There are over 500 actions in the long-term plan, but I am most interested in those that can help leaders to create and maintain positive, inclusive and compassionate working cultures. None of the health ambitions in the long-term plan are possible if staff are not working in environments where they are able to do their very best work. Yet, the long-term plan has only one page on leadership and culture among its 133 pages in total, suggesting there is a considerable way to go and perhaps a lack of understanding of the sustained efforts required to change culture.
I was pleased to see that the plan does include clear statements about the need for compassion and inclusive leadership. The Secretary of State for Health, Matt Hancock MP, has also made several comments about the need to change culture in his recent speeches. Professor Michael West has evidenced that leadership is critical for nurturing high-quality care through an extensive review of the literature, particularly how a collective style ensures that all staff take responsibility for ensuring high-quality care for patients.
Realistically, how far are we from this vision of inclusive and compassionate leadership? I think the long-term plan is overly generous in suggesting that the leadership cultures required are 'not yet commonplace' in the NHS. The current evidence, including the annual NHS staff survey (the 2018 results are out tomorrow), paints a bleaker reality, including the reported levels of bullying and harassment and the fact that 38.4 per cent felt unwell due to work-related stress in the last 12 months.
So, what stops leaders in the NHS from making the necessary progress? Why is compassion still considered ‘soft’ in leadership and management circles, when in practice being a compassionate leader requires guts and tenacity to do the right thing every day?
As I type this blog, I am on a train to London to catch up with Professor Don Berwick. In his review of patient safety in 2013 – commissioned by the Secretary of State in the wake of the Mid Staffordshire tragedy – he highlighted the importance of addressing bad practice, including poor teamwork 'using approaches founded on learning, support, listening and continual improvement, as well as effective appraisals, retraining and, where appropriate, revalidation.' Berwick made it clear that cultural change and continual improvement comes from leaders, through their encouragement, compassion and modelling of the right behaviours.
We are looking forward to welcoming Amy C Edmondson, Novartis Professor of Leadership and Management at the Harvard Business School, to The King’s Fund when she delivers a keynote at our annual Leadership and Management Summit on 10 July 2019. She identified the problem that teams don't learn naturally. The factors that prevent them from doing so include interpersonal fear, irrational beliefs about failure, groupthink, problematic power dynamics, and information hoarding. Does that sound familiar to you in the NHS? It does to me.
So, what will it take to break out of these patterns and pay more attention to behaviours and practice reflexivity in teams? Lord Prior, the new chair of NHS England, recently stated that NHS staff suffer from ‘learned helplessness in a dysfunctional system’ which had been created by ‘targets, competition and a reliance on inspectors’. He argued that the main aim of the long-term plan is to overcome organisational divides and address the ‘hierarchical culture’ and behaviours that have traditionally been associated with top-down management approaches in the service. Yet, just over two years ago, some of the key arm’s length bodies, including NHS Improvement, NHS England and the Care Quality Commission, pledged to change their behaviours to model compassionate leadership. An excerpt is copied below:
From NHS Improvement's 'Developing people – improving care' framework
However, there is currently no formal and safe mechanism, other than via membership organisations, through which individuals or organisations can offer feedback on what it feels like to be on the receiving end of national leadership behaviours. If Lord Prior is serious, then he needs to ensure that leaders in his own organisation and other national bodies understand how they have been complicit in creating the 'learned helplessness' and take positive action in 2019 and beyond to change.
The long-term plan proposes the development of a new 'NHS leadership code' setting out the cultural values and leadership behaviours of the NHS and 'will be used to underpin everything from our recruitment practices to development programmes'.
But surely, we don’t have to wait for an NHS-wide code to start practicing compassion. What compassionate leadership action will you take today?
I raised an issue about an agency member of staff who had been suspended. I asked about her welfare, and was told we don't owe her a duty of care. I said staff care about her and want to know she is OK. A gentle challenge, but someone needed to lead on her welfare, whatever she may or may not have done.
We have a long way to go in breaking down traditional thinking and practice in leadership in management. We have many years of "shoehorning" staff into hierarchical structures, systems and processes. I welcome and embrace the recognition and drive for inclusive and compassionate leadership. After all this is what underpins our patient care too. However, it is another change, and some staff and patients are nervous about recognising their own responsibility.
We cannot underestimate the skill and time required to support leaders to flourish and change cultures.
I've recently given two talks in Bristol to health and social care staff, talking about compassion and how we can learn the skills of self-compassion which help us to cope in difficult situations, but also to be more compassionate as leaders and with our colleagues and patients. I'm looking at ways to increase my reach with these concepts as the feedback I'm getting is "more please, we desperately need this".
Junior doctors in training need to be in a small team and to meet regularly with other team members. If on 12 hour shifts which overun and will do so repeadedly they must have access to rest rooms, mess in a safe room where they can talk professionaly eat and with nearby sleep rooms. They should not have to commute after shifts lasting more than 8 hours and if they do not wish to return home as their patients need them then they should know that accomodation food and parking space is instantly available at no charge.
Finally the effects of shift work on cognition may be equated/ measured interms of blood alcohol concentrations. Mistakes will occur and management as well as other members of the team should be all involved if a team member is reported to their professional registration commision eg the GMC RGM.
If you're interested in learning more from non-hierarchical organisations in healthcare, you might might want to join this upcoming event in London: ‘Next Stage Health Care & Public Services – from thinking to practice’: https://q.health.org.uk/event/next-stage-health-care-public-services-fr… (there are a last few tickets left; it's free).
Also, it needs to be pointed out by someone that a core finding by the great pioneer of organisational learning and organisational development, Prof Chris Argryis, was that a key reason why most organisations consistently *fail to learn* is because leaders and others seek to protect others, seek to avoid eliciting any negative feelings etc.
Unfortunately, if you said to the whole NHS workforce 'Be more compassionate!', or words to that effect, most people will double down on the protective and defensive behaviours - as that kind of protectiveness feels 'compassionate'.
An NHS where it is safe to learn together may get further away, not nearer, with such generalised calls for compassion that don't carefully take this core finding of decades of OD research into account.
Luckily we have Prof Amy Edmondson's new book 'The Fearless Organisation - Creating Psychological Safety in the Workplace for Learning, Innovation and Growth', to help us.
And to see how non-hierarchical organisations work (including ones like Buurtzorg, in healthcare) we have Laloux's Reinventing Organizations.
We also have Prof Kegan et al's book 'An Everyone Culture - Becoming a Deliberately Developmental Organization' on how to build growth cultures in organisations, where it is safe and encouraged to learn and develop together - rather than keep up the expected pretence that you have all the answers and expertise etc.
Both the latter books are based around detailed case studies - take a look. (The Kegan book uses Bridgewater as one case study, and Amy also uses it - as a case study in Psychological Safety - in her new book).