15. Possible Causes: Health Sector Generally
15.1. There are undoubtedly multiple causes of the symptoms described in this report. Finding a simple reason is not always possible. An observer commented: "There is often no explanation or reason one person subjects another to the type of behaviour defined by ACAS..." as bullying.
15.2. Diagnostically, the experiences of many NHSH staff are likely to be attributable to a number of factors which have built up over many years, a number of which have also created difficulty in raising and addressing them locally.
15.3. Some would say these have created a perfect storm in NHSH. Many of the features described in a "VUCA World" (see paragraph 4 above) and referred to in my chapter on human nature are manifest in NHSH. A number are outside the control of an organisation such as NHSH. We should not underestimate the effects in recent years of the general sense of isolation and alienation felt in some parts of society.
15.4. Some factors could be described as cultural and are possibly unique to the specific local and geographic circumstances of NHSH and its employees. I am mindful of emphasis on the importance of "place" in recent years. These factors play an important role. Other matters are relevant in general to the NHS in Scotland and to the provision of health care overall. There are other significant factors which will, I expect, be common to all large organisations. Yet others have to do with a management style which, it is perceived, has been prevalent in NHSH in the past several years and relate also to the effectiveness of the governing body to provide effective oversight.
15.5. I seek to address these and other possible reasons in this and the following chapters of the report. This chapter seeks to cover more general issues. The next chapter discusses matters related to NHSH itself. The succeeding chapters cover further topics which are relevant, including management, governance, HR issues, the role of trade unions and the Scottish Government and other topics.
15.6. In some of this, there is an inevitable amount of conjecture on my part, allied to the views of well-informed respondents, upon whose words I have again placed considerable reliance as authentic and authoritative sources upon which I can legitimately draw. However, this analysis will inevitably throw up questions and comments by those who understand the organisation intimately. If so, that is a good thing. There are matters which deserve to be wrestled with as NHSH seeks to move forward.
Changes in Expectations and Behaviour
15.7. As Mr Gallanders noted in his report, what is or should be tolerated as acceptable behaviour has changed in recent years. It is likely that, more generally, society is experiencing a lower tolerance of behaviour which is perceived to be intimidatory, disrespectful and hierarchical, as we have seen in other areas of public life. There is growing evidence of increased levels of awareness of workplace bullying generally – either because more is happening in fact or because attitudes are changing and mounting evidence reveals more of its existence.
15.8. Workplace bullying is not exclusive to the NHS or to the public sector. We know from recent examples that it occurs in the private and charity sectors, affecting productivity and increasing absenteeism in all organisations. The increased power of social media with no apparent parameters or checks is, I was told, another significant factor:
"Emails and social media have been fatal. People have a glass of wine and then write it all down. I have seen in the past two years, my staff's behaviour change and deteriorate quite dramatically."
"Social media spreads like a disease."
15.9. Further, health care provision across the developed world is increasingly complex and expectations of improved services in the NHS continue to be high among patients, the media and society generally, alongside medical and technological advances. One commentator said:
"Some policies have undoubtedly contributed to the NHS pressures, most recently around patients "rights" to have drugs even when extremely expensive ie rationing/control is now very difficult precisely at a time when extremely expensive drugs are being made available."
Medicine and Hierarchies
15.10. In any event, it seems that the culture in the medical world has probably historically been rather hierarchical and power-based, with a sense of entitlement and status and a corresponding element of bullying behaviour, aspects of which still remain. Lack of respect among and by clinicians still seems to be the norm in some places. A culture of deference may be an associated feature. Changing circumstances can feel like a challenge to ego and authority. The move from the autonomous, heroic "clinician with power" model to a more complicated and shared power / teamwork approach is not easy.
15.11. The perceived rise of managerialism and the clash with clinical leadership is a significant feature I am told. Younger doctors may be more at ease with a changing culture but this can itself lead to internal tension. One senior manager described it in this way:
"I've described it as being ante-diluvian. It's being in James Robertson Justice's Carry-On Doctor. Not everybody, but some consultants who are longer in the tooth. I think that's coming from a place of stress."
15.12. As one senior person put it:
"In terms of structures, I think sometimes some doctors have got an unrealistic idea of the extent of their autonomy and entitlement to do as they wish. Some people can be pretty inflexible and resist what the manager is trying to do. I wouldn't characterise the whole organisation like that, but I think part of it is the doctor's disinclination to step up. It's the model of being an advocate for individual patients being the primary concern, fitting in with traditional medical autonomy. But it doesn't fit into modern view – medicine is now a team game in delivery for care. Constrained resources. Someone has to make decisions about prioritisation. Our doctors sometimes don't step up into that more modern role. If put under pressure, can retreat into that traditional role."
15.13. A former board member told me:
"I found the hierarchy and clinical domination, and in particular deference to medics, noteworthy when I joined NHS Highland. There are tensions and conflict around how individual clinicians and teams manage 'their' patients whereas the board and senior manager's responsibilities span across all services as they apply to the entire population." An HR staff member commented: "There is a superiority thing that informs how people behave. There is a lot of emphasis on patients being important – "I'm saving lives today, what are you doing?" The staff feel that they don't matter..."
15.14. One senior manager commented:
"We have a culture in the NHS which lapses into categorisation of people by their profession, grade, job title or background. It's far from straight forward, however, because senior clinicians (of all backgrounds) have also described how virtually overnight they went from being respected and valued to one of abject disrespect when they moved into management roles."
"I have seen great progress in this regard since joining NHS Highland but medical dominance (in particular) still prevails throughout the NHS. Of course in many ways this is positive but there is a balance to be struck to ensure a healthy culture, where everyone is valued, particularly based on their contribution. Doctors don't always know best, and can and should be respectfully challenged, in the same way as other colleagues would expect to be."
15.15. Power is an important driver. Another former manager told me:
"I've worked in lots of organisations and there are pockets of people who are on the edge. ...But in NHSH, there was nobody catching it. It was the behaviour that was wanted. It's what people wanted to see. There weren't isolated incidents, but an underlying current of it all the time. … I was told to just "manage it". But it was bigger than me, I need help to manage it. We had a good clinical manager and we took a lot of abuse. But ultimately, the power wasn't with us and nobody was willing to help wrestle that power away."
15.16. Issues about education, training and selection may arise which are beyond the scope of this review and which I understand bodies such as the Royal College of Surgeons consider actively. It was pointed out that the NHS was based on a post-World War 2 model of command and control based on a military template, with "officers", divisions, uniforms, hierarchies, unquestioning deference and other attributes, many of which may have seemed valid then and which still remain. (Ironically, some respondents pointed to changes in the way the military handle bullying as a model for NHSH to follow as a necessary stage in its evolution in the 21st century).
15.17. In a later chapter, I address the tension between clinicians and managers and indeed those clinicians who have become managers. It is a complex situation.
Resistance to Change
15.18. It is fair to note that one experienced former director pointed to the difficulty of introducing change in the medical world:
"I mean the unenviable task for managers in managing these disparate groups, but more importantly managing a group of staff who earn salaries far in excess of that of their line manager. This produces a dynamic and power base that is not always conducive to change and can indeed thwart progress. The challenges in recruitment and retention across some staff groups may enhance that power base at times strengthening resistance. In my time in NHSH I have witnessed many managers struggling with budgets, increasing demand for services and expectations in relation to new interventions or medications. Not all staff understand or support these struggles and may wrongly interpret firm and fair management as a result. I believe … that NHSH has a culture of continuous improvement and that resistance to change is a natural consequence of this. NHSH has always had processes in place to support those who resist change and I believe the organisation has always aimed to be open and transparent in implementing these processes."
15.19. A professional lead put it his way:
"You'll get people who can be aggressive in actually saying "you haven't discussed that with me" when we have through consultations. But because the outcome is not what they wanted, they plead ignorance. They become aggressive and then try to undermine you in other ways. I see myself as an isolated voice although there are other ways. People are afraid to put their head above the parapet. Any change is fearful. In the change model, the status quo is the place they know even though they don't like it."
15.20. Again, system inertia is a well-recognised feature of an organisation and affects individuals under strain and who are fearful of the consequences of change. One observer reflected on the result:
"Organisational inertia, which is linked to many things. People get used to nothing happening and get frustrated or give up. This leads to some of the behaviours, whether by those managing or those seeking change or explanation."
15.21. It is perceived that there is significant and increased pressure to perform and meet targets throughout the organisation. This, perhaps underscored by a fight or flight response, has probably often taken precedence over people issues. It was argued that Scottish Government policies such as treatment time guarantees and waiting list targets press NHS Boards to deliver without enough regard for affordability and other resource issues. Unrealistic or unachievable expectations can lead managerial staff to pressurise clinical and other staff to improve performance.
15.22. Thus, these policies may have an adverse impact on the people charged with delivering them, leading to dysfunction and loss of morale which can tend to cascade down through the system. By their nature, they may emphasise a more transactional approach, to the detriment of relationships. Rather than criticising the targets themselves, there may be an absence of the necessary skills to implement them – or realistic conversations about them.
15.23. The emphasis on targets seems to be one reason for tension between management and clinicians. As I mentioned at an earlier point, there may be an inevitable, perhaps irreconcilable, tension between clinical obligations to patients and the management need to cut costs and/or increase efficiency. I am told that this is further exacerbated by the gathering and collation of data for reporting to the Board, which is used to assess targets and measure waiting times rather than shared operationally to enable those on the ground to adapt services.
15.24. One clinician observed:
"Targets are useful, but if all one is doing is working to the target, everything else becomes secondary. Particularly when the directors, CEOs and the like are managed against that target." And that creates problems for others: "People tasked with implementing the approach/regime are not necessarily knowledgeable or skilled enough to do this. Culture of training someone to do something and immediately assuming expertise. That cannot be easy. A large part of our role is to justify the role of management and administration to produce figures for them."
"Management, from the very top down, remain fixated with targets, both for delivery of services (e.g. waiting times) and financial. They have retreated to the lowest common denominator, leading to poor clinical standards, acceptance of poor behaviours and lack of candour. Clinicians have become the tool of management, we exist to allow them to produce reports to demonstrate they are meeting targets. This has led, in some places, to a culture of bullying, often as a response to fear, this is top down. Morale is very low, highly skilled and experienced people are leaving the NHS."
15.25. An employee representative commented on the political pressures and impact:
"But we have also to acknowledge the external pressure on all NHS Boards which comes from above/outside. Political discourse in Scotland around the NHS is largely centred around the meeting/breaching of targets, and success (or otherwise) in delivering a premium service within limited budgets. Government and opposition alike use this as the default for discussion and for measuring success, and that context is mirrored in media reporting. If the workplace culture in the NHS is to change, the effect of this wider context needs to be recognised for the impact it has."
15.26. One GP summarised the effect: "You see the management firefighting all the time. Their reaction under pressure is a bullying one." Firefighting is a description that arose several times.
15.27. Overall, there was a feeling of NHS boards under pressure:
"It is right that the Scottish Government (not just the current administration) places high expectations on Boards to deliver – Governments are after all answerable to the people that elect them. Equally it appears to me that the current administration is not willing to have the difficult conversations with the public over what can be expected from a resource limited public health care system – I see this daily with medicines where I feel we could get better value from investing our resources in other therapies/care. It has provided little constructive leadership and left the Board exposed when making difficult decisions."
15.28. One director expressed the frustration felt by many:
"It's the most unrewarding organisation I have ever worked for. How do you measure success? You're here to deliver care – how do you measure the care? I can tell you how many people are in a queue – how many we have failed. A good day is when you don't fail as much as a bad day."
15.29. The impact on NHSH may be more acute:
"I think the government target driven health service in an under-capacity NHS causes major issues and I have seen this for years with ill feeling and upset. It may work better in central belt with private hospitals with separate managers/nurses and secretaries but in Raigmore it distracts from the capacity we have."
15.30. A senior consultant commented on measurement as against clinical outcomes:
"Financial stringency brings with it challenging issues and the need to make difficult decisions. The way that targets have been achieved has not always been acceptable. There has been a preoccupation with the measurable whilst ignoring clinical important issues. Eg the push to meet cancer targets results in funding for facilitators and clerical staff who monitor performance and chivvy clinicians. Sometimes this can be to the detriment of more clinically pressing cases that do not attract targets and associated funding. Improved funding for staff performing the work might be better for patients in the long term."
15.31. He also said: "Financial stringency has had a major effect on the NHS but it should be possible to run a patient centred and staff friendly organisation even in the face of limited budgets." That is surely the challenge for the NHS generally and NHSH in particular.
Economic and Resource Factors
15.32. To all this can be added more general economic circumstances: over the past ten years, in times of austerity, with budget restrictions and reduced spending, financial constraints can often lead to people feeling overwhelmed at work, with too much to do, and not enough time or resource. This is likely to cause stress and may lead to behaviour which is inappropriate.
15.33. I have heard a number of examples of this, with senior (and other) employees at breaking point. Where there is significant and increased pressure to perform throughout the organisation, this may have taken precedence over people issues.
"Austerity has been a major factor. The NHS was used to solutions made out of additional investment from Government. When this became no longer possible the pressure within the entire NHS system increased."
"These are coming with cuts being made to resources, staff being asked to do more beyond their accountability, experienced staff leaving, newer staff not realising that being stressed at your work was not always a feature, managers becoming process led..."
15.34. The impact on staff morale and the lack of acknowledgment was recorded in these terms:
"I perceive a lack of interest and understanding on behalf of the health board in the day to day experience of staff and patients. I hear many staff expressing the view that their work is not appreciated by the organisation; the organisation does not understand the pressures they are under and does not recognise the impact on patient care. I see good people trying their hardest to provide high quality care in very difficult circumstances with ever fewer resources. We all recognise that resources are very limited and there is no spare money but given the reduction in resource which I have experienced in my own specialty and is mirrored in many other areas, the pressure from the organisation to not only continue with the same level of service, but to increase service provision creates a sense of inevitable failure. Never being able to achieve the standard of care aspired to, leads to low morale and this is manifest in the increasing levels of staff stress and sickness."
15.35. Ironically, the resulting breakdown in relationships may well lead to behaviour which is experienced as bullying:
"There are also the inevitable financial pressures. Currently we are several members of staff down due to problems with recruitment. The perception is that senior management are only interested in saving money and are happy to let the remaining staff pick up the work. This again leads to a general perception that this is not a caring and supportive organisation. In this atmosphere unpopular decisions or inability to progress can be viewed as uncaring and bullying."
15.36. The resulting disconnect was further highlighted in this observation about the impact on front line staff from a team leader who emphasised his understanding of the need for tough decisions and innovative thinking to produce a sustainable and cost-effective service:
"Within NHS Highland and particularly in Argyll and Bute the message coming from senior management has changed as the financial savings targets have increased. The message of changing services to save money but maintaining quality has subtly changed over the past few years so that frontline staff now hear only 'save money' with decisions made arbitrarily and opportunistically which clearly do not fit with the Highland Quality Approach - wholesale cuts to services for more vulnerable patient groups such as mental health are becoming more common. Concerns raised about such cuts are deflected with assurances that services have simply been 'redesigned'. The lack of openness and denial that services have been cut without significant consultation or risk assessment is contributing to the disconnect between staff and senior managers and leaving the staff feeling that cost saving is the only priority of the Health and Social Care Partnership in Argyll and Bute. This disconnect has been highlighted in iMatters staff questionnaires over the past two years."
15.37. He goes on to capture the impact of all of this on perceptions of the leadership and loss of compassion and understanding:
"Overall, morale among frontline staff is pretty low and although not a typical picture of 'bullying' there seems to be a drift towards an oppressive approach to management as the financial savings appear more and more unachievable. Recent managers job descriptions have included phrases like 'manage conflict with assertive responses' and 'assert self in contentious issues' which seems to support the idea that leadership only involves showing strength, excluding compassion and understanding as important aspects of leadership."
15.38. A consultant wrote to me in these terms about the impact on service managers who are caught in the middle:
"The most vulnerable amongst us, as a group, are our service managers. The … department where I have worked now for [a number of] years has had [a number of] service managers, most of them bearing a load of multiple services to manage and being buffeted by our clinical demands from below and financial pressures from above. In my mind, the demand to balance books while ensuring quality comes from the government and is the driver of this bullying culture. Whilst the government may not mean to do so, this is how it comes across."
15.39. A senior consultant reflected a more general frustration with indecision and a poor leadership model:
"…there are frustrations whenever new funding is required. There appears to be a culture amongst some decision makers that they neither say no this is not possible or yes we can achieve this. Instead you find indecision as a way of managing budgets. This means you continue to work up ideas and chase funding over and over again without much luck. This is at best frustrating and can create a deep sense of frustration.
I know there are areas where we are wasting money but nobody really wants to release time to make significant change happen, certainly not at a medical level. Instead unappealing clinical leadership jobs are designed where failure, or at least limited achievement, is almost guaranteed. This is particularly in the medical directorate, there are individuals who work hard and have achieved a lot but I'm certain that this is due to their individual resourcefulness and not driven by structured clinical leadership model."
15.40. Of course, all of these factors can contribute to behaviour which becomes generally unacceptable, especially when in combination or accumulative. One director observed:
"As a senior leader I have felt bullied and harassed by the organisation, by the Scottish Government. What I do believe is that in the NHS now people are feeling so pressurised. It's a horrible environment. It's targets. It's finance. It's political. Populist policies but don't have the resources to fill them. NHSH is just one health board of many that are suffering."
Clinical Governance and Quality Improvement
15.41. It has been suggested to me that there is something to be said about clinical governance and quality improvement when these are carried out as technical skill sets rather than as an adaptive leadership activity. An example would be the way incidents are recorded and episodes of care – or deaths – are investigated with the aim of learning and improvement. If there is a focus on criticising people rather than on the systems that give rise to individual actions, there can be an unsafe outcome. That may occur if clarity of accountability and psychological safety is neglected and activities are perceived to have a blame culture at their centre. This is perhaps another example of the transactional trumping the relational.
15.42. A consultant put it this way:
"There is a need for NHS Highland to shift from a person-centred approach to a systems based approach to risk... Recent thinking (Reason 2000) highlights that 'patient safety cannot be improved by focussing only on the 'person approach' with 'active failures' of the individual practitioner such as forgetfulness, inattention, carelessness and focussing on reducing variability in human behaviour through fear, disciplinary measures, threat of litigation, naming blaming and shaming. By focussing on only persons, the unsafe act of the individual is uncoupled from the systems context."
Other General Factors
15.43. There are other regional and national influences mentioned to me which are beyond scope of this report, such as the no redundancy policy and the number of, and variation in, health boards and support services and the variable degrees of collaboration among them. Concerns were expressed about the amount of time and money invested in the supporting infrastructure.