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.

I am reviewing this blog, a year after the question – do we pivot or push?

Our pivot below worked and we are a service provider and are currently expandng into a possible new workforce. So pivoting worked and now we are pushing and strengthening our model and can now develop our own workforce.

As a blogger on healthcare entrepreneurialism, we have a real life interesting dilemma which I can share and currently do not know the answer. This is on whether we pivot and change direction or continue to push on doors as a new start up business.

We have recognised our own skills in creating workforces with purpose that are happy and enjoy being part of a family and wished to scale our expertise to support wider industry.

For 6 months, we have approached NHS strategic figures, local organisations, both NHS and private to disrupt the locum model of staffing delivery. We believed that we needed to employ staff and support them with a robust wraparound service. This includes training that enables staff to be resilient, understand their emotions and be part of the solution creating a positive culture of ‘Nurture Ripples’. Our model was unfamiliar, with an attempt to provide 3-6 month placements rather than crisis workforce solutions and our staff were paid standard banding salaries but with our nurture support, rather than the elevated agency/locum rates.

On commencing our marketing and due diligence, we identified that there are staffing frameworks which are currently closed until next year. Although, we found possible alternative mechanisms for funding, our model was difficult to explain and possibly confusing and in addition there is distrust of the industry and the anticipation that anything offered is ‘to good to be true’ and ‘we have been promised and let down before.’

Even placing people for free, led to conversations about whether we were going to fund any additional training needs, honorary contracts and secondment that required processes which were already overwhelmed and poor understanding of where accountability and risk lie creating further barriers.

We have reinforced our knowledge that health and social care staff need additional support, that their careers are not meeting their expectations and that they are overwhelmed and often unhappy. Our health and social care workforce themselves are also prepared to talk to new businesses and are asking for support.

We know that our values and content are aligned to the current eco-system with shared language of psychological safety, trauma informed organisations, inclusion, freedom to speak up, authentic leadership, activation to hear hidden voices, sustainability and shared perspectives.

In starting a new business, obviously the best outcome, is that all your assumptions are correct, that the resources flow and that scaling and growth are achieved without challenge.

However, our initial assumptions are incorrect.

• We assumed health and social care would jump at the opportunity for staff
• We assumed attracting the workforce would be difficult

In studying pivot and change, many businesses significantly pivot during their life time.

The path to enduring success is rarely a straight line. ‘Cornelius Vanderbilt switched from steamships to railroads, William Wrigley from baking powder to gum. Twitter launched as a podcast directory and YouTube was once a dating site’.

Research shows that new ventures that reinvent their businesses—even multiple times—cut their chances of failure by conserving resources while continuing to learn more about customers, business partners, and new technologies.

Being able to say I am wrong!

Changing your mind is always hard. Asking questions, challenging assumptions and swallowing your pride is never easy but is part of running a service and creating innovation as it is only through experience that we can learn.

Accepting or Rejecting Conventional Wisdom

When looking at our next step, we have to consider our risk appetite.

My heart says that we should risk everything to make a difference to those we serve and that even the smallest chance should be taken to create a health and social care workforce that thrives.

I, however, recognise that this is irresponsible where resources are stretched and that we need to make the best decisions which utilise our resources wisely and enable us all to have security in our roles.

In addition, many of us have mortgages to pay, limited hours to spend on new endeavours and need to ensure that our futures are secure so cannot take any risk.

Our current position sits between these extremes. We are fortunate that we can take some risk and afford to experiment and redesign but basing this on evidence creating realistic solutions to build success.

So it is our choice whether to pivot or push.

We believe we are looking at true transformation and therefore have to accept a real chance of failure alongside success and this is OK providing:

• The difference we make, really will change culture and enable people to thrive

and

• That we enjoy the journey and through exploration are learning and moving forward

Doing Our Due Diligence

Everything is unpredictable, however we have looked at all our insight from all our sources.

We clearly have the continued crisis of staffing: https://committees.parliament.uk/committee/81/health-and-social-care-committee/news/172310/persistent-understaffing-of-nhs-a-serious-risk-to-patient-safety-warn-mps/,

We have tested the market place and know we can make a difference:

• Helping Hands Team
• Wisdom Academy

Our Business Analysis shows that across our landscape there is significant competition, so our employers have lots of choice and do not have time to analyse competition. They have their own workforce strategies which appear to have many similar threads to our own offering although their ability to provide sustainable change is proving challenging.

Our workforce, despite having numerous organisations, statutory, private and third sector, employer programmes and employer assistance with access to a multitude of education and wider resources are still asking for something different.

Focussing on our workforce as our customer therefore feels the priority, with the challenge of demonstrating credibility, creating a unique USP and a strong brand with an offering that people value and want to return is our challenge.

How to make the best from our pivot position.

While pivoting can breathe new life into something that might otherwise fail, it also means starting from scratch and abandoning the investment that you have put in up until this point.

We do not underestimate the barriers to entry but want to create happier staff, who feel psychological safety in their day to day practice. This enables them to belong, be creative and achieve their ambitions. In turn, they can create a ripple of positivity enabling culture change in health and social care. We believe we can achieve this one person at a time!

In chatting to our workforce, they feel exhausted, overwhelmed and that they came into a role to care for others and find themselves unable to care for anyone. Enabling them direct access to our Helping Hands Team and to source education that supports them to understand how to manage risk and uncertainty, toxic cultures and how these come about, will be our focus.

We have decided to pivot and I can share whether this is a successful strategy from our blog and will share what we learn from the experience and how we move forward.

Below is an interesting Masters of Scale Podcast which explores this subject.

https://mastersofscale.com/jack-conte-2/

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.

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 in all occupations, team work and making a difference alongside showcasing our skills can enable us to feel pride and success.

There is also work in our home lives, with children, household tasks and wider demands. These may inspire however these are equally hard and exhausting. Embracing the chaotic nature of life is to accept that some periods of your life will be filled with ‘work’, while at other times, our homelife may be more present.

What we all need is time to feed our soul!

Reading may be the space to find joy.

Walking might be our sanctuary.

Spending time with friends and family can feed our soul.

For me making a difference to some-one is rejuvenating and 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 liquid.

We need to identify our own energy production activities and dedicate time to creating more liquid in our bucket.

We also need to understand when energy draining experiences occur.

Every day we need to have joy and energy creation and this is then able give us resilience to survive the difficult when our energy is used up.

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.

Through feeding our souls when we can, enjoying the journey that is appearing and finding ways to be resilient when needed, when darker times occur, we will have strategies at hand to move forward through sadness, anxiety and tiredness.

Unlocking Energy with Purpose

By having a sense of purpose, this has been shown to increase our energy levels.

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.”

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 life opportunities which feed the soul as well as demand our energy.

My priorities are:

• Creating purpose which connects us
• Ensuring we take time to enjoy and celebrate our journey
• 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.

We like to think of evidence-based medicine (EBM) as objective, neutral and fair.

But it isn’t.
Not entirely.

Because Evidence Based Medicine (EBM) doesn’t exist in a vacuum, it exists inside systems shaped by power.

And power is uneven. Talking about power in healthcare can feel awkward. It challenges our belief that we work in systems built on equity and fairness.

But if we don’t name power, we can’t see how it shapes decisions, whose voices are heard, and ultimately what counts as “evidence.”

My perspective on this comes from moving between roles: doctor, nurse, board member, patient, and family member.

And here’s the uncomfortable truth:

• As a doctor, my voice carries authority.
• As a nurse, my relationships create richer conversations.
• As a patient, I sometimes choose silence because I do not want to be known as the professional yet as a family member, I use professional identity to influence outcomes.

Same person. Different power. Different impact.

What does power actually look like?

Power is often mistaken for hierarchy, but it is far more fluid than that. It operates across individuals, teams, organisations and systems, shifting depending on relationships, context and access.

It is rarely explicit. Instead, it appears in who sets direction, whose knowledge is valued, who controls time and resources, and who feels able to speak.

We all hold power in different ways, through action, influence, silence or resistance.

Power also exists in the gaps between people. Where connections are incomplete, those who bridge them can enable, shape or restrict what happens next. These “structural holes” are a constant feature of complex systems like healthcare.

EBM is shaped by power—whether we admit it or not

EBM relies on shared decision-making.

But shared decision-making assumes something that often isn’t true:

That power is balanced.

In reality:

• Professionals hold clinical knowledge, system familiarity, and authority
• Patients hold lived experience but have less legitimacy in decision-making spaces

The Inverse Care Law states that those who need care the most are often least likely to receive it. Not just because of access but because of other dynamics.

Patients must:

• Translate their experiences into “acceptable” language
• Fit into service categories
• Navigate complex systems

Some people are better equipped to do this than others.

Even when patients know more about their condition than professionals, their voice can still be overridden especially if they are perceived as ‘the difficult patient’ and increasingly we reference complexity but we are not sure what this is referencing.

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 our own experiences, and through the mutual sharing and commonality of experience, embodying hopefulness. This is underpinned by the concepts of mutuality and reciprocity and the central focus being on building trusting relationships rather than intervention.

Trust is therefore the important element of successful personalised care and being able to discuss the power dynamics to enable us to make sense of the world.

Our latest organisations embed psychological safety, so that we can share our perspectives and the knowledge gained.

Redefining what counts as knowledge

Evidence is often framed narrowly, clinical trials, guidelines and measurable outcomes. Yet it also lives in experience, in relationships, and in context.

When we overlook these forms of knowledge, evidence-based medicine becomes partial rather than whole.

Power within teams

Teams are often spoken about as if they are neutral collections of people working towards a shared goal. In reality, they are shaped by layers of power that influence how people behave, contribute and are heard.

Power sits in status, in relationships, in access to information, and in control over resources. It is not always visible, but it is always present.

You can see it in the flow of conversation and who feels able to speak, who is interrupted, whose ideas are taken forward, and who remains on the margins. These patterns are often subtle, but they shape both experience and outcomes.

When power becomes unbalanced or unacknowledged, it begins to distort how teams function. Information may be withheld, alliances form, individuals undermine one another, or difficult conversations are avoided altogether. Energy shifts away from purpose and into self-protection.

Over time, this doesn’t just affect team dynamics, it alters decision-making itself.

Organisations as power holders

At a system level, power becomes more diffuse, and often more difficult to see clearly.

Large organisations, particularly within health and social care, act as anchor institutions within their communities. Through their size and reach, they influence employment, the distribution of resources, access to services, and ultimately the wellbeing of the populations they serve.

Yet many of these organisations are operating under sustained pressure with workforce shortages, financial constraints and increasing regulatory demands. This creates a tension at the heart of the system, organisations hold significant power, but often experience themselves as constrained or reactive.

When systems feel under strain, patterns emerge. Attention turns towards immediate pressures, with a focus on managing demand rather than shaping improvement. Collaboration can give way to competition, particularly where resources are limited. Short-term performance begins to take precedence over longer-term outcomes.

In this space, the potential of the system is reduced not through lack of intent, but through the way power is experienced and enacted under pressure.

The risk of we ignore power

If we don’t understand power:

• We reinforce inequality
• We silence voices
• We create unsafe systems
• We mistake compliance for good care

And ultimately, we compromise EBM itself.

No one can give you power. Titles don’t guarantee it. Structures don’t sustain it.

Real power comes from awareness, relationships, values and behaviour. It shows in creating space for others, sharing knowledge, admitting uncertainty, challenging when needed and connecting across boundaries. It is often quiet but deeply influential.

Final thought

The admission that we don’t have all the answers isn’t weakness.

It’s one of the most powerful things we can do.

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.