on different occasions may alter)

The more different we are, the more difficult it is to calculate the anticipated linear correlation between cause and effect and this leads to misinterpretation of the data.

Future research methods must find ways of accommodating clinical reality and that we may not behave the same, as currently the sad truth is that the more complex a situation is, the less evidence is available to treat them.

What are Outliers and why do we care about them? 

The paradigm of EBM, through the use of statistics has created a world seen through averages.

The presence of outliers can lead to error in interpretation and tend to be removed through statistic analysis, with the consequence that systemic bias has amplified the mean. 

Casual observation of the literature suggests that researchers rarely report outliers or seek to understand them.  Given that we know through analysing our assumptions, not understanding our outliers requires urgent review.

In the future, the entire Bells Curve should be analysed, with the understanding that the outlier rather than being a ‘contaminant’ to ignore should be considered as a source of insight.

Outliers from data errors. 

Outliers are often caused by human error, such as errors in data collection, recording, or entry. 

Outliers from intentional or motivated mis-reporting. 

There are times when subjects purposefully report incorrect data to researchers, often from the act of trying to please rather than sabotage. Data is often sensitive (e.g., teenagers reporting drug or alcohol use or sexual behaviours) and therefore reporting may not be accurate. Motivated over-reporting can occur when the variable in question is socially desirable such as income, or educational attainment and the Placebo effect and Hawthorne effect are well studied.   

Outliers from sampling error. 

Another cause of outliers or is sampling.  It is possible that subjects are inadvertently drawn from a different population than the rest of the sample such as studying nurses and inadvertently, a paramedic is interviewed but the study is about nursing views. 

Faulty or non-calibrated equipment is another common cause of outliers. 

Finally, it is possible that an outlier can come from the population being sampled legitimately through random chance and this therefore is a valid subject to understand!!!! 

When researchers in Africa discovered that some women were living with HIV for years without treatment, these rare cases formed a source as inspiration for inquiry:  what makes these women different or unique, and what can we learn from them? 

Triangulation of results should form the new gold standard, blending quantitative and qualitative research with a lens of science and philosophy. I would propose that the current landscape, rather than being the Gold Standard, should be considered the minimum standard and we can build on this to form a New Paradigm.

Although this is a long video, it challenges our approach introducing philosophy, new language and constructs. I found this a motivating video that shows there is another way providing hope and inspiration for the future.

Healthcare extends beyond physical illness to include mental, social and spiritual wellbeing. While genetics play a role, they account for only a small proportion of overall health outcomes. Far more influential are personal behaviours, social conditions and the environments in which people live, the wider ecosystem that truly shapes health.

I love new learning so am excited by the use of technology to create new ways of thinking about our health.

Our SMART devices create consumer led health information and positive words create nudges for change and artificial intelligence creating an online presence beyond what can be imagined.

Cloud computing, blockchain, telehealth and health apps are now part of everyday practice. Yet with every technological shift comes discomfort, as medicine expands beyond traditional clinical boundaries into psychology, neuroscience, linguistics, computer science, artificial intelligence and genomics — all shaped by culture, history and environment.

Care itself is becoming more complex, with multiple organisations involved and increasing levels of polytherapy and polypharmacy. Navigating this landscape will require innovation and, above all, a commitment to building shared understanding across disciplines and systems.

Digital systems now capture physical data, lived experience and even social narratives, creating unprecedented opportunities for personalised care, population health strategy and real-time learning.

But most chronic disease management and prevention happens at home. If we want better outcomes, we must meet people in their own contexts while addressing barriers such as distance, digital access, time off work, language, literacy, numeracy, culture and cost. Financial pressure often forces impossible choices and can lead to unfair judgement of how people use services.

Health is shaped far more by social determinants, the conditions in which people are born, live, work and age than by healthcare alone. The new 10 Year Health Plan for England published in July 2025, sets the decade-long vision for how health and care should evolve, including shifting care from hospital to community, expanding digital services and emphasising prevention and personalised care.

Personalised Medicine

Personalised medicine (PM) has emerged through advances in clinical pharmacology, genetics and neural networks, alongside growing recognition that behaviour and the social determinants of health shape outcomes for individuals and their families. We are moving away from a model in which diagnosis leads to treatments based on average results from traditional randomised controlled trials and meta-analyses, towards one in which decisions are tailored to the individual.

Although we share common risk factors for disease, such as age, exercise, cholesterol, weight and smoking, our genetic differences influence how these risks affect us, why some people develop illness while others do not, how disease progresses and how individuals respond to treatment. The genomics revolution has deepened our understanding of these variations, opening opportunities to minimise side effects, improve outcomes and even predict or prevent illness. Crucially, personalised medicine is not simply about more precise prescribing; it is a person-centred approach that integrates biological insight with behavioural, social and environmental context.

Pharmacogenetics

Pharmacogenetics has described how people may metabolise drugs differently due to the genes and our unique biochemical processes which influence our drug response. This has led to the concept of a “personalised prescription” by “tailoring drugs to a patient’s genetic makeup”.

Artificial Intelligence

Utilising collections of data which arise from electronic health records and other sources, means that any aspect of medical practice such as patient characteristics, symptoms of specific diseases, diagnostic criteria, medication doses and abnormal signs on radiographs or other technology can be reviewed and aligned to decisions on diagnosis and treatment. This data can be used to construct algorithms to create action.

AI can interpret visual information such as images and videos, to which it can then react based on its algorithms. Natural language processing (NLP) is how AI can understand and interpret human language, whether spoken or written.

Currently AI and NLP cannot mimic the human connection with others, our resilience and flexibility in response to experiences rather it acts as a diagnostic decision support, often in a specific clinical domain such as radiology and pathology, using algorithms that learn to classify. Examples include diagnosis of malignancy from photographs of skin lesions or from radiography, prediction of sight-threatening eye disease from tomography scans and prediction of impending sepsis from a set of clinical observations and test results.

Subcutaneous insulin pumps are driven by information from wearable sensors, and equipment like ventilator control is driven by physiological monitoring data.

Our clinical roles can be released to spend more time on explaining choices, discussing worries and anxieties and creating a shared understanding.

Digital Therapeutics and Gamification of Serious Play

Digital Therapeutics or DTx is one of the latest buzzwords in the digital health ecosystem.

DTx deliver evidence-based therapeutic interventions that are driven by high-quality software programmes to prevent, manage, or treat a medical disorder or disease. They are used independently or in concert with medications, devices, or other therapies to optimise patient care and health outcomes.

Chronic pain management, oncology support programmes, substance misuse interventions and lifestyle changes including health coaching, meditation and health behaviours such as exercise and diet all feature in our technological world.

SMART devices

Healthcare professionals are very familiar with blood sugar technology and substantial improvements in diabetic management, such as normalising blood sugars through SMART technologies however we need to upskill ourselves in understanding SMART data and their link to health outcomes.

Our devices, smart watches and phones measure our heart rates, count our steps, understand our sleep patterns and are part of Microsoft and other platforms.

This march of health sensors and wearables is expanding exponentially and now is interwoven with our clothes, can appear as digital tattoos and possibly digestibles or in our blood vessels as nanobots.

Digital health technologies can identify environmental factors, including air pollution and UV light, pollen and may lead to new ways of management of asthma or risk of malignancy and population health strategies. Food scanners could alert users to one of the constituents in their meal ensuring those allergic to certain foodstuffs are informed.

Facilitating Off-Site Patient Management through Telemedicine

COVID-19 drove many health consultations to a virtual technology and we then have been increasingly utilising the model of hospital at home, virtual wards and virtual consultation utilising remote devices to share information and provide services in a more effective and often more acceptable manner.

Robotics

Robotics, now are part of many surgical procedures and support simulation and learning, however the technology exists for robots that could undertake phlebotomy and other technical skills, disinfect environments and even be social companions. Toy robots have been utilised as educational resources for children with ASD and other disabilities and artificial limbs have become unique and admired.

However with every great opportunity comes unintended consequence

Algorithm bias has already commenced with the data collection process already mirroring certain population groups. We therefore need diverse and well balanced study populations, paying particular attention to racial and ethnic diversity, gender balance, socioeconomic equity, and other social determinants of health including ability to access a service.

Data needs to be accuracy, have identity matching capability, and privacy protections as part of the governance requirements for successful technology transformation.

The big technology giants such as Apple, Microsoft and Amazon are able to mine their health data creating more data points than traditional health services and may use AI models to create market opportunities.

Other challenges in technology include automation bias describes the phenomenon where we accept the guidance of an automated system and cease searching for confirmatory evidence, transferring responsibility for the decision to the machine. This is already seen in automation of blood pressure and oxygen saturations, believing the machine and not the presentation of the patient.

Cybersecurity and privacy concerns are major obstacles to digital health adoption and interoperability between systems continue to create problems. Cybersecurity requires special attention to avoid intentional corruption of training datasets (training data poisoning), use of AI by attackers, or anti-privacy designs in digital health.

An immediate priority is to ensure access to digital solutions as digital exclusion can reinforce inequity so ownership of devices, understanding of technology and broadband access is essential across all economic groups and all regions of the country and as a clinician this should now be part of our medical history.

Quality control questions that we need to be able to ask are:

• Has the system been tested in diverse locations and populations?
• How can we be sure the training data matches what we expect to see in real life and does not contain bias?
• How can we be confident of the quality of the ‘labels’ the system is trained on?
• Do the ‘labels’ represent a concrete outcome or a clinical opinion?
• How has imbalance in the training set been addressed?
• How is the system going to be monitored and maintained over time?
• Does the system adjust its behaviour (‘err on the side of caution’) where there are high impact negative outcomes?
• Does it produce an estimate of confidence?
• How is the certainty of prediction communicated to clinicians to avoid automation bias?
• How can it accommodate changes to clinical practice?
• What aspects of existing clinical practice does this system reinforce?

The transition from ‘outcomes that matter to the industry’ to ‘outcomes that matter to patients’ has the capacity to transform EBM and will be driven by the technology companies and our own interactions with apps, SMART devices and consumer led initiatives however it is also dependent on a highly-skilled digital health workforce, and the training challenge for leveraging digital health is our next learning journey.

So I will continue to enjoy learning about technology and its opportunities, alongside the responsibility to ensure that the limitations are understood. I look forward to the time saved through AI, leaving me the ability to communicate and create shared understanding with others on how to navigate the complex eco-system of healthcare.

The evidence base for health and care needs to integrate psychology, sociology, linguistics, neuroscience, computer science, artificial intelligence and philosophy, alongside traditional clinical practice taking into account culture, history and our environment.

Crucially, while processes and metrics work for predictable systems, they fall short in the face of human behaviour, complexity and uncertainty. In these contexts, algorithms alone are not enough. Health and social care must therefore place greater value on experience, empathy, professional judgement and shared decision-making.

From Dr Steve Sucklings blogs – https://themaslow.foundation/category/steves-thoughts/

I have been able to explore that we have four types of knowing;

• Procedural
• Prepositional (facts)
• Perspectival
• Participatory

In health, we have focused on policies, procedures and facts rather than wisdom, life experience, reflection, active open mindedness and situational awareness to enable the balancing of view points, appreciate context and provide the aspiration.

INSANITY – Doing the same thing over and over again and expecting different results. Albert Einstein

We often speak about understanding our patients, yet we rarely extend the same care to our staff. Like everyone else, staff move away from threat and towards safety, connection and belonging. Psychological safety and trauma-informed practice are therefore not optional extras; they shape how individuals, teams and whole systems respond under pressure.

When people feel stressed or unsafe, their thinking narrows. Memory and processing decline. Survival responses emerge — fight (defensiveness or aggression), flight (withdrawal), freeze or compliance. These are human reactions, not professional failures.

By contrast, when people feel safe and valued, they collaborate, think creatively and draw on their experience with clarity and insight.

We recognise financial and workforce constraints, but we must also acknowledge the invisible constraints we create through fear, silence or low expectation. Aspiration and ambition matter. So does making space to talk openly about emotions and how they influence our decisions.Power dynamics are rarely named, yet they quietly shape decisions and determine whether people feel safe.

Differences in role, status and professional identity naturally create imbalances of power. When these are unrecognised or poorly managed, they can leave individuals or teams feeling controlled or silenced and sometimes behaving defensively or even oppressively, often from a place of insecurity rather than intent.

If we want healthier systems, we must pay attention to four foundations of safety:

• Inclusion safety — everyone feels valued and respected.
• Learner safety — people can experiment, make mistakes and share what they are learning.
• Participation safety — everyone feels able to contribute meaningfully.
• Challenger safety — individuals can question decisions and challenge the status quo without fear.

Without these, psychological safety remains rhetoric rather than reality.

We have recognised from The Francis Report about Mid Staffordshire NHS Foundation Trust to the latest Ockenden Report about Shrewsbury and Telford Hospital NHS Trust and their maternity services, that we consistently deliver poor care. We have identified the importance of culture and that this is the bedrock of good practice, but we seem unable to move to a new way of working.

When we try to systemise the unpredictable and eliminate uncertainty, we risk reinforcing systems that already feel fragile and fear-driven. Uncertainty is not failure; it is part of working with people. Ignoring it narrows thinking and limits innovation.

Our organisations were built around single diseases, operating in silos. They were not designed for people living with multiple long-term conditions in complex social environments. As a result, we lack the structures, culture and routines needed for truly collaborative, interdisciplinary and person-centred care.

Partnership working adds further complexity. Health, social care and the voluntary sector each bring different histories, accountabilities and cultures. These differences are often poorly understood, yet they shape our Integrated Care Systems and how they function in practice.

At a strategic level, policy is often launched with optimism but limited attention to how it will be delivered. Politicians may overestimate impact, while local leaders grow sceptical. The result is a widening gap between ambition and reality.

Closing that gap requires shared understanding with co-creation with patients, alignment across partners and honest dialogue between strategy and frontline practice.

Most importantly, improvement should be measured over time, not through snapshots or league tables. Sustainable progress is reflected in continuous self-improvement, not comparison.

With a lens of new understanding, we can build on the foundations of EBM to form a new model of best practice which we have called Participation Centred Care where we merge personalised medicine and participation, organisational development and distributed wisdom and systems theories and philosophy with greater understanding of the totality of the statistical bell curve and celebrate our outliers narrative to inform our practice.

Evidence-based medicine (EBM) has transformed healthcare. It replaced intuition and tradition with research, data and measurable outcomes. It helped standardise care, reduce unsafe variation and improve survival in many conditions. Few clinicians would argue against its importance.

But an uncomfortable question is beginning to surface: has our devotion to evidence-based medicine also created blind spots — and in some cases, harm?

Modern healthcare increasingly treats the “average” patient as the benchmark. Guidelines, targets and performance measures are built on population averages, and services are judged on how well they deliver those standards. Yet real people are not averages. They are complex, shaped by culture, poverty, trauma, relationships and circumstance. When systems optimise for the average, those who do not fit the model often struggle to receive care that truly meets their needs.

We have come to see evidence as neutral and objective, but evidence is shaped by the questions we choose to ask, the people we include in research and the interests that fund it. Clinical trials often exclude patients with multiple conditions, yet multimorbidity is now the norm. Minority ethnic communities, older adults and socially disadvantaged groups are routinely under-represented. The result is guidance built on populations that look very different from those seen in everyday practice.

Conflict of interest deepens the problem. Pharmaceutical companies fund many large trials and influence which questions are studied. Positive findings are far more likely to be published than negative ones. Guidelines then lean heavily on what is available in journals, not necessarily on what truly works in the messy reality of everyday healthcare.

Regulatory systems compound the issue. Organisations are measured against performance targets linked to funding and reputation. Predictably, behaviour shifts to protect performance metrics rather than improve outcomes. Workarounds emerge. Patients are moved through services to meet targets. Assessments are relabelled. Care is reorganised to satisfy indicators rather than human need. The numbers improve; the experience of care often does not.

Meanwhile, the complexity of real life continues to resist tidy categorisation. People take medicines differently from how trials assume. Chronic illness rarely exists alone. Poverty, housing instability and trauma influence outcomes as much as prescriptions do. Yet our evidence frameworks struggle to account for these realities.

And then there is us — clinicians and decision-makers — who are not immune to bias. Under pressure, we rely on mental shortcuts. We anchor on early impressions, follow senior opinions, avoid challenging consensus and stick with plans even when new information suggests change is needed. Stress, fatigue and cognitive overload shape decisions more than we like to admit.

None of this means evidence-based medicine is wrong. In many cases it has saved lives. Asthma care dramatically improved through evidence-driven prevention strategies. Countless treatments are safer and more effective because of rigorous trials.

But history also shows how evidence can mislead. Hormone replacement therapy was abandoned by many women following early interpretations of risk that later proved overstated. Opioid medicines were promoted as safe solutions for pain, contributing to a global addiction crisis with devastating consequences.

The problem is not evidence itself. The problem is believing evidence is complete, unbiased and universally applicable.

Healthcare now faces a choice. We can continue refining guidelines and performance measures, or we can widen our understanding of what counts as evidence and whose voices shape it. Lived experience, qualitative research and community perspectives must sit alongside trials and statistics. Research priorities should reflect public health need, not commercial opportunity. Negative findings should be published as routinely as positive ones.

Most importantly, we need to ask simpler, human questions: Could people access care? Was it delivered well? Did it make a meaningful difference to their lives?

Evidence-based medicine was never meant to replace judgement, compassion or context. It was meant to support them. If we forget that, we risk creating systems that perform well on paper while failing the people they exist to serve.

Perhaps the future of healthcare is not about abandoning evidence, but about rediscovering wisdom.

We have built modern medicine on evidence. But what happens when the evidence doesn’t fit the person in front of us?

Evidence-Based Medicine (EBM) shaped my training and early clinical thinking. We were taught that research, data, and guidelines provided the safest route to good care. Follow the evidence, reduce variation, improve outcomes. It offered clarity in environments filled with uncertainty.

But over time, a difficult question emerged: what happens when people do not behave like the averages on which evidence is based?

Healthcare systems increasingly rely on processes and guidelines derived from large-scale studies. These frameworks may have contributed to improved safety and consistency. Yet, in creating them, we may also have built rigid structures that struggle to accommodate real human complexity.

Recent academic critiques suggest that EBM, once revolutionary, may now be facing a crisis of relevance. Papers such as The Emperor’s New Clothes: A Critical Appraisal of Evidence-Based Medicine and Evidence-Based Medicine: A Movement in Crisis? argue that medicine risks mistaking measurable certainty for meaningful understanding.

EBM underpins guidance from NICE and the Royal Colleges, shaping national standards of care. Evidence hierarchies place systematic reviews and randomised trials at the top, while qualitative research, clinical judgement, and lived experience sit near the bottom.

But this hierarchy carries unintended consequences. By privileging what can be measured across populations, we risk overlooking those who do not fit expected patterns. Outliers become statistical noise rather than signals that our models may be incomplete.

Qualitative research captures patient and family experience, offering depth and context numbers alone cannot provide. Yet such work is often treated as weaker evidence rather than evidence answering different questions. Similarly, individual case experiences are frequently dismissed, despite the fact that many advances begin by noticing when something does not fit.

Guidelines, built from aggregated evidence, increasingly shape decisions. While they support safety and consistency, they can also become perceived as unquestionable truths. Clinicians risk becoming passive implementers rather than thoughtful practitioners, with fear of deviation replacing confidence in professional judgement.

If EBM alone delivered transformative health gains, we might expect improvements comparable to sanitation, vaccination, or smoking reduction. While progress has been made, many of today’s greatest challenges: intesectionality, trauma, neurodevelopmental vulnerability, social complexity, long-term conditions and resist protocol-driven solutions.

This is not an argument to abandon EBM. Evidence and guidelines remain important. But medicine now faces a landscape defined by complexity, not simplicity.

We need to expand what we mean by evidence.

We must value lived experience, include families and carers, and recognise that context shapes outcomes. Philosophy, systems thinking, and relational care must sit alongside science to help us navigate uncertainty rather than simply trying to eliminate it. Improving outcomes in the real world requires moving beyond rigid hierarchies of evidence and rediscovering judgement, humility, and curiosity in clinical practice.

A Call to Action

Healthcare leaders, clinicians, commissioners, researchers, and educators now face a choice.

Do we continue refining systems designed for predictable problems, or do we build new approaches capable of holding complexity?

We need to:

• Treat lived experience as essential evidence, not an optional addition.
• Support clinicians to use judgement alongside guidelines.
• Design services for people who do not fit standard pathways.
• Learn from outliers rather than exclude them.
• Create systems that value reflection and learning over blame and compliance.

Evidence should guide us but it should not blind us.

The future of medicine will belong not to those who abandon evidence, but to those willing to broaden what counts as evidence in the first place.

And that work starts now

We have discussed culture, creating a vision, bringing together a team but what is it that can catch us out?

Most of us, feel “If only I work harder, learn more and perfect our skills, with passion and positivity, I can be an expert and will feel good enough.”

We need to shift from being an expert and competent at everything and doing it alone, to mastery, wisdom and achieving things collectively.

Children naturally practice mastery, uninterested in their performance when they are young enjoying experimentation and having fun.

As they become oriented toward performing well in education, children who meet a challenge, often feel that they are not good enough and abandon learning.

We know there is a whole range of knowledge, skills and competencies that people need to develop in order to succeed in a role. But, if we focus on growth and development and life long learning, we could find joy even when we are not good at it yet!

The path to mastery

While we are exploring and learning, the process transforms who we are. We grow and develop, connect and can share our ideas and knowledge.

Mastery requires endurance, dedicated time and continuous effort. It takes hundreds and thousands of repetitions, trial and error before we succeed.

As a leader myself, there have been times when panic has set in. Imposter Syndrome undermines my efforts and I am unable to be creative or share my guilt that I am letting everyone down.

By opening up, using a coach who created a reflective mirror, I explored new opportunities, stopped competing and put aside my short term goals to find a new direction.

Inspiration has come from understanding psychological safety, servant leadership, values led systems and distributed wisdom. This is supplemented by the joy of empowering others and using problem solving as a fun exercise.

Why is mastery out of vogue?

Our pull for perfectionism, gathering knowledge, creating correct systems and success tend to get in the way of being flexible, adaptable and always learning.

We feel guilt and shame for failing and letting people down. Rather than ask for help when we hit a barrier, we often feel we are stupid for not being able to solve the problem and hide when we make mistakes.

Real mastery requires us to become lifelong learners and coaching others.

• Purpose gives us energy
• Wisdom gives us energy
• Belonging creates energy
• Growth generates energy

Compassion fatigue and burnout are features of a dysfunctional workforce!

How do we develop mastery?

Benner: From Novice to Expert: Excellence and Power in Clinical Nursing Practice Novice is a good model of educational progression and we need to build on this foundation.

When we start a job, we acquire knowledge and develop skills, meaning we can follow a task to an end.

Then, we perform group of tasks with understanding, growing capability and confidence in the role. As our intuition develops, we become truly competent.

When we are competent, we grow the capacity to do more and find space available for us to help others. This is when we become an actual contributor to the broader team and meet the proficient criteria.

By contributing, others start seeking us for ideas, opinions and we become able to create solutions, connect the dots or bring teams together.

Experts grow from our own personal insight, becoming an influencer and modelling adaptability and mastery.

In The Nurture Wisdom Academy we deliver training in relation to roles:

• Nurture Ripple Induction and Competency include acting as a ripple of positivity. Our thoughts, actions and words have the power to affect great change far beyond ourselves. The small decisions we make every day – to laugh, to smile, to share a kind word – create an impact that spreads far and wide.

• Nurture Cultural Architect forms our proficiency programme building practitioners with confidence, psychological safety and reflexivity, whilst acting as a change agent. As a Cultural Architect, we consciously role model values and behaviours.

• Nurture Expert Academy, through mastery we are enabled to become aware of our latent power and grow trust in our collective ability to overcome hurdles and act as influencers to create ongoing transformation.
• By being part of teams, we do more than build technical competence, we cultivate principles, psychologically safety, and reflexive leaders who embody our core values of Ambition, Belonging, Creativity, Psychological Safety, and Nurturing Our growing alumni network will be committed to lifelong learning, peer support, and influencing systems change.

Through mastery, we will be both a leader and a follower in our individual and collective transformational journeys, igniting and inspiring change to create a journey of discovery.

You can change an organisation to adopt a new culture changing people in organisations to be cultural architects and you can create whole systems change through culture.

We know that this is achievable as we watch social influencers, technology companies and people adopting their latest craze and we see transforming communities across the world. They use technology, phones and self driving cars. We have a computers on our wrist and wecommunicate virtually.

So transformation is possible, happens and is achievable.

So why has changing organisational culture been so challenging.

Many of these blogs explore why we have found change so challenging.

We have put systems, policies and processes in place, hoping these will enable us to implement change however change is about people, with a shared mission not rules.

What are the first steps?

To create a different culture, we need to share a common vision. This vision needs to make sense and be logical. Even where individuals, are sceptical, they can be followers and build the foundations as a legacy for the future.

The flip side of leadership is followership.  It stands to reason that if leadership is important, followership must have something to do with it too.  But curiously, followership is not spoken about and will be negatively framed as ‘sheep’ and ‘being easily led’.

Followership is the ability to take direction well, to get in line behind a plan, to be part of a team and to deliver on what is expected of you. 

Good followers have a number of qualities:

• Judgement

Followers have an underlying obligation to follow only when the direction is ethical and proper.

• Work ethic, competency and being a team player

Followers are diligent, motivated, committed, pay attention to detail and make the effort to participate.

• Courage

Good leaders are grateful for constructive feedback and followers need to have the courage to be honest and share wisdom and experience

We need to understand how to include, not exclude individuals, and create a momentum of change which embraces followship alongside leadership.

Using this strategy of enabling people to step back and see the wider picture, identifying threads and relationships, a new common vision, goals and behaviours can be achieved with shared understanding.

Do not underestimate the dynamic of Power

Power lies at the heart of change and understanding where power is held or who is experiencing marginalisation is critical to success.

Power in organisations is often captured through professional identity or department identity but can be economic, political, social, cultural or symbolic. People’s experiences of power depends on their identities, related to age, gender, race, class, ethnicity, religion, sexual orientation or disability status.

A common conception of power is control over others, having authority and control over individuals, groups or institutions which can be backed up by action – often loss of a job.

Visible power is when decision making is observable and leads to formal and recognisable rules, laws, structures and procedures.

Resistance is a form of power often influencing of the agenda from behind the scenes.

However, power is subtler and can be positive.

• Collective Power is the strength and capacity gained from joining others in working towards a common goal.

• Power within is personal self-confidence and role modelling can be a form of power.

• The norms, values, attitudes, beliefs and ideology that shape a person’s way of thinking can influence decisions and form a powerful opportunity.

So looking into the organisation to identify how power can be understood and utilised to create a positive optimising effect is important.

What is Needed to Build a New Culture across Systems?

To create whole system transformation, organisations need to share a common vision, role model successful application and create win:win changes recognising the value we all bring to the whole community.

We can create powerful workforces to drive change and role model improvement.

Finding Inspiration in a Journey

With cultural change, embrace the journey and focus on making small, incremental steps and work closely with your workforce to create a movement of change.

Even when you are struggling, walking creates a pathway of footsteps and others can follow.