Module 9: Holding the Destination, Changing the Route

One of the more uncomfortable parts of clinical leadership is being expected to provide certainty when certainty does not exist.

Waiting lists grow. Theatre capacity changes. Staffing becomes fragile. Financial pressures increase. Patients want answers, while organisations want plans, trajectories and measurable assurances.

The natural response is to produce a detailed plan. The danger is that the plan becomes a promise about a future we do not fully control.

My latest MBA module focused on strategy in a complex and uncertain world. The most useful lesson was simple: leaders need to distinguish between the destination and the route used to reach it.

Changing the plan is not always failure

In surgery, we begin with an intended operation. We review the imaging, anticipate difficulties and agree a plan. However, no experienced surgeon assumes that everything will look exactly as expected once the operation begins.

Adapting the technique does not mean that the original plan failed. It often means that the surgeon responded appropriately to better information.

The same principle applies to leadership.

One theory discussed during the module was the difference between deliberate and emergent strategy. A deliberate strategy describes what we intend to do. An emergent strategy develops as we act, learn and respond to changing circumstances.

Most successful strategies contain elements of both.

This made me recognise a bias in my own leadership. I have often associated consistency with credibility. Once a plan has been announced, changing it can feel like a loss of authority.

But persisting with an obsolete plan simply because it has already been communicated is not strong leadership. Sometimes the destination remains correct while the route needs to change.

What this means in the NHS

Many of our strategic objectives should remain stable. We want safer care, better access, a good patient experience and responsible use of limited resources.

How we achieve those objectives cannot always be fixed years in advance.

A recovery plan may depend on workforce availability, theatre capacity, bed pressures and support from services outside the department. Any one of these can change. A sensible strategy should therefore include review points and allow the implementation to adapt.

I am increasingly interested in plans that make their assumptions visible.

What needs to be true for this plan to work? Which factors are within our control? What evidence would tell us to continue, accelerate or change course?

These questions create a more honest plan without weakening its purpose.

Looking beyond the department

The module also reinforced the importance of seeing a service as part of a wider system.

It is easy to treat a theatre productivity problem as a theatre problem. In reality, productivity may depend on pre-operative assessment, beds, sterile services, equipment, anaesthetic capacity, rehabilitation and social care.

A department can work extremely hard while the overall pathway continues to struggle.

This changes the leadership question. Instead of asking how the department can work harder, we should ask which constraints are preventing the whole pathway from working better.

That distinction matters. The first question often creates pressure. The second has a better chance of producing improvement.

Resources are not the same as capability

Another useful insight was that owning a resource is not the same as having the capability to use it effectively.

A hospital can buy new technology without achieving digital transformation. It can own expensive equipment without building a sustainable service. It can employ excellent individuals without creating a reliable team.

The important capability often sits around the visible resource: trust, relationships, shared knowledge, governance and the ability to keep improving.

I can see this clearly in the development of the Postgraduate Virtual Learning Environment.

The PGVLE began during the pandemic as a practical solution for around 100 users. It now supports approximately 60,000. Its success did not come from predicting every future requirement at the beginning.

The purpose remained stable: improving access to postgraduate education. The platform, partnerships and delivery model evolved as we learned what users needed.

The software matters, but it is not the whole capability. The network of educators, accumulated content, clinical credibility and understanding of postgraduate training are much harder to reproduce.

This has influenced how I think about future digital projects. Technology is rarely the difficult part. Creating something that people trust, adopt and continue to support is the real strategic work.

Better strategy also means clearer communication

The feedback from the module reinforced another lesson that applies directly to my professional life: good analysis can still produce a poor message.

Our group presentation contained extensive evidence, but at times we tried to say too much. The detail demonstrated the work we had done, yet it weakened the focus of the recommendations.

Healthcare presentations often suffer from the same problem. We include every caveat, table and historical detail because each feels important. The audience may leave better informed but still unclear about the decision required.

I now try to reduce a strategic discussion to a few questions:

• What decision is needed?
• What evidence materially affects it?
• What is the main uncertainty?
• What happens if we do nothing?
• When will we review the decision?

The analysis behind these questions may remain complex. The message should not be.

What I will change

The value of an MBA module lies in whether it changes what I do after the assignment has been submitted.

I will be clearer about which parts of a strategy are fixed and which can adapt. I will make assumptions and dependencies visible rather than hiding them beneath confident timelines. I will also build review points into plans from the outset, so that adaptation feels like responsible governance rather than retreat.

Most importantly, I will focus less on producing certainty and more on creating direction.

The NHS is too complex for any leader to predict every obstacle. Strategy still matters, but it must leave room for learning.

The destination should be clear enough to bring people together. The route should be flexible enough to survive contact with reality.