Fiona Day  0:03  

Welcome to transformational thinking for health leaders. I'm Dr Fiona Day, Master Practitioner, coach and chartered coaching psychologist. This is a podcast that will help you meet your most complex leadership challenges and transform your perspectives, helping you to become a more effective and creative leader with a deeper understanding of yourself and your own world of work. Professor James Dunbar spent 25 years as a GP in Dundee, also part time in forensic medicine and as an academic. His MD was a study of problem drinking, among drinking and driving offenders, which widened his knowledge of population level health. GP fundholding gave him an opportunity to improve the quality of primary care. After two years as the medical director at borders Primary Care Trust, which is when he was my boss in 2001 he arrived in Australia to set up the greater Green Triangle University Department of Rural Health Flinders and Deakin universities, which allowed him to work on both population health and quality improvement. Welcome to transformational thinking for health leaders. James,

James Dunbar  1:11  

Thank you, Fiona. Nice to catch up with you again.

Fiona Day  1:13  

It's always a pleasure. 

Fiona Day  1:16  

James, I'm going to start by asking you a question that you asked me 25 years ago, when I was still in my late 20s, which is when do you first remember thinking that you were a leader?

James Dunbar  1:26  

I suppose I'd have to say that it was before I really had a concept of leadership. As a kid, I was the one who was trying to organize things. When it really became clear to me was as a student. I was the president of the British Medical Students Association, as it was then, and went on to be the president of the International Federation. Both these were elected positions. Classmates didn't just elect me. They pushed me into it. You grow from these experiences. You learn as you go. 

Fiona Day  2:02  

So something about, like, back when you were kind of a child, but didn't really have a kind of concept around that, but then kind of moving into elected positions as a as a student, then, so thank you for sharing that. And in terms of, you know, like you're saying you've been a student leader, a reserve army officer, you've also been a healthcare and an academic leader as well as being a clinician, I suppose. What things have you learned from leading in these different settings? And what would you say are the common behaviors and skills that are needed to lead effectively? 

James Dunbar  2:35  

There are a lot of things that are common, and then there are specific things. I'd say there's more in common than different.  Seeing the big picture, being able to explain to people what they're part of, instilling the belief that it can be done. I tend to go a bit beyond that, because I usually try to have them believe that they can excel. 

Having a network on whom you can draw to get advice. I'm an enthusiastic asker of advice. I always pick up the phone. 

Not taking ‘no’ for an answer. Something that the army taught me was never ask a question if the answer might be ‘no,’ ask forgiveness, not permission. If you think you've got it right, you will be given the license to do it because you are on the ground and best able to make the assessment. But if you make a mess of it, you can expect to pay the penalty. 

Giving credit to teams while taking the responsibility and always remembering to say thank you. Celebrate success and recognise, of course, that success breeds success. When they are successful as a team, they go on to further successes.  

Another army thing is the division into four phases when you're going to make things happen.  Consultation. Everybody is consulted. Consideration. The boss considers every viewpoint, then gives a Decision, and Implementation. Everybody puts their shoulder to the wheel, even those for whom the decision the decision didn’t go their way. I think that's what distinguishes the disciplined, functioning organisation from one where every decision is the basis for yet another discussion. 

It works well everywhere. If you set off explaining to people, “This is how I work. I will listen to you. I'll weigh up what you've got to say. I'll tell you what the decision is, and then I expect you to put your shoulder to the wheel.” iI helps to get people going. 

One of the other common things, in almost any leadership position, is enlisting people. Working with volunteer soldiers, reservists, was a tough discipline, because if you didn't get it right, if you didn't enlist their support for what had to be done, they just didn't come the next weekend or didn't come to the annual camp.  It's really a good training ground. You have to enlist people in all sorts of other situations.

I think also it helps if you can plan and like and if you can explain your plans clearly to people. If you can make complicated things easy and sometimes challenging orthodoxy. Today's heresy is tomorrow's orthodoxy. It's back again to asking forgiveness and not permission, I suppose. 

These are the kind of general things that I would pick out as the skill set, and then along the way, you learn from your mistakes. Certainly, I've made many. Useful training comes along, and I guess that's exactly what you're doing. 

I deliberately had a peer mentor and a senior mentor at both my jobs in Australia and when I was a fundholder. They are really useful. When you scratch your head thinking, how do I get around this one, having two people who are not in the same organisational arrangement as you, they're outside it, is valuable. Mentors whom you can just phone up and say, “Look, this is what I'm trying to deal with. Have you come across this problem?” Usually, they have an answer. 

I guess the other thing, which all leaders have trouble with and isn’t taught at medical school or in postgraduate training, is dealing with organisational psychopaths and histrionic personalities. Unfortunately, they're rather more prevalent than we might like. They're a real downside because of the damage they do. 

I think that's probably enough for just now. You now know what the generality that I would have applied in most places where I've led.

Fiona Day  6:49  

I love that, and I really resonate with everything that you've said, but particularly, one thing that stood out for me is when you said about that, you know, creating that culture of excellence. And that's really what I saw you do at a very formative stage of my own career. I remember, you know, I kind of rocked up on your doorstep with an interest in a piece of work that your name was down next to, which was to evaluate homeopathy service. Actually, I don't know if you probably don't remember this far, far back, and then you kind of positioned me around the whole kind of chronic disease management leadership for the whole of the region that we were working in. And you gave me three things. You gave me a primer on leading the improvement of systems. You gave me a book on project management, and you gave me something else, and you said, just like, just go and get on with it. And you could just kind of like, left me to get on with it, but you were kind of always very much there in the background around kind of stretching me and my own potential and helping me to really see that. So I just want to acknowledge you around that, and I really recognize that that's you know that aspiring to excellence is something that has been very much a golden thread in your career. And I know that when you kind of then moved in, into your new role in Australia, which is quite a long time ago, and you set up this new University Department of Rural Health, tell us about that, because I know that this is also kind of that theme about aspiring to excellence is something that was really important to you at that stage.

James Dunbar  8:16  

First of all, Fiona, I recognised your talent; that I could just do that with you. Here's three things to read, and now get on with it. I wouldn't do that to everybody, Fiona, that's for sure! 

Australia. Well, my wife  was a GP, and we were fed up with the NHS. One Saturday morning in the days when the BMJ came in the post, people looked at the adverts at the back and said, “I'd like to be a cruise doctor” or whatever. She was making breakfast and said, “We don't have to put up with this. We are in a global economy.” 

I started looking for jobs elsewhere, and this job appealed to me. It was setting a university department up from absolute scratch. I'd done enough academic work and was an Honorary Reader at St Andrews. I could pass muster.  A generous budget, an absolute greenfield site, no staff appointed. Within a certain framework, I could, decide what work I did, and with whom. What a privilege, what a wonderful thing! 

The first appointment I made was a senior program manager, because I wanted my academic staff to do only academic work, and not the silly form filling the university kept giving them. I could employ administrative staff to do it cheaper and better. The senior program manager was in for her first day, and I said, “I want you to know I've come to Australia not to set up a University Department of Rural Health.” Pause – astonished look from her!  “I've come to set up THE University Department of Rural Health.” She ran with it, and within five years, we were the top primary care research centre in Australia. We were beating the top universities, the Sandstones. That is something about how, if you aim for excellence, people love to be on the winning team, and they will work hard to achieve it. 

When it came out for interview, they said the task was to present my research plan for the new department. Cheekily, I said, “You Australians have absolutely no idea why your rural health is worse than in the capital cities. It's like the medieval explanation for malaria,  the miasma. As you drive down the freeway towards rural areas, you suddenly get infected by breathing.” Since cardiovascular disease is the commonest cause of mortality and morbidity, I'm planning to do a risk factor study. We know three risk factors explain most of cardiovascular disease. We will look at these risk factors and see how they compare. So we did, and I was able to bring in great collaboration from Finland to help. 

We were able to demonstrate exactly what the explanation for poor rural health was. Rural people are older, less educated and poorer. The risk factors were the same as socioeconomically matched groups of Metropolitan people. Having the Finns was a bit of luck. They are the world experts. The second piece of luck was that the Finns had just pioneered Diabetes Prevention at a time when the Australian government wanted a pilot of diabetes prevention. We were able to offer them a twin project with us running it in Australia. That gave us two strands of work, which propelled us right onto the national scene. For almost 25 years, the diabetes prevention work has been running in the state health services of Victoria. In that regard, we're way ahead of the UK. So

Fiona Day  11:59  

it sounds like some really fantastic work that you, that you did when you kind of came to Australia, and they using the kind of Finnish models and identifying these wider determinants of health.

James Dunbar  12:10  

We were able to pick somethings that were important to do, and it has been fun along the way. That's the other thing. Everybody who has been involved has enjoyed their work. And

Fiona Day  12:21  

That's so important, isn't it, that, you know, the good work is good for us, and part of good work is the joy in work.

James Dunbar  12:27  

One of the things about the NHS, when I left it, and I hear a bit of it from people still there is the joy has gone out of the work. That's terrible. The joy going out of your work. 

Fiona Day  12:40  

We're on a mission to put joy back into work at Fiona Day Consulting. So  James. Do you think then, I mean, I'm really interested in adult development and developing medical and public health leaders? Do you think there's something about how leaders brains work that allows them to lead in different circumstances. What's your observation around this?

James Dunbar  13:05  

Let me start from something I noticed because I have read quite a bit of military history. I noticed that when I was reading biographies of generals, they had frequently read the biographies of other generals. I wondered if the explanation was not because they sought tips about how to win battles, but that they wanted the vocabulary to describe what generals do, what goes on in their heads, intuitively. 

We've known for a long time that there were people at school who did physics and maths well, but not French and German, and vice versa. We know there were differences, and there were people we called clever and people we called not so clever. Now we know about neurodiversity, so we're beginning to open up our thinking. 

For me, it really opened the day when one of my partners in general practice, who was 40 at the time, came in and said, “I've read in the Sunday Times that I've got synesthesia. I thought, everybody thought in colours” she said. We all said, “What's synesthesia?” “ Well,” she replied, “every word, every number, has a unique colour.” I said, “Everything.” She said, “Oh, well, maybe the really abstract things are all black, but otherwise, everything's got a unique colour.” I thought, my God, imagine going through life thinking everybody else is like that. 

It took me another 10 years to realise that I think in projects. They are visual for me. When someone says, let's do this project, I either have shutters, I don't see anything, and I avoid that project like the plague, or I see the whole of the project right in front of me in seconds. 

I use the description of it being like a journey where you're standing on the top of a very high hill and heading for another very high hill in the distance. You can see much of your route, not all of it, some of it. You know you must get maps out and ask people, and so on. I have this ability to see the project instantly, which has great blessings, because I can describe it to people. But it has two downsides. The first one is that it took me a while to realise that people at least as clever as me weren't following what I was saying, and I'd have to explain it in different ways. It was just that their brains weren't thinking in the way mine was. Management people call this a problem with pace. You can get the pace wrong. The other one, of course, is if you're working on someone else's project, you have the Curse of Cassandra. I will have seen all the problems that will go wrong with the project. You can make yourself unpopular telling people about it. Also when your Cassandra prophesy transpires, don't say, “I told you so.”

I don't know how many leaders have brains that work this way. 

I think most of us are intuitive leaders. We can get better with practice, but I think the view that you can just take anybody and make them a leader is not that great an idea. Armies do it to some extent but people rise up to certain levels, and then they hit their ceiling. I think mostly leaders are intuitive, and they've probably got things going on their head that they're not even aware of. It’s just how their brains work.

Fiona Day  16:25  

So there's already some kind of foundations in place that provide a stronger or a more rapid way to progress in terms of leadership, for some people than others. But personally, I subscribe very much to the view that you know, like, we can all learn certain leadership skills, and we can all enhance our ability to lead. And that is, you know, leadership is a that never ends, that you never get there. There's always more kind of ability to lead in complexity that you can do

James Dunbar  16:56  

Absolutely. I would pick out John Cleese, as having shaped a lot of what I have learned. In the ‘80s, John Cleese, fed up with how British industry was underperforming, created a company called Video Arts. 

He famously said, “I learn nothing while asleep and very little when I'm bored.” He deliberately created these really amusing but highly educational videos. You can find them on YouTube. For example, Every Complaint is a Gem. Instead of being angry about complaints, you can learn lots and improve your setup with them. Meetings, Bloody Meetings. Efficient running of meetings is important. Behaviour breeds Behaviour. And, of course, a heap of things on managing change. 

The one that transformed our fund holding practice was Belbin team types. Each team member fills out a questionnaire. We each have a team type with strengths, and what are called allowable weaknesses. Team strengths, which is the team roles we each play is not our personality, intelligence or our job. We just play that role in the team and we also have allowable weaknesses. Sharing our team types with the rest of the team was terribly important for team building because we could then all recognise what strengths we brought to the team. We did this for the whole team, receptionists, everybody. I'm a shaper. The moment they realised I was a shaper, they would tolerate me saying, “Let's get this done now!” Belbin was very important. 

I'm great believer in training. The army does it deliberately. If you're an officer, you start off as a Lieutenant, and then if you're good at that, Captain, and so on. Every year, you get feedback on your performance. At each level, you go on a course. First you go on a junior officers course, and then a senior officers course, and then a commanding officers course. The army very deliberately sets about training and advancing you. 

Health Services do that a bit, but not much. The vacuum must be filled by you, Fiona.  Plugging the gap by the work that you're doing.

Fiona Day  19:10  

Something about that, that kind of spiral approach to leadership, isn't it? How you kind of keep building on it and keep raising people's capacity to lead in increasingly complex environments, and I suppose, just thinking about artificial intelligence and kind of, you know, what's emerging around that, I'm curious. I'm sure you'll have some views James around AI and leadership.

James Dunbar  19:34  

Well, AI, the short answer. I have absolutely no idea what AI is going to do to leadership. You can make some guesses. Already ChatGPT could make the communication of a plan or a proposal, much easier. You could set it so that it moved at the pace that individuals needed. It could have feedback loops built in almost like self-learning and program learning, but rather cleverer than that. AI could help a lot with some routine things, like developing plans and so on. 

My doubts are about whether AI can mimic that ‘being yourself,’ which leadership is, whether you're speaking to a small group or standing in front of 200 people, that bit that is you, which comes across. I'm not sure that we're going to allow a robot to influence us in quite the same way.

Fiona Day  20:35  

Who knows? So interesting, isn't it really like, what is that essence of humanity in the leader, which is the bit that can't be replicated, or that we think probably can't be replicated. I'm curious about that. And James, you know, you continue, I know you've retired from your kind of, your main job, but you carry on. And you're, you know, you're now an environmental activist and you've been involved in the Australian healthcare policy collaborative, just tell us a little bit about that kind of transition from your main career and what you're doing at the moment.

James Dunbar  21:10  

Well, that's that's quite easy. I'd retired from the job I came here to do. After about a week, and I had two phone calls that started with the same sentence, “You'll have a bit of time on your hands now. How would you like to .. “ Now, the great thing about retirement, of course, is you can say yes or no. One was short term and was very interesting. It was a small project for the Australian Primary Care Collaboratives, which I had set up. 

The Australian  Health  Policy Collaboration was different. It is a policy think tank which is set up to influence the Australian Government on preventive policies. It was something completely new for me and challenging. The post I have is the Clinical and Research Director. We've worked on targets - what should the targets for the Australian public health be? It was great fun, because I worked with Australia's 60 leading public health experts, setting targets for cardiovascular disease, tobacco, alcohol, food and so on, then trying to influence the government. 

In the most recent project we did aimed to narrow the life expectancy gap for people with serious mental illness. One in 10 of them die from suicide, and nine out of 10 die from the same causes as the rest of us. They just die 10 years earlier. We know very well how to deal with cardiovascular and respiratory disease risk. We know about diagnostic overshadowing. We know about the cancer screening programs. The challenge was to set a system up in which people with serious mental illness participated, would be come in to have their risk factors assessed, participate in the programs, go to quit smoking classes and all the rest of it. 

So why did we do it? Well, the interesting thing, Fiona, is that New Zealand, Australia, and the United Kingdom, all have high level policies for solving this problem, and they've achieved nothing. At the start, one thing I said was, “The reason they've achieved nothing is if you show these policies to people at the front lines of care, they mean nothing to them. They're going to say, what do you want me to do with this?” I argued that we needed to start the other way round. We need to ask people at the front lines of care, which is the only place you can improve quality, what are the tools to do the job better? Involved them in the redesign. 

There was a strong push that we should also bring the consumers in. Nowadays, co design is a buzzword. It's a Shibboleth. You have one of the consumers on everything, and they're supposed to somehow represent all. We did something quite different. We enlisted some of the national consumer leaders. We give them their own group. We also had a microsystem group, a macro system group, meso system group, and a quality improvement group, and they and the consumers’ group were all equal. 

We used thematic analysis so that in real time, not as a research thing, every group knew exactly what every other group was talking about. It became clear, we needed to bring the chairs of all the groups together and have a real head-to-head, hammering out what needed done. It was a highly successful process that came up with a practical plan for what people at the front lines of care could do to improve outcomes. The consumers were in support. 

So there we go. Our reports have been accepted by the Australian Government and we are writing up a paper on our novel methodology. I would think the kind of clinical leaders that you are training would find this approach to policy infinitely better than some bureaucrats  in London or Canberra coming up with stuff. It's just gobbledygook they turn out.

Fiona Day  24:53  

It like a really radical and effective way to bridge that gap between research, policy and practice in a really empowering way that's hopefully going to really kind of translate to impact population outcome. 

James Dunbar  25:08  

At the end of the day, it's the people at the front line who change the quality. Nobody else does. The front line being where the patients and their families meet the system, the GPs or the emergency department, or wherever it is. That's where you can improve it, not in London or Canberra.

Fiona Day  25:24  

I really look forward to hearing how that project, you know, manifests, and perhaps you'll come back on a future episode.

James Dunbar  25:30  

The Australian Government has already put A$78 million towards it in the last budget. So we're on our way. Some of the implementation is just using the existing funding well. Therefore, some progress will happen anyway.

Fiona Day  25:45  

That’s wonderful to hear. And just before we close, James, you know about the environmental activism that you're engaged in, because I suppose I've noticed a lot, lot of my clients over the years have become increasingly concerned and wanting to not, maybe not even work in health anymore but want to work in environmental issues, but tell me about your role in environmental activism.

James Dunbar  26:12  

First of all, your people are merely expressing what WHO has said, which is climate change, Global Warming is the largest threat to health. I often say I do these things for my grandchildren because I'm concerned about the world they're inheriting. 

The story is that a group of us who are retired meet on Wednesday mornings for coffee. Most of them are ecologists from different disciplines. One coffee morning, nearly four years ago, someone said the gas companies were holding a consultation that night. They're going to tell us all about the offshore seismic surveys they're planning. We said, “What are seismic surveys?”

 We went along, and three of us just looked at each other and thought, this is such nonsense. We came out of the meeting and asked ourselves, “Who is going to call this nonsense out?” Then we looked around and thought, it'll have to be us. We formed the Southwest Coast Scientific Group, and there's an NGO here called the Clean Ocean Foundation, which was willing to give us a home. We operate through it.

We have a regulator to which the gas companies have to apply before they can carry out these surveys. We looked at their applications. People can comment on their plans. We went through them. 

Fortunately, one of us is a physicist, so he understood the seismic surveys are blasting at 250 dB every 10 seconds, for 20 hours a day for up to 200 days. The marine biologist understood what that would do to the environment. Everybody had been worrying about the whales.  No one had thought about the krill, which is the keystone species. Kill the krill, nothing left, ocean dies. We worked out that they were going to kill the krill many times over in an area half the size of Tasmania. 

The company has been sent back for the third time to rewrite its plan on environmental grounds. We assume that we've managed to find their Achilles heel. You probably know that Exxon knew about climate change in the 60s. They hid it from everybody, attacked the science and attacked the scientists. It's very likely that the gas companies know exactly what the effect on the krill is. They're simply not prepared to admit to it. 

That's what we're doing, and we're having a bit of success. We've recently submitted a paper for peer review where we've modelled exactly what will happen to the krill. We know what they're doing out there, how close the sail lines are, what speed the ship goes at, how often they blast, what the effect of the blast is, and it's five kilometres of seismic slaughter with every blast. They're moving so slowly, just wiping everything out.  Our paper calls from a moratorium. But of course, that's only a stop gap. We really shouldn't have any more exploration for oil, coal or gas. It should have stopped by now.

Fiona Day  29:29  

You really have had or and are still having a career that bridges that research, policy and practice, haven't you? James, and it's really, really inspiring to hear all of that, and you know, the environmental issues that you're engaged in are very real and very serious. And I'm really glad to know that you're out there, you know, with your Wednesday morning group taking a stand about this, because there's something about the quality and the excellence and the rigor of your thinking that you're collectively bringing to this, and then you're able to go. Kind of both influencing what's happening, but also writing that up academically and documenting it, which I think is also really, really important, really wonderful to hear.

James Dunbar  30:09  

It is, and it's often underestimated by people in the service how important it is to use the peer reviewed literature so that your findings are never lost. Then it's always there. You can prevent some bunch of politicians coming along and rewriting history. 

The truth is, I'm never out of trouble for very long, Fiona, as you probably remember, but I've been very lucky. I've had a most enjoyable professional life, I have to say,

Fiona Day  30:39  

Well, it's been wonderful catching up with you and hearing about all of your multiple you know, multiple aspects of your career and how you've continually reinvented yourself over the years and changed with the circumstances around you. And you've gone on and done some amazing work and still doing amazing work. So James, thank you so much for being again.

James Dunbar  31:00  

My pleasure, Fiona, thank you. Have a good day.

Fiona Day  31:05  

If you've enjoyed this podcast and would like to find out more, head over to www.fionadayconsulting.co.uk and you'll receive three hours of free CPD, the health career success program when you sign up to my newsletter. And there's loads of other resources to support you as a medical or public health leader on my website too. Thanks for listening.