System leadership viewpoints: Kim Holt

Dr Kim Holt is a consultant paediatrician, trained in London and Manchester. Her first consultant post was in Salford where she developed a ‘one-stop shop’, for children with visual impairment. Always striving for excellence in community child health provision, she was a member of a newly formed community team recruited to develop and improve community services in Haringey in 2004.

This interview is taken from our report on the practice of system leadership.

Do you see yourself as a system leader?

It was only very late on that I realised basically that what I was doing was showing leadership. It eventually dawned on me that that’s what was happening!

What are some of the challenges you've faced?

There’s a high probability, if you do what I did, that you will get attacked in some way or another. Not everyone is going to be agreeing with you. So that’s one of the real challenges. And you do need to have quite a good support network. I’ve had a very strong support network, which grew bigger and bigger and bigger. The most important support in the first instance is the people close to you.

So you take a particular position, and you find that you survive that particular position, and you get more support, and that then gives you the confidence to continue. But it still hasn’t got to the point where it is all plain sailing.

So I am back at work now, doing fully what I was trained for. And it was four and a half years to get back to that, so that is a completely different situation to the one it was. I was placed on secondment for two and a half years. And I did a Masters degree and some voluntary work for Kids Company. So in terms of not working at all, and totally doing nothing, it was only about six months.

And doing the Masters in complex care and child protection, I’ve learnt quite a lot about organisational systems, and unconscious processes, and group thinking and things like that. So that was really helpful in terms of my understanding about what had been happening to me, and why I was facing such hostility. It helped me a lot to depersonalise it. It just happened to be me; it could have been someone else who raised all this. So that’s been really helpful.

You are talking about this to me in terms of system leadership. But I think of it simply as leadership.

You can be a manager and not be a leader. And you can be both. And leaders have particular qualities – very strong values, and having a very clear vision of where things should be, where we should be trying to go.

Even now, with the work I have been doing at the Care Quality Commission, I get attacked by others. Because they don’t trust the CQC and they don’t trust the system.

Working with other people who have been whistle-blowers, some of them slip into some of the negative bullying behaviours that they were trying to address. So I’m quite interested in bullying, why people start behaving in these negative ways. Some of it is around unresolved issues… People who haven’t been able to resolve their own situation… They haven’t been able to move on from their own position and see the bigger picture. And I was able to do that relatively quickly, and see that it was the system, not me, that was the problem.

People attacked me, but actually they would have attacked anyone who challenged that culture, who challenged that system. So the system, at the moment, does not support and protect whistle-blowers. We have to raise awareness about that.

I was traumatised by it, and if I talk about it in depth I still am, even though I have moved on, long ago, from my personal problems and my personal position. I lived it. I know how bad it feels. I haven’t forgotten that.

But I know that I was fortunate because the very high-profile situation that Haringey was in made it very difficult for my employers to sack me. That’s the key reason I survived – that, and the fact that some journalists did lots of investigation and found the truth in a way that I would not have been able to. I know that there are other people who don’t have that. So I recognise that. So that’s why I fight for the system to be changed so that they will be protected, other people will be protected.

And it can be very difficult for those whose situations have not been resolved. So I still get attacked. Because if you’re somebody who’s stood up and done the right thing, and then lost your job, and lost your career and lost all your money, and you are possibly losing your house, and you’ve suffered in your health as well – then to see somebody else, like me, who is in employment, who has done some work with the CQC – they feel that you, that someone like me, has gone over to the other side, so to speak… That I’ve betrayed them. That maybe I have moved to the other side. Obviously I know, myself… I know I’ve not done that.

So [at the time of the interview in January 2015] we’ve had some very difficult weeks in Patients First. So we have put together a code of conduct – so that if you disagree with something, there is a process by which you can discuss it. You can’t just have wild allegations thrown around. So, despite being seen by some as possibly a rebel and not very corporate because I blew the whistle, you end up being quite corporate because you have to have structure.

We are not going to tolerate bullying, even if it is from another whistle-blower, and – sadly – whistle-blowers can bully.

I came to realise that what I was involved in was a system issue – that our department was very dysfunctional, and that if it wasn’t sorted out it would happen again. I went to my MP, Lynne Featherstone, and she took up the mantle, and she put me in touch with Ed Balls who put me on to NHS London. And I thought that was the system, and it would all be fine. Maybe I was naïve. And I was being offered money to leave my job – sign a gagging clause and go.

The unions don’t support people very robustly. The British Medical Association, by the end, were very good. But at the beginning it was very hit and miss. They were more like ‘take the money, go and find another job’. You know? ‘Leave and just put this behind you.’ They even supported (and still do) the confidentiality clause aspect.

On the whole, unions let health professionals down. They’re not involved early enough; they don’t deal with the bullying issues. If it does progress into a whistle-blowing case, it’s very difficult because of the problems with the law in terms of winning the case. So they tend to go for a compromise agreement, which is not what is needed – either for the individual or for patient safety.

And when I went public, it was in fact very refreshing. The first journalist I spoke to said, ‘look, they’re trying to bribe you’. They just understood it straight away, because journalists see corruption all over the place.

What do you think about the culture in the NHS?

There’s something very strange about the culture in the NHS. You have this set of beliefs, that everyone is going to do the right thing, and everyone is going to support you, but, actually, pretty blatantly, they are doing completely the opposite. And yet somehow we try to convince ourselves that they’re going to do the right thing because it’s too painful for us to believe otherwise. So it’s a bit like having to acknowledge sexual abuse… Having to recognise that such injustices are happening within the health service to very professional, very highly skilled members of staff. It’s almost as bad as recognising that sexual abuse happens, because it’s so appalling. It’s so appalling that people who’ve stood up and done the right thing have been treated in such unjust ways. That is a real shock.

I do think the Care Quality Commission have understood it. In their inspections they are now looking at the ‘well led’ domain. How well do you support your staff if they raise concerns? Do you encourage them to raise concerns? How do you respond to them if they raise concerns? What’s your bullying policy? How are you monitoring your bullying policy? How are you monitoring your whistle-blowing policy? And so on. And they have started to identify a number of trusts who have bullied their staff quite badly, and they’ve been quite critical of them. So there is a recognition on the CQC side of the link between bullying, whistle-blowing, and patient safety, which, basically, is the key thing. They are taking it very seriously. But it takes a lot of determination and a lot of persistence to change the culture.

The law isn’t really the answer to this. It needs to be there as a back-up. But it should be very far down the line, a last resort. What is needed is an early intervention policy, so that if you are raising concerns and you are getting nowhere, then there is somewhere you can go.

One part of the problem is that when things go wrong, people look for a head on the block. And it can be the whistle-blower, not just others, who is looking for a head on the block – that someone, or a certain person, needs to be fired. And that doesn’t really help the patients, you know? It might help the patients in that it sends a message. But 80 per cent of the time, when things go wrong it is a system thing.

What is wrong is the cover-up. It is the cover-up that needs to be held to account.

If people deliberately hide the truth, that’s what we need to hold to account. And if we are encouraged and supported to raise concerns, we are less likely to have as many bad things go wrong. Obviously, things will still go wrong. But it will reduce the risk of that happening… Reduce the scale of the problem.

Read the next interview: Joanna Killian >

More on system leadership