Board leadership: handle with care

Sir Bruce Keogh’s review of the quality of care and treatment provided by 14 hospital trusts in England was hard-hitting about the need for change and supportive for those who will need to drive it. This is a delicate and subtle balance, but an important one if the NHS is to achieve the openness that Keogh calls for.

However, the government’s response to the proposals and, in particular, the tone of Jeremy Hunt’s response to the Keogh Review in the House of Commons in which he promised to ‘tackle and confront abuse, incompetence and weak leadership head on’, risks threatening the openness urged by the Review.

So how can boards foster openness in their organisations? The most pointed accusation by Keogh is that boards are not learning from feedback from patients. Whether organisations are actively seeking different ways to get feedback and learn appears to be a more important indicator of quality outcomes than the level and type of complaint. Why is this? Because cultures of curiosity and openness suggest an organisation is confident enough to hear complaints and has the spirit of learning and innovation needed to correct problems.

Creating cultures in which staff engage with complaints from patients seems difficult to achieve in practice. A chief executive speaking at The King’s Fund recently said ‘letters to patients are too often a smokescreen, a carefully worded response and a displacement from the organisation looking under the surface’. As an aside, it is a governance risk when boards don’t know about the culture(s) in their organisations.

What can improve our ability to listen? We hear criticism more easily when we trust our surroundings; when we don’t, our behaviours are defensive and avoiding. When we open ourselves up to scrutiny we need to trust that we will be supported and get a proportionate response from those scrutinising us. Future regulation will need to be mindful of this as it introduces a new focus on culture and what it means to be ‘well led’. 

Constant criticism of NHS leadership doesn’t help boards to be transparent. Political rhetoric that the role of non-executives and executives is to ‘challenge’ has probably done more good than harm and kept the board’s focus on scrutiny. But challenge that is poorly delivered achieves the opposite: it ruffles feathers and causes colleagues to ‘back off’, reducing trust at board level.

Boards need stability to have good discussions. Constant changes in leadership make it impossible to embed a single strategy. Losing and de-motivating good people won’t help either. Rumours around the lack of internal candidates for a replacement to Sir David Nicholson suggests that senior leaders are turning their backs on the top jobs.

Board leadership must be treated with care. Jeremy Hunt’s Commons response to the Keogh Review used strong language about incompetence and weak leadership. For some NHS organisations this criticism may be justified, but it does send signals that leaders will be scrutinised, named and shamed. It would be a shame if, as a result, some of the policies that boards may wish to get underway to increase their openness may be halted directly or indirectly. Creating conditions that mean that boards retreat from positions of greater openness with staff, with one another and with patients would be a backwards step.

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Comments

#40712 Richard
Private doctor
self

I cannot understand why we don't have a "CHIRP" (www.chirp.co.uk) for medicine and similar organisation for patients concerns. This would help to institutionalise learning from incidents. What are other's thoughts?

#40715 Kadiyali M Srivatsa
Doctor
Private

Why? Only because the politicians want you to hate NHS so that you pay all the money and take private health insurance. You must read all about this in NHS SOS.

I have been following the change and criticised the approach in 1996. Initially they introduced "Preprinted Assessment Sheet" and created algorithms and guidelines by forming NICE.

The politicians and people in power in the NHS have failed to identify the role of a doctor.

Diagnosis and treatment is complex and can never be treated as a business or work in a strict binary frame work like the airlines. If some can create a perfect algorithm, I am sure a computer could do a better job than us.

#40724 Jeremy Marchant
mentor/trainer/facilitator
emotional intelligence at work

You write, “We hear criticism more easily when we trust our surroundings; when we don’t, our behaviours are defensive and avoiding”. That might be true, but I read it as “we have to be able to trust our surroundings before we can hear criticism”, and that’s just a belief (which needn’t be true).

If we set an intention that we are going to listen to criticism (not quite the same thing as hearing it), then we create a situation in which we can, however difficult at first.

If we encourage everyone in the organisation to have this intention to be open without any expectations that the culture we be a certain way before we start, then we will become mutually supporting, and the endeavour is likely to succeed.

You write, “When we open ourselves up to scrutiny we need to trust that we will be supported and get a proportionate response from those scrutinising us”. Again, it would be helpful if that happened, but we mustn’t make it a prerequisite. If leaders do nothing else, they show the way and, in this, I am afraid that boards have to be open first and in all respects—and unconditionally so—if they are going to have any chance that those they lead will do likewise.

This might be so important that it becomes the only thing that boards have time to do.

That politicians are unwilling or unable to do the same thing is very unfortunate, but hardly surprising. However, behaving in their way is tantamount to an act of collusion with the unintended consequence of perpetuating the fight between politicians and the NHS.

#40746 haihuynh
You write, “When we open ourselves up to scrutiny we need to trust that we will be supported and get a proportionate response from those scrutinising us”. Again, it would be helpful if that happened, but we mustn’t make it a prerequisite. If leaders do nothing else, they show the way and, in this, I am afraid that boards have to be open first and in all respects—and unconditionally so—if they are going to have any chance that those they lead will do likewise.
#41834 alixresch

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Creating conditions that mean that boards retreat from positions of greater openness with staff, with one another and with patients would be a backwards step.

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