Leadership Listens 7 – Compassion in primary care

This recording is a conversation between Michael and Dr. Rachna Chowla a Joint Director of Clinical Strategy, King’s Health Partners and a GP at Albion Street Group Practice in Rotherhithe. The conversation and focusses on compassion in primary care between clinicians and patients, between colleagues and underlines the importance of self-compassion.

Paul O’Neill [00:00:02] Hello and welcome to leadership listens, curated podcasts for leaders in health care. My name is Paul O’Neill, head of strategy, research and development at the NHS Leadership Academy, part of the People Directorate of NHS England and Improvement. This mini-series of podcasts as part of Leadership Listens, is a series all about compassionate leadership. It’s a collection of conversations between Professor Michael West and a leader from the health and care sector. This recording is a conversation between Michael and Dr Rachna Chowla, joint director of Clinical Strategy, King’s Health Partners and a GP at Albion Street Group practice in Rotherhithe. The conversation focuses on compassion and primary care between clinicians and patients between colleagues and underlines the importance of self-compassion.  


Michael West [00:01:01] Welcome everybody. My name is Michael West, I’m senior visiting fellow at the King’s Fund and professor of organisational psychology at Lancaster University, and it’s such a privilege and pleasure to be involved in these podcasts, focussing on compassionate leadership. And today it’s a particular pleasure because I’m joined by a friend and colleague and co-worker and fellow traveller in this amazing journey of our lives. Dr. Rachna Chowla. Rachna, a really warm welcome to you.  


Rachna Chowla [00:01:33] Thank you, Michael. It’s always a pleasure to be spending time with you.  


Michael West [00:01:36] So I must tell listeners a little bit about your enormous experience and varied background. Your joint director of clinical strategy at King’s Health Partners, which is an academic health sciences centre, and you lead on collaborations with primary care and emerging primary care networks with a focus on how we can improve the health well-being fulfilment of local people served by the organisations in that area. You’re also a practising general practitioner at the Albion Street Group practice in Rotherhithe and you’ve been working as a GP for many years, and it’s particularly apposite because today we’re talking about compassionate leadership in primary care. Your clinical lead for clinical effectiveness in southeast London, based in Bexley, also incredibly impressive. You have an MBA from INSEAD, one of the top business schools in the world, and you’re also there, part of the Health Care Management Initiative. You’ve had enormous experience working at, I think, health tech start-up and in strategy in marketing for a large pharmaceutical company in Milan where you learnt Italian and also working with the King’s Fund on compassionate leadership in innovation. And you’ve also done research for the Health Foundation on Innovation in healthcare. So we are in the company of somebody who has an enormously wide range of experience and great richness. So our focus today is on compassionate leadership in primary care, and it does feel really important to begin by just seeking to understand what the context is currently in primary care day to day. What’s it like working in primary care at the moment, both in the context of the pandemic, but, you know, in the years leading up to the pandemic as well, what’s been your experience and what have been your perceptions of the context in primary care?  


Rachna Chowla [00:03:34] Thank you, Michael. I think it’s a really important place to start. There’s so much goodwill in primary care. I think I’d start there. We work in small teams most of the time. We have good personal relationships there’s a sense of family, and I think that helps us be cohesive during times of difficulty, which is what the last two years have been in a very acute way. But there’s been a slow drip, drip of difficulty, maybe over the last 10 years or so. Let me talk a little bit about COVID because it was such a difficult time for many of us. But in healthcare, especially, we have to go from seeing our patients face to face to going online or to the telephone literally overnight. And you can imagine that in primary care, we have a bit of a reputation for being slow about taking up technology, but we embraced it and we did it as difficult as it was. But it really signalled the continuous change that we had to manage during that very difficult and unpredictable time. And we did it, but I think it’s taken a toll, sort of this sense of underlying anxiety that was there because of the pandemic. But then you had this additional level of continuously having to change almost from day to day. And there’s this chronic kind of stress and exhaustion that comes from that and then the fear of what was happening to our patients and their families in the midst of the birth of a new disease that we weren’t very sure how to look after at the beginning. So, you know, there’s that diagnostic kind of stress that comes in primary care where you’re trying to do your best, but actually, we didn’t know at the beginning. So there are all of these things. And then I guess on top of that was worries for ourselves because we were in the frontline with this infectious disease. Many of our colleagues did become sick, which then added to the additional pressures. So it’s been really two difficult years. And I think without having at the core what we do enjoy more, I think in primary care is the cohesiveness because we’re smaller teams. It would have been impossible.  


Michael West [00:05:42] So the sense of uncertainty in all of this, the anxieties, personal anxieties, the anxieties for patients, the fact that your small teams or small groups of people was a positive but just the overwhelming burden of the pandemic. And I guess seems what’s been really significant in all of this as well is that people sometimes forget that general practice is the first port of call for people with health care problems or health care concerns. So in a way, general practice is the entrance door to the whole of the NHS, and so it places a particular burden, especially in times of crisis. But even before, I imagine.  


Rachna Chowla [00:06:23] Yes, and we feel the burden and we also feel the responsibility. You know that the two go hand in hand. And it. Was much more evident during COVID, when in addition to, of course, being the front door to our patients, we were being asked to set up new services in the community to kind of look after patients with COVID that they weren’t mixing with our patients who didn’t have COVID. Normally, it would take us months to create a new service, and we were making things pop up within a matter of weeks. And I think the last few years of sort of highlighting the capacity that we have, there’s a latent capacity that we do have and that we’re able to explore. But I think it’s also highlighted a lot of the gaps. And coming back to your point about being in some ways, the gateway to the NHS. Yes, we are. Of course we are, and we’re happy to be. But perhaps the NHS administrative side doesn’t always represent that, I guess in some ways. So from a funding perspective, for example  


Michael West [00:07:28] And how has it affected, do you think GP’s and their well being? I mean, what’s been the personal impact on you of working in primary care over not just the pandemic, but over recent years?  


Rachna Chowla [00:07:39] Well, I speak quite honestly and openly about it. It’s something that I have found increasingly difficult. If I look back to when I was a registrar, the job in itself was less complex. And why is that so? I think there are administrative things that happen within primary care that have become more complex. We sort of have a lot of hoops that we need to jump through. You know, you talk about the emotional centres of regulation when it comes to compassion. And I was pondering on the fact that we have QOF (The Quality and Outcomes Framework) and we have all of these continuing targets and we continually in that place of targets and motivation. So that’s one side of it. And then actually patient demand has gone up. We have for demographic reasons and ageing population where problems are now more complex and perhaps some of the support that we used to have in the community isn’t there. So we remain the front door. We’re always open in the same way as A&E is. And so people come wanting support, which we’re not able to always give ourselves or signpost people to. And so we’re always then in sort of this place of firefighting, fight and flight as it were. So putting those two things together, the interactions between a clinician and a patient are just beautiful. When we are there and we’re present and we have time and we can explore and we can listen, there is nothing really better than that. But the context within which that happens can make those moments few and far between. And there’s a moral injury that comes from that. Then there’s the kind of physical exhaustion that comes from most people working 10 to 12 hour days and sometimes painting our days by numbers. So having x number of letters x number of blood test results, x number of appointments, x number of home visits. And it’s just this continuous churn, which when it takes its toll, of course, it does not just on us, but on the interactions that we have with our colleagues, but especially with patients. There’s is much less being it’s doing, doing, doing without drawing breath to reflect.  


Michael West [00:09:55] And so I think that paints a very vivid picture for me and I’m sure for others listening. And I’ve been working in primary care doing research over several decades now. And I guess what I’ve observed as well is the continuing increase in pressure. I know that in the last GP working life survey three or four years ago, that GP stress was at the highest level that it had been since the introduction of the GP Working Life Survey in 1998. And of course, then the pandemic struck. And so, in thinking about what we can learn for the future, I mean, there are key issues to do with workforce shortages. I think that we need to address and we need clearly more GPs in the system. We need more paramedics working in primary care. We need more pharmacists working directly with primary care. We need more physiotherapists, more mental health nurses working in primary care to help relieve the burden and to use skills more effectively, I suppose. But you mentioned and you mentioned the importance of the family, the feeling of family in teams. Can you say a bit more about that in terms of how compassionate leadership is or is not important in creating that feeling within the primary health care team?  


Rachna Chowla [00:11:14] I think it’s essential the sense of belonging to a place where people care about me, not because of the job that I do, but because of who I am. And the same being for them is essential because our work is around health care and that caring cannot just be one way towards our patients. Of course, there’s a sense of care that also reports out and should ripple out to our colleagues as well. We work in a high stress, high demand kind of environment, and we need those sorts of relationships actually just to get our job done, but also to thrive as much as we can in that sort of setting. And I think there are small things that can help make that happen. It is the way that people behave with one another. It is the Hello, good morning, how are you? Actually, I baked some biscuits there in the corner. Oh, actually, I was a bit short with you. I didn’t mean to be. I’m sorry. This is why it happened and acknowledging that and oh, noticing someone said something and they looked upset. So there’s a sort of paying attention to the relational aspects that I have to be there at the foundation of what’s then the running of a complex organisation? Because I care, of course, can’t and doesn’t just happen inside the consultation room. It’s everywhere. And it really struck me during the pandemic that I think certainly the practice I’ve worked at that was so important it was already there, but we needed to kind of strengthening even more because who wasn’t feeling anxious during COVID? And then you’re working in an environment where we have to make decisions about other people with diagnostic uncertainty. And so that sense of care also adds to the sense of safety and psychological safety as well. So I think it’s absolutely key. It’s sits there at the core of it’s at the heart of it.  


Michael West [00:13:15] I remember in one of our research studies in primary care some years ago, now one of the receptionists in a primary care team told one of our research team that they found the senior partner in the practice really difficult because he came in every morning and just walked past the reception desk to his consulting room without ever saying Good morning. And for some reason, this research team member took it upon herself to give that feedback to the GP in confidence. And his reaction, by the way, was, he said, but I had no idea. I had no. He was horrified and they had this call from one of the researchers two weeks later to say, you wouldn’t believe it. He’s coming in every day with biscuits, chocolates, flowers. It’s transformed who he is. So, creating that sense of belonging family psychological safety feels important. But I think, you know, I have a sense from what I’ve observed in some primary care settings is that compassionate leadership is also about being effective and that it’s important that teams have a clear vision of what their purpose is and have a limited number of clear goals. Forget all of the 87, 200, 300 targets that are being imposed, but what are our key goals? And are we meeting regularly as a team to figure out how to work effectively as a team? To what extent in primary care do you feel those basics are in place?  


Rachna Chowla [00:14:41] So I think this is also completely key. It’s not just how we are, but absolutely how we work, and we have external targets that are given to us like QOF and CQC inspections and so forth, and these can sometimes become the goal unintentionally.  


Michael West [00:15:01] So QOF is the quality outcomes framework that is a structure for helping us focus on how well the outcomes we seek are being achieved in primary care.  


Rachna Chowla [00:15:15] And so I don’t think we always engage with the question that you’re asking, which is actually as a practice. How is it that we want to be? What is it that we want to do this year? What didn’t work so well last year? What are we taking forwards? How is it that we’re working? Often team meetings are kind of rolling sheets of issues that come up. Of course, they need to be addressed, but I’m not sure that actually in primary care, the evidence base around team working and effective team working has we’ve become that aware of it? My feeling is that we haven’t. I think that we absolutely do our best, but we could do so in a more intentional way, knowing that there is evidence around it. I mean, we do it for everything else in primary care. If someone has got a blood pressure problem, I know where the NICE guidance is. I know where my local guidance is and I implement it because I know that this is evidence based medicine. And I think there’s something about how do we take a similar approach to evidence based leadership, i.e. compassionate leadership? And I think we need to start having conversations about this. This this feels new and reflecting a little bit on some work that we’ve done at King’s. We are running a pilot around organisational development, which includes aspects of compassionate leadership and your involvement in that, Michael, and the concepts have been new to the cohort that we’ve been taking through. So I don’t think it’s that people would not or don’t want to try and learn and implement these things that are not opening to different ways of working. But we’ve simply been overwhelmed by the external targets that are set to us and then have had the or, don’t have the awareness or haven’t had the sort of education, training or whatever you want to call around the evidence base that it’s robust, that exists around how we can make team working more effective within our practices. 


Michael West [00:17:12] It is fascinating. I mean, in a way, primary health care teams, primary care teams, general practices are reasonably sized small, medium sized enterprises with actually considerable sums of turnover in terms of financial performance. And yet somehow it sounds like what you’re saying is we don’t train people to work effectively in those teams or those medium sized organisations. And certainly the data that we’ve gathered over many decades in primary health care teams tells us that having a clear direction in terms of an inspiring shared purpose or mission or vision and translating that into four or five key strategic goals is kind of key indicator of effectiveness. But also what we’ve observed in recording meetings of primary health care teams is that some don’t have them on a regular basis and in others, the meetings, as you say, are just chock a block with agenda items, and those meetings can be dominated by one or two voices, rather than everybody in the team feeling that they have a contribution to make. So it sounds like maybe we should be ensuring that people who work in primary care receptionists, general practitioners practice nurses, paramedics have some basic training, an effective team working so that they can ensure that they are taking shared responsibility for the effectiveness of the entity of the enterprise of the organisation.  


Rachna Chowla [00:18:48] Yeah, I would agree with that. I think making this business as usual for us, it’s not something in addition to do, but this is how this is the best way to behave. When I’m part of a team. This is my contribution. You know, making that part of our core training kind of, for me feels like, why have we not done that? We have the evidence. Why have we not done that? I think. Going back to your point around a shared vision versus the tension of targets, we do have to kind of acknowledge that, as you say, we are SMEs and  


Michael West [00:19:22] small and medium sized enterprises. Yeah?  


Rachna Chowla [00:19:25] Yes. So and we are therefore employers, if we’re partners in a practice, we have colleagues and we have a responsibility to ensure that our organisation is sustainable. And so we have to pay attention to the sometimes myriad of targets I used to do the contract review in my practice, wherever year I would review all of the contracts, all of the incentives and make a big spreadsheet. And it was a big complex spreadsheet to make. It would take two days to do so. Someone needs to keep an eye on that because we have to be sustainable. You know, if we’re not sustainable, people can’t pay their mortgages. You know, there’s that degree of responsibility, of course, but that’s part of the story. You know, it’s not. It’s not all of it. I think we have perhaps focussed on that bit. And then how CQC inspections can completely take over what we’re doing for the next six weeks when we know it’s on the horizon. And I think we focussed on those things more than we have. What you’re talking about, well, as a practice, what is our shared vision? How is it that we want to work together? How is it that we ensure that all voices are heard? How do we make sure that at meetings, yes, we talk about the core business things, of course, and the issues that have to be resolved. But for these four or five things that we have chosen as a practice, are we making progress? I think there’s probably variation in that in primary care, but I would suspect most practices find it hard to do that because of the administrative overwhelm, because of the workload overwhelm. But it doesn’t mean that we shouldn’t. We have to find a way of doing it. But it’s just to acknowledge that there’s a tension.  


Michael West [00:21:05] Absolutely a tension and I think that the problem is with that administrative overload and the targets and so on, that the important elements of compassionate leadership can be lost because we then maybe neglect key goals like the well-being of staff, patient experience, the development of new and improved ways of doing things, addressing chronic excessive workload on staff, which are important indicators for the outcomes we seek. Ultimately, care quality and so on. We can become, I think, quite overwhelmed by targets and structures and institutions and inspections and mandates and so on. That sometimes feels as though they suck out compassion from teams and organisations. Are we getting it right?  


Rachna Chowla [00:21:56] I think we haven’t quite got the balance right, and we do need to strike a balance when we talk about targets they have, they have a place, you know, I need to be an effective clinician. It is good for me to help my patient with their blood pressure because it reduces their chance of them having a stroke. Yes, it’s important that I’m kind of that might also help with their blood pressure, but I can’t just be kind. I also have to be an effective clinician. So there is, of course, a place for targets that are around clinical outcomes. And yes, they are incentivised, so there’s a place for them. But I wonder if the balance has been a little bit too much in a different direction because being effective as a clinician, having financial sustainability, they are important. But there’s also this importance around our sustainability as human beings within organisations. We talk about the system. Is it a system or is it human beings that are just helping working and collaborating together? And we are, you know, in in my practice or in any practice where interdependent what happens to one colleague does affect the rest of us. So I don’t think we should see in any way as a trade off. Yes, in a practice where you have to, of course, keep an eye on the financial side to make sure that you are sustainable and doing the things that you have to do for QOF outcomes and so forth, that should be part of it. But there is this relational side that is equally important, and you could argue that focussing purely on the financial targets, just you can’t achieve them, really, if you don’t have the relational side that’s been paid attention to. So they’re not a trade off, they’re complementary. But I think the emphasis has been too much on one side rather than the other so far.  


Michael West [00:23:47] So we need to take time regularly to reflect on that balance and making sure that we’re getting it right and developing new and improved ways of doing things to be effective for the people we serve. And the question that I think arises for me about compassionate leadership in primary care is who are the leaders? Who is it that needs primary care?  


Rachna Chowla [00:24:12] Yeah. I mean, that’s a good question. I guess I’ve been in primary care. I’ve been in I’ve been every which kind of GP you can imagine in five weeks away, so I can give you lots of different perspectives. I think ultimately we all have a leadership responsibility in primary care. Of course we do. I don’t think, though, that we have explored that or articulated that. I think if you came to my practice and asked my reception colleague, does she feel like she’s a leader or if he’s a leader? I don’t know if they say they would. And I think that’s an issue because we all have some sort of leadership responsibility within our scope. I think there is something to acknowledge about. The way that primary care is most structured is there’s a partnership model. So you do have people who whose responsibility, ultimately the running of the practices. And there it’s so important that certainly when I was a partner that it was important to me that I modelled what we’d be talking about in the meetings. Otherwise, you know, I’d lose credibility. So the way that we’re structured might make people have the kind of title of a leader just because they’re perhaps a partner or senior lead. But there is something about how in primary care we come to, the codeveloped understanding that we all have leadership responsibilities within the scope of what we’re doing.  


Michael West [00:25:37] And if we asked the receptionist in your practice overall, who leads it, who is the leader, what would he or she answer?  


Rachna Chowla [00:25:45] I think they’d say the partners, certainly in my practice, I think that that’s clear who’s the leader of the day or the person in charge on the day, that’s a different question. You know, there’s this part time fluidity that exists in primary care. I think that’s an interesting question. So who is the person to go to on the day for issues when we have this part time culture?  


Michael West [00:26:09] So we know that in looking at health care teams, that when people are unclear about who the leader is of a team, that that has consequences in terms of team functioning. And it is an interesting question. I think about these small and medium sized enterprises, as you say, which actually don’t have a managing director, a chief executive officer. I mean, there is the lead partner maybe, but it feels like it’s more fluid than that. And I guess it leads to a question about if we’re trying to create compassionate environments, then one of the potential threats to those compassionate environments is chronic interpersonal conflict. You know, where you have small families, you can get conflicts that inevitably flare up. And you know, in families, we hope what happens is that there’s a brief flame, there’s some heat and then there’s a letting go. There’s forgiveness there’s loving and there’s a sense of deep and safety because we’re able to fall out and make up and we know how to do that. But in teams and work in primary health care teams, I’ve certainly seen and heard about chronic interpersonal conflicts between partners, between other members of staff that kind of corrode what goes on. And I suppose my question is how much awareness is there within primary care of these issues? And how much are we developing the skills of people to be able to manage those sorts of conflicts effectively? So there isn’t an issue like the toxicity of chronic interpersonal conflict?  


Rachna Chowla [00:27:48] Yes, how fascinating. My feeling is that I’m sure there’s variation around that. So I give you a politically correct answer. But I think this sort of touches on the point of how aware we are of ourselves a little bit. You know, there’s something about a group awareness, team awareness. And if we’re meeting to talk or just about the transactional things and hiding the conflict or not dealing with it then perpetuates that sort of culture and you need someone to kind of point it out, but in a way that’s safe and with a roadmap of helping to deal with it. But this is also where the cohesiveness in the family like nature can help, even in a practice that comes because there is a sense of love between people who’ve often been working there for four decades, three decades, you know? But I think it’s an area that we need more awareness about because in the end, it ends up affecting patient safety. So maybe the way to approach it is from the perspective of patient safety and understanding what are the different threads that can lead to eroding that patient safety? I’ll give you an example to do with transparency. So in my practice, we have daily debriefs for the clinical teams so that we can come and talk about things that we found difficult or diagnostic difficulties in a way that you just come and share and we will try and support each other. And it doesn’t matter whether you are the registrar or the senior most partner people come and ask and everyone helps and gives their opinion. And in much the same way, we have meetings around significant events, and it was one significant event I was involved with, where by mistake I sent a letter which did have patient, identifiable information to an incorrect email address. So that’s a data governance breach. And thankfully, that email address I went to was kind of defunct, so nothing happened. And you know, I did whatever I needed to do, but I thought when I brought it to the clinical meeting to discuss it, this can’t be the first time that this has happened, even though it’s the first time that we were talking about this. So I then took it to the practice meeting to say, Well, let’s talk about a significant incident that I was involved with, and I wanted to bring it up to show that these things happen. It was a mistake. I did whatever I did to correct it, but kind of opened the door to other people to feeling comfortable about those sorts of things, probably day to day occurrences. We don’t mean them to happen. We have to then think about the systems to prevent them. But you know, I was a partner at the time and I wanted to show that we can all do these things and there’s no come back on this there’s a way of rectifying it. You ensure that this duty of candour and the patient’s been told about the mistake and you try and rectify and so forth, but this is a safe place to discuss things like this. So the kind of modelling, the kind of transparency of communication, I think all of these things then help in the end. Also, when it comes to the conflict resolution, which, you know, was initially what you were asking about.  


Michael West [00:30:57] So we create a more psychologically safe environment where we can discuss mistakes and be open about mistakes in order that we can learn from them. We seek to develop compassionate relationships with each other through attending, understanding, empathising and helping each other within the primary care team. And that compassion and that openness translates into the interactions with patients for whom, of course, the relationship with the clinician that they’re seeing. The quality of that interaction is so important in terms of how well they’re able to communicate. What’s their concern, the extent to which they understand the treatment protocols they’re required to adhere to, the extent to which they feel reassured and comforted by the interactions so it feels like this is about. If you like the compassionate culture, the compassionate learning environment that we create in these entities that we call primary health care teams. And I suppose it raises for me the question about the boundaries and the shifting boundaries of primary care and what that means in terms of how we think about compassionate leadership. So I’m thinking about the development of primary care networks now, where groups of practices start to collaborate and cooperate. We’re seeing, for example, the Bromley by Bow practice in London seeking to involve the community in providing care. Volunteers visiting people living alone, encouraging people to go to gardening clubs, encouraging people to link with voluntary sector. And we’re seeing some evaporation of boundaries so that patients and service users become more involved in, if youlike, like coding and co-designing that care. And the idea that primary care begins to work more effectively with secondary care, with voluntary sector, with community groups and patient groups, that feels like a process that’s currently happening. How is that going? Does it make sense? And what’s the role of compassionate leadership in that?  


Rachna Chowla [00:33:09] It’s definitely a process. It’s definitely in progress and. I think the initiation of these PCNs or primary care networks being in the formal system are just a start because they again have been given various targets, they’re well-intentioned organisations whose role, it is eventually to reach out and to involve and work with community organisations. But the targets that they’ve been given to meet at the beginning, yes, will help them to kind of coordinate and collaborate. And certainly the vaccination programmes that they have been instrumental in delivering have helped them become more cohesive entities. And my suspicion is that with the vaccination programmes and reaching out and working with community organisations to support that, actually some of that work has maybe been accelerated because of COVID. But I think the scope or the ambition of them needs to still be realised. There’s still a staffing problem within PCNs. PCNs are entities where groups of practices come together. Yes, they have funding to recruit additional staff, which is great, and staff who are not always clinical, which is what we need. So social prescribing, link workers and so forth. And I think the challenge is to really reach out and work with community organisations who are already engaged with the local community and already have built trust and have the relationships so that they can work in partnership with them so that the boundaries of compassion are blurred completely. Because for PCNs to be able to deliver truly on what they’re trying to do, it cannot just happen with them on their own. It’ll become a tick box exercise, which no one really wants. And I think my other reflection is over two years of COVID, we have all become so much more engaged with our health. It doesn’t matter which arguments we identify or don’t identify with. The point is that at a global scale, we are all engaged with health, and that can only be a good thing. I think the question really is now when it comes to learning about trust, which has been an issue during these two years, what do we need to learn so that we bring those two parts of the debate together? So creating trust within the community when it comes to formal and informal parts of the health care system? So yes, PCNs working together with the community for the greater good. So I think there’s something quite profound that might have happened in the last two years, which we can capitalise on because of COVID and also because of the negative sides coming up around trust. But there’s something there I think that can be built upon.  


Michael West [00:35:59] Primary care is in really extraordinary sector. It’s the first point of call for everybody in our society to take care of their own health, to get help with their own health and sometimes just to get reassurance or even just to connect. And you deal with such a great diversity of people, of people from different backgrounds, demographic backgrounds, professional backgrounds and a great huge diversity of presenting problems and sometimes with people who are very angry or very difficult or broken or at their wit’s end. How do you deal with all of that compassionately?  


Rachna Chowla [00:36:44] Yeah, I think there’s something about seeing it as a privilege. You know, people, when they come into our consultation door, gift us this immediate sense of trust. And that is just an utter privilege. And with that, they open their hearts to all sorts of things that have happened to them and to really connect and to help. You can only do that from a place of openness and from a place of listening and from a place of compassion. And they do so even more when they invite us into their homes and they’re unwell and we go along in a home visit. And I have such funny stories about going on home visits and people have got pet squirrels that will come in from their garden, and one of them kind of poked his head above the laptop when I was listening to his chest and bizarre things like that to really sad things where people are living in the most dire and difficult conditions. And in those sorts of situations, it can be really easy to just think, Well, what is it that I’m actually doing? Am I making a difference? But to remember that for so many people who are living difficult and sometimes isolated lives, we can be their advocate. And in some ways we’re a universal advocate for school letter or housing letter or all sorts of things, where do they come to? They come to us. We’re also someone that’s a human face and someone who can listen. Someone who can touch, hold hands. And I might not get to sort out someone’s housing problems and all the rest of it. But maybe me doing my tiny bit of medicine does make a little bit of a difference. I think it’s important that we try and remember that and remember that it’s a privilege to be invited into people’s lives. So that’s sort of how I see it. And I have to say I learnt so much from my patients as one of my patients who she passed away. She was a lady that I looked after during the last six months of her life. It’s probably one of the most profound experiences of my clinical career, and it’s so I think we’re so lucky in primary care because our job is about people and when we’re more centred in ourselves, it’s ultimately about care and compassion and about love and to remember that it’s a place of privilege and that these small interactions can make a difference. And often even bigger things can happen. And so it’s important that we can play our role. But to do so from a place of compassion makes it all the more fulfilling and more effective, more effectual because people feel it.  


Michael West [00:39:26] There’s been a sense this last two years where we’ve all had to take more responsibility for our own and other’s health, and it seems really important that we, as you say, embrace that and recognise that the health and happiness and well-being and fulfilment of everybody in our communities is dependent on each of us, of course, taking care of ourselves but taking care of each other. And that’s what compassion is about. Of course, the danger, I think for many health care professionals and it’s been to some extent exacerbated by some of the public comments in relation to general practice is that. There’s this notion that I as a primary health care professional. Be it practice nurse, receptionist, doctor, I’m here to care for others. And there are enormous burdens and work demands on people working in primary care. I’ve come to feel that self-compassion more and more I’ve come to feel it’s hugely important for all of us to learn, and I think we need to teach children infants early on what self-compassion is about. It’s not about being self-indulgent or about being selfish. It’s about nurturing our being so that we’re able to contribute, fulfil our lives, be happy. In primary care. Do you see an awareness of the importance of self-compassion or an emerging awareness? And how important do you think it is in that context? And why is it important in a context above all?  


Rachna Chowla [00:40:58] I think we’re starting to talk about the word compassion and kindness of words that we have started to talk about. And do we have an awareness about how or what? I don’t think that’s there yet, but should we? Absolutely. I mean, I’m happy to kind of share some of my own experiences around that. Compassion has been something that I’ve been interested of for a while, but I think I had an experience a few years ago where I had had a completely typical normal day in primary care. It was a long day. Lots of patients. Lots of things to do, and I don’t quite know what happened, but I burst into tears as I was going home and in my 40s, sought out my father and cried on his shoulder. And I can’t explain what that happened, but something that day was too much. But that’s a completely typical day, and I’m sure that what I felt is something that many people are feeling, but I sort of acknowledged it for the first time and I listened to it. I heard it. And since then, I’ve been much more aware of about how is it that I want to spend my moments in my days at work? What sort of place do I want to be in? When I say place, not physical place, I’m talking about how I am in my being so that then I can support my patients to the best of my ability in those moments and understanding that there are limitations actually to how I can do that. There are a finite number of hours in the day. Appointments are not infinite. I can’t just keep adding them on and when I do, it has an impact on me and it has an impact on my patients. So, you know, we are part of this together. There’s there isn’t a separation between me and my patient when I’m in a consultation. And so the chronic stress the chronic exhaustion, those things at some point they have an impact on our patients. So we have to become aware of that. Becoming aware of that is part of being compassionate to myself. So acknowledging this feeling for myself, but then also doing something about it, taking some sort of action to help. And for me, it’s meant lots of different things. It has meant changing how I work. Yes, it’s meant changing my work plan and that was done in a quite intentional way. Actually, interestingly, at the practice that I am at because of COVID and the unpredictability of work and the difficulties the practice chose. Kind of a year into COVID to try and reduce the workload for everyone because it just would not have been sustainable, the practice would not have functioned if we were just going to continue to sprint round this marathon track, which is what we all sort of think we can do. And we couldn’t, we couldn’t continue. And in order for that to happen, there has to be some understanding for self-compassion to happen at a practice level and therefore compassionate leadership. It has to come from a place of understanding that within oneself. And I don’t know whether in primary care or even in general life, we’re so stuck in the fear, anxiety, fighting for targets achieving place to have not realised that we’re so stuck in those two places and that there is this place of stillness and being and compassion and a sense of love, which in the end is what sits at the heart of a consultation between a clinician and a patient. When I gaze into the eyes of my patients, whether it’s a baby or, you know, one of my patients who was passing away, we both felt that when it’s that, we both feel it, when it’s there. So it’s not something that in primary care we don’t know, it’s not something that it’s human beings that we don’t know. I just wonder whether the context has become a bit too out of control for us to connect with it. But it’s there, it’s there.  


Michael West [00:45:13] It’s really hugely helpful and profound and moving Rachna. And my last question? Almost feels too blunt in a way. But what’s your one practical recommendation? For people working in primary care to take away from your experience of working in this context and your wisdom.  


Rachna Chowla [00:45:39] I think we will work in primary care because we care. And there is something about us all sort of going within ourselves and connecting with that place because that is the place from which we care when we are with our patients. And you can call that self-compassion or you can call that whatever you like, but people know what that place is, and I think we need to spend more time there. And once we have, there is something about making that into a lived reality. Actually, that is how I wish to spend my moment to moment experience in practice. What is it then collectively, we need to do to make that happen? And that’s the conversation to be had because we all know that we can’t continue as we have been and there’s no need to. Why not find this place of you can call it compassion or presence or stillness, or this place that we have within ourselves, where we connect with each other and with our patients? And let’s try and make that the core of how then the rest of the practice revolves, rather than it being the other way around.  


Michael West [00:46:50] Rachna, it’s been an immense privilege and immensely moving and inspiring to have this conversation with you. Thank you. 


Rachna Chowla [00:46:58] Equally for me, thank you so much, Michael.  


Paul O’Neill [00:47:04] I hope you enjoyed this conversation. Please look out for others in this mini-series and subscribe to the Leadership Listeners’ Collection for more content like this.  

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