“No kind action ever stops with itself. One kind action leads to another. Good example is followed. A single act of kindness throws out roots in all directions, and the roots spring up and make new trees. The greatest work that kindness does to others is that it makes them kind themselves.” – Amelia Earhart
After months of waiting, we finally have the NHS long-term plan. So, was it worth the wait? Does it really matter to the day-to-day work of staff delivering care? And what changes will be required to deliver on its ambitions?
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
Will regulators and inspectors back the framework? Yes. We’re changing the rules and how we oversee them to back it up (see Section 3, Condition 5 for details). But we understand there may be scepticism about our ability to demonstrate the compassionate leadership called for by the framework. To show our conviction, we’re making three pledges. Please hold us to account for keeping them:
We will model in all our dealings with the service and in our own organisations the inclusive, compassionate leadership and attention to people development that establish continuous improvement cultures.
We will support local decision-makers through collectively reshaping the regulatory and oversight environment. In particular, we owe local organisations and systems time and space to establish continuous improvement cultures.
We will use the framework as a guide when we do anything at a national level concerning leadership, improvement and talent management so we engage across the service with one voice.
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?