From clinician to academic, from public service to leadership, forever shaping change.
Martin Marshall is the Chair of the Nuffield Trust, Emeritus Professor of Healthcare Improvement at UCL and a non-executive director of the Royal Devon University Healthcare Trust.
Martin was a GP for over 30 years, initially as a GP partner in Devon and more recently in Newham in East London and was Chair of the Royal College of General Practitioners from 2019 until 2022. He was appointed as a deputy Chief Medical Officer for England and Director General in the Department of Health in March 2006, and in 2007 became director of clinical quality of the Health Foundation. He was previously Programme Director for Primary Care at UCL Partners, a clinical academic at the University of Manchester and a Harkness Fellow in Healthcare Policy based at the RAND Corporation in Santa Monica, California. He received both the John Fry Award (2005) and the James MacKenzie Award (2008), from the Royal College of General Practitioners, and in 2005 was awarded a CBE for Services to Health Care.
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“… in that typical GP way I quickly realized that the thing that gave me a real buzz was people rather than diseases. Understanding the human condition, and understanding how people respond to health and well-being and ill health, is what really fascinates me and gives me a buzz.” Martin Marshall
In conversation with Chris Salisbury
Emeritus Professor of Primary Health Care at the University of Bristol. He was a full time GP for more than 10 years and an academic doing research and teaching alongside general practice. His academic work focused on how to ‘do family practice better’ and the impact of new models of care.
Hello, I’m Chris Salisbury and today I’m talking to Martin Marshall. Thank you very much for joining us. I think I first met you when you were a senior lecturer in general practice in Exeter in about 1998. So, just give us a quick recap of how you got to that point. Had you always wanted to be a GP? Had you always wanted to be an academic? Tell us your story.
Martin Marshall: I was the first member of my family to go into medicine, so I didn’t have a clear perception of the opportunities available but, as I worked through medical school and certainly by the end of medical school, I knew I wanted to be a GP, partly because I enjoyed every specialty and I couldn’t imagine giving up psychiatry or paediatrics or whatever along the way, and partly for the rather negative reason that I don’t like hierarchies. I’m a free spirit. And that suits being a GP rather than working in a big structured hospital.
But mostly, I think, because in that typical GP way I quickly realized that the thing that gave me a real buzz was people rather than diseases. Understanding the human condition, and understanding how people respond to health and well-being and ill health, is what really fascinates me and gives me a buzz. So, I knew I wanted to be a GP and I went straight into GP training after my house jobs.
I didn’t know that I wanted to become an academic when I was at medical school, I did a BSc in biochemistry, which involved lab-based research – elastase induced emphysema in the rat lung- where I spent time playing with test tubes and I thought, if this is what research is about, it’s really very boring. I didn’t have any other inclinations towards an academic life until had I finished my GP training. I was offered a partnership in the practice that I trained in- a part-time partnership for two or three years until the senior partner retired. I was looking for other things to do with the rest of my time and I almost by accident fell into a post as a research assistant in a health service research project and really enjoyed it. With the help of very good mentors at the time, I then decided to do a Master’s and climbed onto the slippery slope of academia where I found I really enjoyed social sciences. That’s what really gave me a buzz. So, I guess my academic career was not planned, not thought through, but something that I’ve enjoyed enormously.
CS: Around that time you did a Harkness Fellowship, would you like to tell us about the Harkness Fellowship, and what it meant to you?
MM: The Harkness Fellowship is a traveling fellowship to the United States. At that time it was open to English speaking countries, the UK, Canada, New Zealand, Australia but now it’s more broadly available. It’s an early to mid-career type fellowship funded by an American foundation called the Commonwealth Fund of New York. And it offers an opportunity to spend a year in the United States learning with the leading health service research thinkers.
It was a fantastic experience, a particularly good one for me because I’d been in my practice building my research career, I’d got a doctorate and by then I was then a senior lecturer in Exeter. They were very interested in my background as a GP, something they weren’t familiar with in the United States particularly. My wife and I went to the US for a year and we had a wonderful time. I was based at Rand in California in Santa Monica and was exposed to the best thinkers in the field, particularly in the field of quality of care.
And that completely changed my horizons. From being someone committed to being a GP throughout my career, doing some research on the side, I now had a different set of ambitions. As soon as I came back I handed in my notice to my colleagues in the partnership and moved up to Manchester where I developed a serious nearly full-time academic career alongside my clinical practice.
“I had moved from being a clinician running a practice, to being an academic working in a university with fairly clear boundaries, to then working as a senior civil servant and national professional leader. It was a risk, and one that I learned a lot from.”
CS: You moved up to Manchester but you weren’t there that long before you were on the move again, and you became Deputy Chief Medical Officer for England and Director General for the Department of Health. Those are really big roles, and it must have taken a lot of confidence and gumption to think that you, a relatively young professor and GP, could do that…
MM: Confidence or naivety on my part. I’m not sure. I had been in Manchester for about seven years, working in the National Primary Care Research and Development Centre, and had been increasingly exposed to some of the policy leaders, civil servants, and politicians through my research. I became more and more interested in policy and was doing policy related rather than clinical research at the time. I built a relationship with the then CMO, Liam Donaldson who, when one of his deputy roles came up, asked me to apply. I think he liked the work I was doing, and I got on very well with him. It was a massive move, and I was pretty unprepared for it in many ways. I had moved from being a clinician running a practice, to being an academic working in a university with fairly clear boundaries, to then working as a senior civil servant and national professional leader. It was a risk, and one that I learned a lot from.
We managed to deliver what had to deliver but I found that I wasn’t enjoying the role that much. Certainly, the nature of working in a political environment was exciting, but also very frustrating. There were things that you knew needed to be done and weren’t done. You might develop bits of work to the point of where they might be implemented and then a minister would suddenly change their mind. I think some people are cut out to operate in that kind of very political and party-political environment but it wasn’t an area where I felt I had a lot to contribute. As I say, I found it frustrating. So I left that role after about two and a half years.
CS: In preparing for this, I reread your James McKenzie lecture from 2009, and I got the feeling, reading between the lines, that it was influenced quite a lot by your engagement with politicians and policymakers at that time. You don’t ‘pull any punches’ about how we as a profession need to take responsibility for ensuring quality of care. And how we need to engage with politics and improve how we communicate our purpose. Is that how you still see things 15 years on?
MM: Very much so. More so, if anything. The two experiences that influenced that lecture were partly my experience of government and recognizing how to get the best out of your relationship with political masters and senior leaders. And partly a recognition of my strength as an academic in asking questions that are relevant to the service, particularly to patients receiving the service and then implementing the results. But not the bit in the middle, that bit that most academics love. I never regarded myself as a talented methodologist- my interest was in the beginning and the end of the research process.
I was very aware, from working in government and from my experience of working in the service, that a lot of research gets lost in its own vortex and doesn’t have very much influence on practice. That’s a consequence partly of the nature of researchers who historically may have been less interested in implementation, but also in the nature of the clinical community, who weren’t sufficiently interested in pragmatic research and making use of evidence-based findings. I was very aware of how much better general practice could be if it was guided by the kind of practical pragmatic evidence that many of my colleagues and I were developing.
CS: It felt to me that you were showing some frustration, not only with government and politics, but with the profession itself. Having been on the other side of the fence, you were saying that if you want to get things better, you’ve got to take responsibility for making them better and not just make excuses. Is that fair?
MM: It is fair. Julian Tudor Hart, that great South Wales GP, once described doctors and particularly GPs as politically naïve, and I think that’s right. There is in doctors a sense of passion and a sense of service. But also, I think, an inappropriate lack of respect for those who run the system, whether they be politicians or civil servants and a belief that they just don’t get it. Working with these people, recognizing how intelligent they are and often how passionate and committed they are but also, that they are bound by the environment they’re working in. That’s the constraint that we see as clinicians and it made me want to push GPs into a space where they understood where politicians are coming from, understood how to influence them, and to be willing to make the effort to do so. That’s one of the reasons, I guess, why I shifted from a clinical or an academic career to a policy career, and then into leading the College, because that’s where you have the ability to exercise that influence.
“What’s the foundation of good general practice? It’s certainly this ability to form relationships with people and to be able to communicate effectively and understand what motivates them. But we don’t often talk about the fundamental clinical skills that are also necessary to be a good GP.”
CS: A big theme of your work, your academic work, is about measuring and rewarding quality and promoting quality in clinical care and healthcare. And, you’ve talked about the risk of focusing too much on a specific biomedical agenda and then losing sight of things that are harder to measure but important like patient-centred care, relationships, comprehensive care. I’d argue that’s exactly what happened with the Quality and Outcomes Framework and also more recently with digital consultations, that we’re losing all those things, to focus on the individual transaction and individual biomedical problems. How do we square that circle? We need to measure things to ensure quality, but the most important things are hard to measure.
MM: Yes, and you’ve been a great advocate throughout your career of the broader range of things that we, particularly as GPs but as medics and as clinicians more generally, bring. What’s the foundation of good general practice? It’s certainly this ability to form relationships with people and to be able to communicate effectively and understand what motivates them. But we don’t often talk about the fundamental clinical skills that are also necessary to be a good GP. I understood why the Quality and Outcomes Framework and the incentivization of specific clinical processes came in, because there’s no doubt that we weren’t doing the basics well, we weren’t measuring things that effectively, we weren’t committed to improvement, and we weren’t working as effectively as we could as a multidisciplinary team. All of those things were transformed when QOF was introduced.
All of a sudden we started collecting data, started using data, and we focused on clinical processes. In the beginning it was an experiment and there were some silly indicators, but gradually over the years it got better and better. I don’t completely damn QOF. The prediction that you and I and others made, that it would change our focus from what is really important to patients, which is that personal relationship and that deep understanding of their needs, to something which was a much more technocratic function- yes, that happened. So, we had to draw back, we had to consider other ways of rewarding the things that really matter to patients. And I think we’ve got there. When QOF was first introduced It represented about 20-25% of a practice’s income and now it represents about 7% of a practice’s income. There has been a shift away from rewarding the things which are easy to do, to creating space for the interpersonal more effectively. Have we done that effectively? I’m not sure we have. I think there’s a degree to which GPs have become socialized into doing the technocratic stuff well. The combination of that cultural background, together with the highly pressured, overworked environment that we find ourselves in, where the easiest thing to do is to close down a consultation rather than open up a consultation, has meant that general practice is not in a good place at the moment. That’s a source of enormous regret to me and to you and to many others.
CS: You talked about how quality improvement initiatives need to align with professional values, and how initiatives fail if they don’t- a lesson we need to keep on reminding ourselves of. Some of GP’s frustration these days is because they’re being asked to do things that don’t match with the kind of doctor that they thought they were going to be. How can we recover, aligning quality initiatives with professional values?
MM: In some ways, I’m less concerned about what we’re being asked to do than I am about what we have the capacity to do. We still have a high level of autonomy, and if we want to operate in a practice that does the basics really well, and you’ve got a really good systematic approach in providing care, you can then focus on the other things that are important, whether it be interpersonal care, whole person care, shared decision making, or public health, all the other things that matter. We have the potential to do those things and to be professional, to be autonomous, and to drive them, because they’re important. The problem now is that, while people might have the capability and may have the training, they don’t have the capacity. And that’s the issue that’s so hard for people in clinical practice now. It’s not an accident that people like you and me, and people in our age group, have largely given up clinical practice because we couldn’t practice how we wanted. It’s the sheer pressure of work that is driving clinicians away from being the good GPs that they were trained to be. And the deep frustration that you can’t put your training into practice.
“I had a very clear idea of what I wanted to achieve as Chair, the kind of direction that I wanted to take our members, and that was partly about rethinking and re-emphasizing the importance of relationship-based care. And it was partly about going back to our roots and recognizing the importance of population health and the role that general practice can play in population health or public health.”
CS: The next big stage in your career was that, in 2019, you became chair of the Royal College of GPs. Why did you want to do that, and did you have a particular of agenda, things that were priorities for you? And what were the joys and challenges of doing that?
MM: A lot of questions! I’ve always been involved in the College. One of my mentors, as a GP trainee and as a young GP, was Denis Pereira Gray, one of the great leaders of the College. And I’ve always regarded the College as making a really important contribution to my professional practice. I always found it a really stimulating environment and fun to be in. I had a very clear idea of what I wanted to achieve as Chair, the kind of direction that I wanted to take our members, and that was partly about rethinking and re-emphasizing the importance of relationship-based care. And it was partly about going back to our roots and recognizing the importance of population health and the role that general practice can play in population health or public health. So, I had two areas that I really wanted to work on.
I came into office in November 2019 and by January 2020, the pandemic had struck so, in some ways, everything was turned upside down. I was Chair at a challenging time, partly because of the pandemic, and partly because the enormous pressures on general practice were just starting to surface at that time. I had two major crises to handle. It was fun. But it was really challenging as well.
CS: It was probably the most rapid period of change in general practice in my lifetime. In a very short space of time, we had to completely reorganize everything, and the College was the responsible organisation for the profession, so a really important time to be Chair.
MM: It was. And for that reason, very exciting. It’s remarkable. During that period, the first year of the pandemic when the brakes were taken off, there was no limit to the resources available if you do the right thing. So it was really exciting. And, as you say, general practice really did transform itself, particularly in terms of non-face-to-face consulting, remote consulting, but also in terms of our contribution to the vaccination program. And reforming in the way that we work. It was an exciting time, but it was a tough time too.
CS: You’ve worked across many sectors, clinical, academic, professional, political. How does it feel to span all those different arenas? What have you learned?
MM: I feel very privileged. I think it’s going to become increasingly common for the next generation of doctors to have career portfolios like I’ve had. It’s already very common in the United States, but it wasn’t common in the UK when I started it. There was always a common goal of improving patient care, specifically through the promotion of primary care and general practice, but to do that with a range of different lenses- as a clinician, as an academic, as a policymaker and as a professional leader. I enjoyed each role in isolation but most importantly, I really enjoyed working at the interface between those roles and trying to make sense of how we work together across sectors in order to make a difference. In some ways, I guess, I’m continuing that as in my non-exec roles. I’ve another career now, since giving up clinical practice and giving up my academic practice, and stepping down from the college, which is as a non-executive board member with the Nuffield Trust, the National Centre for Creative Health and the Royal Devon University Healthcare Foundation Trust. These roles allow me to use my experience and wisdom in a more strategic way. I’ve been very fortunate in my career and I’m very grateful for the opportunities I’ve had.
“…somewhere between 70 to 80% of our health is determined by social factors, and not by factors within the remit of the NHS. Social intervention, therefore, makes sense. That’s why I’ve always been a strong advocate of social prescribing, even though it’s been quite difficult to implement in the NHS…”
CS: Tell us briefly about the Nuffield Trust, what it does, and the key priorities.
MM: The Nuffield trust is a think tank. It’s a policy influencing organization. It’s a charity that was set up by Lord Nuffield in 1940. There are three health and care think tanks in UK, the Nuffield is the smallest, but we punch well above our weight. The others are the King’s Fund and the Health Foundation. Our role is to influence policy, and we always do that on the basis of evidence. We create evidence, and we work with others to create evidence, about the organization and delivery of services in the health service research sphere, and we present that evidence to policymakers and to NHS health and care system leaders, and to clinical bodies. And we critique policy so that, when policy ideas come out, our job is to constructively and apolitically critique policy on the basis of the evidence and experience that we have.
CS: And, you’ve recently you become chair of the National Centre for Creative Health, which I don’t know anything about. So what’s that?
MM: That was a really interesting opportunity. As a GP, I’ve always been interested in having a broad range of interventions to use. We’ve already talked about the biomedical interventions. But the evidence is that somewhere between 70 to 80% of our health is determined by social factors, and not by factors within the remit of the NHS. Social intervention, therefore, makes sense. That’s why I’ve always been a strong advocate of social prescribing, even though it’s been quite difficult to implement in the NHS and the National Centre for Creative Health is one element of that social prescribing basket. Specifically, it’s about creative activities. It includes the performing arts, the visual arts, any activity that stimulates your imagination. It might be gardening, it might be cooking, it might be reading a good book or watching a good film. And the evidence is very clear that If your imagination is stimulated, you feel better about yourself. And, as a consequence, your health and wellbeing improve.
CS: Looking back on your really busy career, if you met your 22-year-old self, recently graduated, what advice would you give?
MM: Number one, I think our credibility as senior professionals is based on being a good, experienced clinician so, get a really good clinical foundation under your belt. The wisdom that comes along with having been a full-time, or near full-time clinician, early in your career, is important. So be a good clinician.
Add strings to your bow and don’t constrain yourself. Take risks. I’ve described some elements of my career, all of which have been enjoyable – some more successful than others. But each of them has added something to what I’ve been able to bring to the field that I’m in later in my career. Add strings to your bow, take risks, and enjoy what you’re doing.
CS: You’ve certainly done that. I can’t think of anybody who has packed in as many different roles into their careers as you have done. And I could talk to you about this for ages. It’s a really great privilege to hear about what you’ve learned from all these different roles. Thank you so much.
