Michael West: Collaborative and compassionate leadership

Thank you, good morning. So I’d like to address three questions in this privileged time that I have.  How can we care for the health and wellbeing of NHS staff to ensure their effectiveness and their wellbeing?  How can we promote the innovation in the NHS which is essential to meeting the needs of our communities?  And, how can we ensure the collaboration across boundaries that Matthew talked about which is so important for the health and wellbeing of communities?

The challenges we face in the NHS are varied and complex. In the process of trying to respond to them we’re damaging the health and wellbeing of the very people we ask to deliver the health and wellbeing of our communities.  Of the 1.4 million people who work in the NHS in England, more than 50% say they’re unable to meet all of the conflicting demands on their time at work.  Nearly 40% say that they’ve been unwell as a result of stress at work in the previous year.  Around 50% more staff report debilitating levels of work stress, compared with the general working population as a whole, and we know that this has an impact on the quality of care, we know that it affects error rates, it affects people ability to be compassionate and it affects in the acute sector, patient mortality.  And only 44% say that they’re able to make improvements happen in their area of work.  So what are we to do?

Well there are various top down initiatives which become more complex and demanding, but maybe they don’t actually meet the kind of cultural demands that we are facing here. So what are we do to?  And also, there’s the concern that the regulatory and inspection regimes we have, have been in danger of creating cultures of blame and fear rather than cultures of compassion and innovation.  So what can we do?

I think we have to go back to the heart of what this is all about. When the NHS was set up in 1948 by a deeply traumatised post-war society, it was with a commitment to caring for everybody in the country, regardless of wealth, status prestige, background.  A compassionate and inclusive system.  NHS staff have virtually all made a decision to dedicate an enormous part of their precious, unique, mysterious lives, to caring for their fellow human beings, so they too have a core work value of compassion.

So what is compassion? Compassion for me is the healthcare assistant I saw who stayed for an hour after her shift had ended, holding the hand of an elderly lady who was in distress and talking to her lovingly and caringly, until she was calm again.  It was the GP who told me she danced in her surgery that day with an elderly lonely man when she discovered they had a shared interest in dancing.  And it has, I think, four components.  If Matthew here is in distress, god forbid Matthew, then for me to be compassionate I first have to be present with you, I have to pay attention, I have to listen with fascination to you.  Second, it’s important that I arrive at an understanding of the causes of your distress.  Third is, I must empathise, I must feel at some level the feelings of distress that you have, which gives me the motivation then to help, to intervene to make a difference.  You’re feeling better already, aren’t you?  And when NHS staff are able to deliver compassionate care, patients are more satisfied and that in turn affects staff commitment and wellbeing.  We get a virtuous cycle of compassion.

So, the question is, how do we create cultures where staff can deliver compassionate care, cultures of compassion? Well, in order to nurture cultures of compassion, we’re all responsible for culture.  Every interaction by every individual every day, shapes or nurtures the culture of the organisation.

But leaders play a particularly powerful role. What leaders pay attention to, what they monitor, what they reward, what they talk about, communicates to staff what it is that’s valued in the organisation, i.e. the culture.  So, it’s really important that leaders embody compassion in their leadership, and that means for behaviours.  Leaders who pay attention to staff, who as a consequence have an appreciation of their frustrations, their difficulties, their hurts, their challenges, their delights, their successes, leaders who arrive at an understanding of the causes of the distress of difficulties staff experience.

Remember what I said about levels of stress of staff at the beginning? And ideally, that’s a shared understanding because it’ll be both more accurate and more helpful.  Leaders who then empathise, who have a felt reaction to the difficulties staff face, who are able to tolerate that distress rather than over identify with it, and then leaders who take action to help staff, that after all is what leadership is about, is helping those that we lead to do the job that we want to do.

The social movement for compassionate leadership is strengthening, and particularly as the result of the publication that Matthew mentioned of the national strategy developing people improving care, a framework for developing compassionate and inclusive leadership and improvement skills across the system that has been sponsored by all of the national NHS bodies and is associated with pledges that they’ve made around their own compassionate leadership and their own cultures in organisation.

So compassionate leadership feels fundamental to a way of responding to the health and wellbeing of staff within the NHS. What about innovation and improvement?  Only innovation can enable modern healthcare organisations to respond to the challenges of meeting the neds and expectations of their communities, while adequate financial support is a necessary precondition, it’s clear that more money on its own will not be enough.  We need transformative change and that’s the second question; how to foster innovation in the NHS to ensure the health and wellbeing of communities?

I was fortunate to start researching innovation in the NHS in the mid-1980s, looking at innovation amongst student nurses, then health visitors. We spread the research to look at innovation amongst primary healthcare teams, community mental health teams, breast cancer care teams.  We started to look also, and published around innovation among executive teams in NHS organisations and then we began to look at the cultures of NHS organisations in terms of the extent to which they promoted innovation.

Over thirty years of research into innovation and research in other countries and in other sectors, has given us power insights into the conditions necessary for staff to innovate within the NHS and compassionate leadership is fundament. Compassionate leadership enhances the intrinsic motivation of staff and reinforces their fundamental altruism.  It helps promote a culture of learning where risk taking is accepted within safe boundaries, and where there’s an acceptance that no all innovation will be successful.  Diametrically opposite to cultures of blame and fear and bullying.

Compassion also creates psychological safety so that staff feel safe to raise concerns about errors, near misses, problems that they perceive in the workplace and they empowered to develop and implement ideas for new and improved ways of doing things, and when there’s compassionate leadership we saw more collaborative and cooperative work within compassionate cultures. In climates characterised by cohesion and optimism and a sense of efficacy.

And we know from extensive research into cultures of innovation, something of the key values and factors in organisations that make a difference in terms of levels of innovation. Particularly important ones I think for the context of the NHS are these four: inspiring vision and strategy, compassionate leadership involves offering inspired vision, powerfully focussed on providing high quality compassionate care because that’s the fundamental orientation of compassionate leadership, but it means ensuring that leaders are focussed at every level of the organisation, every day, on that vision, through their behaviours, through what they pay attention to, what they monitor, what they rewards.  A good example is Narayana Health which was founded by Dr Devi Shetty in 2001.  He believed he had a moral obligation to ensure there was cardiac surgical care available for everybody who needed it and so he created the conditions where people could access those services by providing insurance schemes, flexible insurance schemes and support so that only some 40% of people pay heavily discounted rates for cardiac care and 20% pay nothing at all.

Another example was Jos de Blok’s founding of the Buurtzorg organisation, a new model of community care in the Netherlands in 2007, based initially on one team of four community nurses. His idea was that good healthcare should connect to the intrinsic motivation of nurses.  It had to be inspiring so that the nurses themselves would be the carriers of the vision of high quality care.  Today, it’s a highly effective organisation employing 9,500 community nurses, in 800 independent teams.  Such clarity of vision in practice, not just as an espouse vision, is really important in terms of promoting innovation in organisations.

Second is positive inclusion and participation. Compassionate leadership by definition is inclusive.  It’s about hearing all voices, involving everybody including of course patients and community groups, but diversity of voices must be complemented by positive attitudes to diversity, consistently whether of opinion or demographic background, professional background or experience.  And positive inclusion must exist in every team, in the organisation, not just an organisational aspiration.  So, the difference and voices are valued in every part of the organisation and this in turn nurtures psychological safety, trust, engagements, all of which promote innovation.

Such compassionate leadership must also apply to the involvement of patients, patient leaders, community groups, in the genuine co-design and development of organisational structures and treatment options and health and care delivery. We know that extensive user involvement in organisations, in any sector, is associated with high levels of innovation and improvement leading to radical change.

In Buurtzorg, family members of service users are included in the care process, nurses are supported by volunteers or informal carers and they’re part of the community.

And patients and citizen groups that model compassionate leadership in their relationships with the health and care organisations they interact with, create a powerful basis for cultures of innovation.

And third is, support and autonomy. Engagement and creativity are elicited when leaders support staff to cope with the inevitable negative experiences of healthcare, pain fear and the death of patients.  When leaders take time to help staff process negative emotions, for supporting shorts rounds, they enable staff to develop resilience and creativity.

Compassionate leadership also involves addressing the enormous problem of work overloads, which by the way, has a direct influence on patient satisfaction and it damages employee wellbeing of course, and little bits of effective innovation.

In Birmingham Women and Children’s Hospital, listening to staff highlighted a major problem, endemic in the NHS.  The pressure on junior doctors was intolerable.  Gaps in rotas meant that junior doctors were working in unacceptable conditions and that their learning and potentially patient care was suffering.  The organisation responded by bringing together junior doctors, consultants, other clinicians, the finance department, the HR department, in order to listen deeply to understand the issues involved.  These events led to a much wider understanding of the grim experience of the junior doctors.  All involved committed to making the hospital, the trust, the best organisation in the country for junior doctors to work in.

Weekly Thursday morning meetings became the medium for innovation. Thirty four rotas were redesigned and clinical staff led the initiative to create new roles to support the work, advanced clinical practitioners and physician associates.  Some of the toughest areas such as surgery became the lead ambassadors for the changes, and the organisation is now an exemplar for others across the country in terms of their work with junior doctors and the integration of junior doctors, and by the way, they had an outstanding rating from CQC this year.

For innovation and quality improvement to be the texture of NHS organisations, command and control has to give way to more collective leadership styles which we’ve talked about in The King's Fund previously. Research into individual, team and organisational level innovation has consistently shown the importance of autonomy as an enabling condition for invocation.

And the fourth area is enthusiastic team and cross boundary working. Compassionate leadership of teams involves leaders encouraging team members to listen to each other with fascination, to understand each other challenges, to empathise and support each other.  Such teams, our research and others research consistently shows are far more innovative than teams that don’t practice such simple team working skills.

Moreover, those supportive teams with compassionate team leadership have lower areas of errors, stress, injuries, bullying and harassment whether from colleagues or from staff towards team members, and in the acute sector lower levels of patient mortality, and in turn that creates the conditions for higher levels of innovation.

What about the third question; how can we ensure effective cross boundary working? STPs are the main vehicle for transforming health and care in England.  The success of these collaboratives will depend on compassionate system leadership across organisations that historically have little experience in working together to bring about change at the scale and pace that now seems essential.

Fifty odd years of research into inter-group contact and into belonging and trust in human relationships have demonstrated what that compassionate system leadership must comprise. It means five things; the first is a compelling shared vision of transforming the health and wellbeing of community, a shared commitment to work together, not just for the short term, but to establish long term and medium term objectives so there’s a real sense of stability and continuity.  It’s not just another short term initiative.  It requires frequent contact, face to face contact, between leaders who must work together to build trust and make real progress for their communities, and it requires the speedy surfacing, a shared covenant to surface and resolve conflicts quickly, fairly transparently and with a commitment to collaborative problem solving, ideally using a shared conflict management model across these organisations, and it requires an overt commitment to behave altruistically towards each others organisations, mutually supporting success, always asking the question to other organisation: how can we help you?  What can we do that will help you to ensure the system is functioning effective, and that has to become a norm in these organisations.

Canterbury Healthcare System in Christchurch, New Zealand demonstrated the value of such in approaches when in February 2011 Christchurch was struck by a major earthquake which devastated much of the city centre. It killed 185 people and more than 6,500 were injured.  Most health buildings, including hospitals were badly damaged.  On the day, five general practices were completely destroyed with 11 clinicians among the dead, but Canterbury Healthcare System has been able to respond, adapt and rebuild because they were already working to build trust and understanding and collaboration across the system.  They were working with a set of principles, first that they had to deliver the right care in the right place at the right time, by the right person, and the whole system had to make the best possible use of resources rather than individual organisations and practitioners simply arguing for more money, and they had to recognise that there was one system and one budget.  The process of building trust and integrated working helped Canterbury in Christchurch to react effectively to the earthquake.

As David Meates said, the chief executive, we need the whole system to be working for the whole system to work, and compassionate leadership is fundamental to whole system working.

So in conclusion, the evidence of the links between leadership that creates psychological safety, supportiveness, positivity and empathy in short compassionate leadership and the wellbeing of staff innovation and collaborative working is deep and convincing for all NHS organisations to meet the challenges that they face, they must draw on this deep knowledge base about innovation which exists and begin the process of transforming strategies and visions, cultures and leadership, diversity and participation and their systems and processes to support staff wellbeing, innovation and cross boundary working.

Fundamentally this requires compassion leadership at every level of the sector. The pledges made by the national bodies and the work being pioneered by individual organisations that Matthew mentioned, East London Foundation Trust, Northumbria, Central Manchester Foundation Trust, it’s inspiring and encouraging but the whole system must be working for the whole system to work.  That requires all of us who lead to have the courage to be compassionate in all our dealings, with colleagues, with staff, with patients, with community groups and to have the courage to develop new and improved ways of working and to persist in their implementation, to have the courage to persist in their implementation and it requires we develop our own personal capacity and resilience to be compassionate by practising self-compassion.  That means paying attention to ourselves, understanding the challenges we face in our work, and indeed in our lives generally. Empathising with ourselves, taking care of ourselves and then taking thoughtful, intelligent action to help ourselves in order that we can be who we can be and stay close to the core values that give our lives meaning, like compassion and enable us to have deeper more authentic and compassionate relationships with all.

And when we spread that compassionate leadership from ourselves across the system, we then have the ability to transform the health and wellbeing of communities.

Thank you very much.