I wasn’t a very good clinical pharmacist.

I wasn’t terribly diligent and had a pretty relaxed approach to learning. I’d got through school and uni doing just enough to get through. That meant that my approach to clinical knowledge was similar – just know enough to get by. I didn’t have enough of the clinical curiosity to go above and beyond.

That doesn’t fit well with being a clinical expert, because when you’re dealing with patients being good at your job usually means knowing things. Having instant recall of the guideline or the evidence. Or knowing when you don’t know the answer and finding it out.

Nobody wants a pharmacist improvising their way through clinical practice. And I knew at the time I wasn’t very good at it. But I also knew what I was good at, and that was navigating the complex MDT politics, making decisions when the situation was ambiguous, identifying systemic or process problems, and creating a vision that people could follow.

So once I moved into my first leadership position, things became clearer and easier for me. I’m still not sure how I managed to get there in the first place, but once I was managing and leading services and people I found my groove. The further you move into leadership, strategy, transformation, commissioning, or senior operational roles, the less often you are dealing with problems that have objectively correct answers.

The NHS doesn't struggle because there aren’t enough intelligent people in it. Sometimes there are too many all in a room together.

It struggles because complex organisations are full of competing pressures that can’t all be optimised at once.

In any complex decision people are juggling finance, safety, access, workforce, politics, performance, public expectation and organisational reputation.

Most senior decisions are trade-offs between competing versions of good enough, not a choice between right and wrong. And that’s the difficult thing about stepping from a clinical role into a clinical leadership one. I’ve found that my expertise helps me identify problems, but can actually be a hindrance in navigating the uncertainty.

I think this affects us in pharmacy more than some other professions. Partly because we are trained to a high degree of accuracy and certainty,  and often risk elimination more than risk management. Partly because we are trained to avoid overstepping expertise (defined areas of competence and a professional deference to medics), but partly because making decisions carries accountability.

So pharmacy professionals often tend to retreat into information overload. We caveat everything we say, produce 69 page slide decks and drown people in detail and analysis. We tell people how complicated everything is and warn people against making decisions when they don’t know for certain what the downstream consequences will be.

But at some point, somebody has to make a judgement. If that’s not us, and we are positioning ourselves as advisors rather than decision makers, then someone else is making a call based on what they understand of our advice.

So there’s something I want us to learn:

good judgement is not false confidence. It is the ability to make proportionate decisions despite incomplete information.

The paradox is that pharmacists already operate in uncertainty every day. The best example of this I can think of is community pharmacists working in professional isolation, often with no clean and quick access back to the prescriber, are making judgement calls all the time in the absence of certainty.

So why as a profession are we held back by ambiguity? It’s worth thinking about what makes a good decision maker, and how we use that knowledge to individually and collectively become more influential?

Good decision-makers tend to do a few things differently.

Firstly, they identify what the actual decision is. That sounds obvious, but lots of conversations drift into answering other questions because people confuse information sharing with decision-making. You’ll often hear twenty minutes of discussion about background, process, caveats and extraneous detail, without anyone asking: “What are we actually trying to decide here? What’s the exam question?”

People with strong judgement and influence simplify the problem first. Usually by helping people focus on the real issue and bringing them back to the ask. Often the most influential voice is the one who says:

“So if I understand correctly, the real question is whether the risk of delay is greater than the risk of acting now?”

 Secondly, they distinguish uncertainty from paralysis. I used to think good leadership meant having enough information before making a decision. But in complex systems and pressured environments there is almost never enough information. At some point, you realise that waiting for certainty is itself a decision. And not a neutral or safe one.

There’s a concept from behavioural science and economics called bounded rationality, developed by Herbert Simon. The basic idea is that human beings do not make perfectly rational decisions because we never have:

• complete information

• unlimited time

• unlimited emotional energy

• unlimited organisational capacity

So instead of optimising perfectly, experienced people learn to make decisions that are workable, proportionate and safe enough within the constraints they are operating inside.

The irony is that in most cases I think we are already good at this clinically, but we lose confidence when stepping into leadership positions.

Thirdly , good decision-makers help other people think. This is probably the most underrated skill of all, and when you see it in action it’s a beautiful thing. The best leaders I’ve worked focus discussions and bring people in to it in a way that gets the best from them, rather than dominating with their own voice. Simple actions like:

·       Slowing things down when emotions are escalating.

·       Regularly summarising complicated discussions.

·       Helping groups identify what matters most.

·       Stopping people disappearing down rabbit holes.

·       Creating enough psychological safety for uncertainty to be discussed honestly.

Remaining calm and focused is the key to this. Panic destroys rational thinking, and in most situations clear thinking and open challenge is more valuable than fast thinking.

And finally, we need to recognise that someone has to make a decision. The best decision-makers I’ve worked with are not reckless people. They recognise when there is enough information, the exam question is understood, the consequences are as clear as is reasonably possible, and when more discussion or analysis is unlikely to materially improve the outcome.

At that point they are willing to say: “Given what we know right now, this is the direction we should take.”

 So to recap, if you want to be a more effective and influential decision maker:

1.       Be clear on the exam question
What is the actual decision requiring a judgement?

2.       Identify and accept the uncertainty
Stop pretending certainty is achievable if only more slides are produced.

3.       Create the environment for better thinking
Use other people well. Stop them panicking. Openly discuss disagreement. Encourage people to explain their thinking.

4.       Be willing to put your neck on the line
At some point somebody has to make a proportionate call and carry accountability for it.

Maybe that’s why I found leadership easier than clinical practice. The further I moved from questions with objectively correct answers, the more useful my way of thinking became.