Ruth Carnall explains what she learnt after becoming a trust chief executive overnight, working in the civil service and serving as chief executive for NHS London

I started out in the NHS 36 years ago in finance at St Mary’s Hospital in London. I thought it was “just a job”, but it turned out they expected me to study to become an accountant. For anyone who knows me, this was not a good choice.

‘Instead of coming back as the finance director, I came straight back as the chief executive − and I didn’t find out about it beforehand’

I had to spend over 10 years in finance, and even become a finance director despite being no good with figures and having no process skills. For those who know their Myers-Briggs, I’m an ENFP (extraversion, intuition, feeling, perception) type; not an ideal profile for an accountant. Finance directors who know me now find it inconceivable that I could ever have passed the exams, let alone done the job.

Possibly the most “developmental” point in my career came with my first chief executive job, in Hastings. Unfortunately, it coincided with my very first day back from maternity leave after the birth of my first child. The previous incumbent had departed overnight, so instead of coming back as the finance director, which was my substantive job, I came straight back as the chief executive of the acute trust − and I didn’t find out about it beforehand.

Anyone who has experienced coming back to work as a new mother will know that it’s very stressful, exhausting and riddled with self-doubt and guilt about everything − from what you look like to the long-term damage your career is causing your child.

I think surviving this, with the amazing help of colleagues and friends, was perhaps what gave me the resilience necessary for the rest of my career. I think I quickly became a much better chief executive than I ever was an accountant − but as I said, this was a low base for comparison.

A different world

The second most “developmental” opportunity came in 2000, when I became the regional director for the South East at a point in time when regional offices became part of the civil service. I had been a chief executive for quite a few years by then, and felt pretty comfortable with the role.

‘I soon upset the secretary of state, as a result of a letter about deficits and the need not to have them − which leaked just as he was making a speech’

I then made the almost fatal mistake of thinking that this job was just a sort of bigger version of my old role. I had zero understanding of the different culture of the civil service and my place within it. I knew nothing about working with ministers and policymakers. I thought my job was still to “run” something.

It felt like I was blundering around in the dark; as though I had gone from being a competent, experienced, senior leader to being a naïve, stupid and clumsy ingénue. There was no induction programme to help.

I soon upset the secretary of state, as a result of a letter about deficits and the need not to have them − which was leaked just as he was making a speech about how much more money there was than ever before.

That was nearly the end of my civil service career. I survived and got over it because of the loyalty and support of my colleagues, who protected me from the wrath that descended. But I learnt about how to operate in a very different world.

Above the parapet

My final most memorable moment came when, having left the NHS (in my mind) for good, David Nicholson asked me to come and be the interim chief executive for London for six months − and I stayed seven years.

‘It’s impossible to avoid controversy if you want to change anything in the NHS’

It was the most fantastic job in the NHS, and a real privilege to work with such a great team and so many brave and ambitious clinical leaders. Healthcare for London, a strategic plan developed with Ara Darzi, had huge potential. We made some real progress, especially in centralising specialist services.

We were not so successful in investing in and developing primary care, though progress is now being made, nor did we have as much impact on that and on some other services as I would have liked. We faced a lot of controversy. In fact, the programme became Andrew Lansley’s bête noire.

It’s impossible to avoid controversy if you want to change anything in the NHS. You can keep your head below the parapet, and even appear successful, but you won’t move anything forward. I would have happily continued in that job till retirement, but the recent reforms intervened. This was my ninth major national reorganisation and my fifth abolition, so that feels like enough.

Overall, that is my biggest regret: so many upheavals, so little continuity, such a loss of talent over the years. That aside, it’s been a fantastic journey, which started out as “just a job” and in the end gave me a fantastic career, and the privilege of working with some of the most committed and capable people in any sphere anywhere in the world. It’s also provided almost all of my closest friendships.

Dame Ruth Carnall is a director of Carnall Farrar LLP