Dr Reva Gudi is GP and healthcare leader in Hayes, Middlesex, she is also a former Conservative parliamentary candidate, and serves as a local school governor and charity trustee.
The NHS is full of brilliant people, many of whom I have had the privilege to work with. Clinicians, managers, leaders, public servants who have given their working lives to the health of this country. Who understand the system deeply. Who see what needs to change. Who are more than capable of changing it.
But brilliant people, in an institution that makes dissent costly, will often choose silence. That is not a failure of character but a rational response to a system that rewards going along and penalises speaking up.
Throughout, I never left clinical practice. Which means I have seen the consequences of boardroom decisions at close range — in the consulting room, with the patients who live with whatever the system becomes.
My experience taught me that what really shifts the energy in a room is someone willing to go first. Someone prepared to say what everyone else is thinking. Someone who, when the institutional reflex kicks in, asks the question nobody else will. And hope that others follow suit.
As lead commissioner for the hospital CQUIN programme, I had a clear view of how it should work, and an equally clear view of why it hadn’t worked in the past.
So, when I suggested a different approach, the response was:
“But this is not how we do it in the NHS, Reva.” An experienced commissioner pointed out to me.
“Why not? I asked. “It’s not as though it’s delivering”
My question was followed by silence in the room. Then a discussion, a few smiles. I was an experienced clinician, leading on the programme. If it went wrong, the blame was mine to carry, and I was confident it would not come to that.
And frankly we had nothing to lose. Here is why.
CQUINs, Commissioning for Quality and Innovation, are the financial incentives through which commissioners push hospitals to improve the quality of care they deliver. The orthodoxy was settled: commissioners designed the incentives, presented them to hospitals, and hospitals delivered against them. Money followed performance. Targets were set. The programme, on paper, was coherent.
In practice, the results were consistently disappointing. The money was being spent, the targets were being met or said to be met, but the quality improvements were patchy, clinical engagement was thin, and patients were not seeing the benefits the programme promised. The reason was not difficult to identify. Hospital clinicians were being told what to do rather than asked what would work. Commissioners appeared to be designing incentives for a clinical reality they did not fully inhabit. The result unsurprisingly was that delivery fell short.
The approach we took was different, and I was fortunate to work with brilliant clinicians and management who were fully on board. Hospital clinicians came into the design process from the outset, before the incentives were set, before the targets were written, before commissioners had decided what the answer was.
There was pushback — some principled disagreement, some frankly about the established power relationship between commissioners and providers. But the clinicians who had previously been passive recipients of targets became active authors of them. The programme we delivered was one we believed in. It sustained long after the financial incentive had done its work. Patients had a better experience over a longer period than the old approach had ever produced.
This became my established way of working: challenging the assumption, bringing the right people in from the start, and being willing to be the one who said, “This is not working, let’s think this through differently.” If it failed, at least we would have tried.
After three years on the board of the Clinical Commissioning Group, when the Vice Chair stood down, I put myself forward against strong competition. What I was told afterwards was that colleagues had voted for me because they trusted that if something would not work, I would say so. Not obstructively, but honestly, and with a willingness to see it through.
I have thought about what that meant ever since.
It was not a compliment solely about my competence. Nor experience. There were plenty of people around the table with both.
It was a compliment about a single quality: the willingness to refuse.
The willingness to be the person who says: this is not working.
The willingness to accept the consequences of saying it.
And the persistence that followed.
There is a cost to this that is worth naming honestly. Saying no in an institutional setting is not just professionally risky. It can be lonely.
But I never felt alone.
The NHS has people who want to do things differently, because it is the right thing to do, for reasons that are evidence based. They will back you and stand right by you, as the person accountable. And work with you when the going gets tough. The resistance I encountered at times was seldom personal; part habit, part institutional inertia, part fear of consequences and the simple fact that change is hard.
When you find your critical mass, the people who see what you see and are willing to act on it — things can happen. Part of what made that possible was being unafraid of the consequences, as we knew what we were proposing was right for our patients, and for the system, in the long term. To me it was the most obvious thing to do.
I often found myself saying what everyone else was thinking. If experienced, capable people had privately reached the same conclusion and said nothing, the problem was not a shortage of good judgment. It was a shortage of willingness to bear the cost of expressing it. And when that becomes the norm, institutions lose the ability to correct themselves. They do not fail because nobody saw what was coming. They fail because the people who saw it looked at each other and said nothing.
Saying no was never the end of the conversation. It was the beginning of a harder one. The hardest part was not the initial refusal. It was staying at the table afterwards — longer, and with more difficulty, than simply going along would have required.
One senior leader told me: “You are a glutton for punishment, Reva.” They meant it warmly. I think the diagnosis was the correct one.
But silence is not only to be found in the room.
Recently, an ENT colleague working in the private sector told me he could run the same service in his NHS job, the sort that reduces waiting times, cuts unnecessary appointments and improves the patient experience. “But nobody had ever asked me,” he said. “And I did offer. So why would I bother?”
My concern is the NHS does not just risk losing talented clinicians when they retire or leave. It risks losing them when they stop offering ideas, when they conclude that their expertise beyond the consulting room is not wanted. When being consulted turns out not to be the same as being listened to.
There are many examples of what happens when brilliant minds are allowed to flourish — when the institution steps back and trusts the people inside it. The pandemic showed us this at scale. In a matter of weeks, services were redesigned, pathways were rebuilt, and the people inside the NHS were trusted to act on their judgment without waiting for permission. What had taken years to argue about in committee was implemented overnight. The question the NHS has never adequately answered is why that culture of trust and urgency disappeared when the emergency did.
The answer, I suspect, is that we go back to doing what we have always done.
The NHS has developed a habit of treating structural change as a substitute for difficult conversations and has been reorganised more than 20 times since 1974.Organisations have been abolished, merged, renamed and redesigned, each presented as the answer to the shortcomings of its predecessor, each consuming vast amounts of money, leadership time and institutional memory. The fundamental problems – waiting lists, workforce shortages, broken relationship with social care and the list goes on- are largely intact. All of this in the face of growing demand and finite resources.
It is difficult to believe that nobody saw the risks. More likely, there were rooms full of intelligent people who recognised the problems but calculated that speaking up was riskier than staying quiet.
From where I’m standing too few said no. And those who did were not always heard.
NHS England, whatever its flaws, provided something crucial the Department of Health structurally cannot: continuity across ministerial change. Seven Health Secretaries in eleven years, from both parties, each with new priorities and instincts bearing little relationship to what their predecessor had been doing. NHS England absorbed some of that churn. Its senior leadership carried institutional memory across the transitions and kept the NHS’s knowledge between ministers.
The answer was not to abolish it, but to ask what is working, what is not, and fix what is broken, building on what works. But do not replace it with another set of initials and another promise that this time will be different.
What the NHS needs now is the institutional equivalent of what happened in that commissioning meeting when a room stopped, heard a question it had not been asked before, and decided to try something different. It needs people around the table, in Parliament, in the Department of Health, in the NHS itself, who are willing to say: not like this. Not again. Show me why this time will be different.
I am aware that saying so carries a cost. There are easier things to do than put your name to an argument that implicates organisations I am so much a part of. Playing it safe would be the easier choice. But playing it safe is precisely what I am arguing against. If the argument is right, that institutions fail when capable people choose silence, then the least I can do is mean it.
And then stay at the table for the harder conversation that follows.
Dr Reva Gudi is GP and healthcare leader in Hayes, Middlesex, she is also a former Conservative parliamentary candidate, and serves as a local school governor and charity trustee.
The NHS is full of brilliant people, many of whom I have had the privilege to work with. Clinicians, managers, leaders, public servants who have given their working lives to the health of this country. Who understand the system deeply. Who see what needs to change. Who are more than capable of changing it.
But brilliant people, in an institution that makes dissent costly, will often choose silence. That is not a failure of character but a rational response to a system that rewards going along and penalises speaking up.
Throughout, I never left clinical practice. Which means I have seen the consequences of boardroom decisions at close range — in the consulting room, with the patients who live with whatever the system becomes.
My experience taught me that what really shifts the energy in a room is someone willing to go first. Someone prepared to say what everyone else is thinking. Someone who, when the institutional reflex kicks in, asks the question nobody else will. And hope that others follow suit.
As lead commissioner for the hospital CQUIN programme, I had a clear view of how it should work, and an equally clear view of why it hadn’t worked in the past.
So, when I suggested a different approach, the response was:
“But this is not how we do it in the NHS, Reva.” An experienced commissioner pointed out to me.
“Why not? I asked. “It’s not as though it’s delivering”
My question was followed by silence in the room. Then a discussion, a few smiles. I was an experienced clinician, leading on the programme. If it went wrong, the blame was mine to carry, and I was confident it would not come to that.
And frankly we had nothing to lose. Here is why.
CQUINs, Commissioning for Quality and Innovation, are the financial incentives through which commissioners push hospitals to improve the quality of care they deliver. The orthodoxy was settled: commissioners designed the incentives, presented them to hospitals, and hospitals delivered against them. Money followed performance. Targets were set. The programme, on paper, was coherent.
In practice, the results were consistently disappointing. The money was being spent, the targets were being met or said to be met, but the quality improvements were patchy, clinical engagement was thin, and patients were not seeing the benefits the programme promised. The reason was not difficult to identify. Hospital clinicians were being told what to do rather than asked what would work. Commissioners appeared to be designing incentives for a clinical reality they did not fully inhabit. The result unsurprisingly was that delivery fell short.
The approach we took was different, and I was fortunate to work with brilliant clinicians and management who were fully on board. Hospital clinicians came into the design process from the outset, before the incentives were set, before the targets were written, before commissioners had decided what the answer was.
There was pushback — some principled disagreement, some frankly about the established power relationship between commissioners and providers. But the clinicians who had previously been passive recipients of targets became active authors of them. The programme we delivered was one we believed in. It sustained long after the financial incentive had done its work. Patients had a better experience over a longer period than the old approach had ever produced.
This became my established way of working: challenging the assumption, bringing the right people in from the start, and being willing to be the one who said, “This is not working, let’s think this through differently.” If it failed, at least we would have tried.
After three years on the board of the Clinical Commissioning Group, when the Vice Chair stood down, I put myself forward against strong competition. What I was told afterwards was that colleagues had voted for me because they trusted that if something would not work, I would say so. Not obstructively, but honestly, and with a willingness to see it through.
I have thought about what that meant ever since.
It was not a compliment solely about my competence. Nor experience. There were plenty of people around the table with both.
It was a compliment about a single quality: the willingness to refuse.
The willingness to be the person who says: this is not working.
The willingness to accept the consequences of saying it.
And the persistence that followed.
There is a cost to this that is worth naming honestly. Saying no in an institutional setting is not just professionally risky. It can be lonely.
But I never felt alone.
The NHS has people who want to do things differently, because it is the right thing to do, for reasons that are evidence based. They will back you and stand right by you, as the person accountable. And work with you when the going gets tough. The resistance I encountered at times was seldom personal; part habit, part institutional inertia, part fear of consequences and the simple fact that change is hard.
When you find your critical mass, the people who see what you see and are willing to act on it — things can happen. Part of what made that possible was being unafraid of the consequences, as we knew what we were proposing was right for our patients, and for the system, in the long term. To me it was the most obvious thing to do.
I often found myself saying what everyone else was thinking. If experienced, capable people had privately reached the same conclusion and said nothing, the problem was not a shortage of good judgment. It was a shortage of willingness to bear the cost of expressing it. And when that becomes the norm, institutions lose the ability to correct themselves. They do not fail because nobody saw what was coming. They fail because the people who saw it looked at each other and said nothing.
Saying no was never the end of the conversation. It was the beginning of a harder one. The hardest part was not the initial refusal. It was staying at the table afterwards — longer, and with more difficulty, than simply going along would have required.
One senior leader told me: “You are a glutton for punishment, Reva.” They meant it warmly. I think the diagnosis was the correct one.
But silence is not only to be found in the room.
Recently, an ENT colleague working in the private sector told me he could run the same service in his NHS job, the sort that reduces waiting times, cuts unnecessary appointments and improves the patient experience. “But nobody had ever asked me,” he said. “And I did offer. So why would I bother?”
My concern is the NHS does not just risk losing talented clinicians when they retire or leave. It risks losing them when they stop offering ideas, when they conclude that their expertise beyond the consulting room is not wanted. When being consulted turns out not to be the same as being listened to.
There are many examples of what happens when brilliant minds are allowed to flourish — when the institution steps back and trusts the people inside it. The pandemic showed us this at scale. In a matter of weeks, services were redesigned, pathways were rebuilt, and the people inside the NHS were trusted to act on their judgment without waiting for permission. What had taken years to argue about in committee was implemented overnight. The question the NHS has never adequately answered is why that culture of trust and urgency disappeared when the emergency did.
The answer, I suspect, is that we go back to doing what we have always done.
The NHS has developed a habit of treating structural change as a substitute for difficult conversations and has been reorganised more than 20 times since 1974.Organisations have been abolished, merged, renamed and redesigned, each presented as the answer to the shortcomings of its predecessor, each consuming vast amounts of money, leadership time and institutional memory. The fundamental problems – waiting lists, workforce shortages, broken relationship with social care and the list goes on- are largely intact. All of this in the face of growing demand and finite resources.
It is difficult to believe that nobody saw the risks. More likely, there were rooms full of intelligent people who recognised the problems but calculated that speaking up was riskier than staying quiet.
From where I’m standing too few said no. And those who did were not always heard.
NHS England, whatever its flaws, provided something crucial the Department of Health structurally cannot: continuity across ministerial change. Seven Health Secretaries in eleven years, from both parties, each with new priorities and instincts bearing little relationship to what their predecessor had been doing. NHS England absorbed some of that churn. Its senior leadership carried institutional memory across the transitions and kept the NHS’s knowledge between ministers.
The answer was not to abolish it, but to ask what is working, what is not, and fix what is broken, building on what works. But do not replace it with another set of initials and another promise that this time will be different.
What the NHS needs now is the institutional equivalent of what happened in that commissioning meeting when a room stopped, heard a question it had not been asked before, and decided to try something different. It needs people around the table, in Parliament, in the Department of Health, in the NHS itself, who are willing to say: not like this. Not again. Show me why this time will be different.
I am aware that saying so carries a cost. There are easier things to do than put your name to an argument that implicates organisations I am so much a part of. Playing it safe would be the easier choice. But playing it safe is precisely what I am arguing against. If the argument is right, that institutions fail when capable people choose silence, then the least I can do is mean it.
And then stay at the table for the harder conversation that follows.