16. Possible Causes: NHSH and the Highlands
Geography and Scale
16.1. As I mention above, there are also factors which are likely to be unique or specific to NHSH. I explore some of these in this chapter, starting with geography. The area covered by NHSH is a vast one and very diverse (41% of the land mass of Scotland; possibly the largest area covered by any health body in the UK?).
16.2. A senior employee commented on "a service under pressure":
"There is no doubt that NHS Highland feels like a Board under great pressure to achieve a balance between acceptable quality, performance and financial outcomes across a large area. It is neither a large but geographically contained Board nor a small island Board and is a difficult challenge to achieve satisfactory outcomes for all populations across all three of those domains. It is my view that as a consequence staff, patients and the public are left feeling dissatisfied with what is achieved/not achieved. That is expressed by the public in their dissatisfaction and mistrust with the way services could be restructured for the better eg in Skye and Caithness. Inevitably this has an impact on staff in both remote and central services."
16.3. To this he added observations about "a workforce under pressure":
"Trying to keep up with larger boards whilst operating across the geography of a rural Board is a significant challenge. The economies of scale available in a large Board to do work do not exist, which when added to travel across distance places significant pressure on staff/services both clinically and managerially. That said NHSH has a dedicated and innovative workforce that in my view is committed to providing the best service it can for each and every patient."
16.4. The national and political context in which NHSH sits is reflected here:
"Any actions by NHS Highland Management have to be seen in the context of the national picture, with huge pressures on both primary and secondary care, some the result of fiscal pressures but many resulting from workforce shortages. All Boards face these pressures but it is clear that the further north the Board, the more significant the workforce pressures become. Over time, these pressures have increased. In NHS Highland, the pressures of sustaining the service to remote geographical locations have not been helped by party political pressures as well as the pressures from politicians who have remote constituencies. There is an impression that these pressures, and what some might describe as a bullying culture, start in Edinburgh and perhaps the way that chief executives are treated by their superiors gives some of them a comfort zone in dealing with their subordinates in a similar manner."
16.5. A team lead in a more rural setting said this about the adverse effect of location:
"At the highest level we have a government which is advocating financial prudence and value for money and rightly so; however there is no allowance made to rural health and social care boards for the higher cost per person in delivering these services. This immediately places a relatively greater financial burden on rural health boards and their senior management team. Rural areas are also struggling to attract clinical staff adding additional costs to already stretched budgets. I do realise that city and urban health services are struggling too but wanted to highlight the additional burden NHS Highland has in comparison."
16.6. The effect on communication may be marked:
"However, perhaps NHS Highland faces additional challenges with staff spread across such a large area counting against face to face communication and visibility, certainly at board level."
16.7. The following further factors have been suggested to me:
- NHSH is the largest employer in the region
- the relative insularity of the organisation geographically and culturally as distinct from other organisations
- there is no alternative NHS body in the area to which disaffected or unhappy employees can transfer – "leaving is not an option"; "being a monopoly employer in the area prevents staff finding easy employment elsewhere"
- there is little opportunity for career progression, so people are very protective of their position and tend to hang on to their jobs for a long time: as a result, norms develop which can allow 'the unacceptable to become idiosyncratic'
- lots of promotions are due to reorganisation and posts are not advertised externally where better candidates could possibly be found
- it may not be so easy to attract staff from elsewhere; there is a smaller pool of potential staff and some may be over-promoted
- lack of leadership development and management training means it is "dead man's shoes" – even if they have aspirations, "people are sitting and hitting their head off a brick wall. Little things become more important and have more currency, as does history."
- staff are often related to one another and conflicts of interest can arise
- people tend to live and work in the area (and even one department) for many years and are committed to it culturally, socially and economically so that the workplace can assume great importance as a community
- preservation of jobs, livelihoods and status in the community is very important at many levels
- communities are smaller and more tightly knit, people know each other, memories linger, trust may be harder to build; conversely, the fact that everyone knows everyone can be a positive – bringing more closeness and understanding rather than anonymity
- NHSH staff, especially doctors, are very visible in communities and influential in how they represent NHSH: a "goldfish bowl" as it has been described
- there is a "culture of silence"; in the Highlands, folk are more reticent about coming forward; ironically, it's also "very gossipy and if you don't join in you are seen as an outsider"
- there are stronger religious affiliations than in other parts of Scotland
- there may be tensions between those who stay and those who leave - and those who are perceived as "incomers" with a different view of the NHS from those who are local
- NHSH can be viewed by some as a modern institution, different from "the Highland way"
- there have been big population changes in recent years: Inverness is apparently one of the fastest growing cities in Europe
- Raigmore is a disproportionately large, somewhat anonymous, even oppressive, facility and attracts news stories
16.8. One person summed it up as follows:
"There's a thing about Highland, it's not like the Central Belt. When people get good jobs, they tend to stay in them for a long time. There are a lot of individuals who have been in roles for a long time. Our recruitment process is that we can't replace people. There's a worldwide shortage. When you're competing with the Central Belt and the opportunities there, it's difficult. People come here for a lifestyle choice. They see potential in our HQA and links to the university. But I think that whole dynamic is an issue."
16.9. At the same time, I am told that high-quality people are attracted to NHSH and often come to the Highlands because they want to live and work there. I understand that Inverness has been ranked very highly for its quality of life and has been described as the happiest place in Scotland.
"When friends and family ask me what is it like working in the Highlands? I invariably reply – "It's like being on holiday but going to work through the day". I really like living and working here."
16.10. For some, uniqueness works well:
"Across NHS Highland, notwithstanding some of the complexities I have described, the vast majority of working relationships are really positive. My experience is there is much mutual goodwill, respect and commitment across the whole board area, and would suggest there is much that is uniquely positive in NHS Highland."
16.11. As ever, there is a need for balance and an encouraging view comes from another senior consultant:
"I would like to highlight some of the others positives of working here. Since August we have been working on NHS Highland based senior medical training, this is mushrooming with many trainees keen to stay in Inverness due to the clinical experience, teaching experience and opportunities here in Highland. We have increasing strengths in research and development and the introduction of new undergraduate curriculums all of which have been positively received."
Insiders and Outsiders?
16.12. Diversity of origin seems to be an issue:
"Differences even between Scottish staff, eg Highlanders and Lowlanders, East coast and West coast. Inherent nature of Highlanders (to feel put upon, taken advantage of good nature and gentle ways) ousted by others (Highland clearances and now 'incomers' buying up property, changing the community dynamics). The sense of being 'taken over', 'outsiders can do it better'."
"Been thought of as slow and stupid." "Lack of respect for the locals."
"These issues are not being raised for fear of being seen as racist, prejudiced, unwelcoming. 'Need to be careful when you ask where someone is from'."
16.13. These remarks capture the impact of behaviour regarding "out of area" staff:
"Although the publicity so far appears to concentrate on bullying coming from senior staff one must also be aware that there is another form of bullying which has a detrimental knock on effect right across the Organisation. Although there are many good and kind staff working within NHS Highland they are afraid to speak up against a small portion of staff who were not only resistant to change but disliked/ resented any staff who came in from out-with the area particularly if placed in a more senior role. If their behaviour was challenged they became offensive, intimidating or made claims of bullying, therefore creating a situation in which the person they accused would lack credibility if they tried to defend themselves or made their own complaints."
16.14. Some of this has to do with language:
"Misunderstandings in language, the way people talk, phraseology, terminology, manners. Misconstrued as being 'bossy' or arrogant just by different mannerisms and ways of speaking."
'Lots of different accents', 'hard to find someone local'. 'Quite a few 'foreigners' from different cultures and religions'.
"Communication issues, misunderstandings in ways people speak, their delivery might sound angry or rude, but is just the way they talk. Highlanders tend to be soft spoken, polite, sometimes speak slowly, can sound laidback."
16.15. As ever, many issues come down to communication within and throughout NHSH. As one member of staff observed:
"Communication with staff tends to be on a need to know basis. Changes made tend to be done with little consultation and an expectation that they will not be questioned even if problems are experienced by staff or patients with the changes. It appears that questioning decisions even if it's just to gain information is seen as disrespectful and reacted to badly. Simple things like changes to tone of voice, a certain way of answering etc gives the impression to staff that they are being scolded and there is a definite treatment of staff that mimics a parent child type relationship. This authoritarian way of dealing with people is certainly not the way most adults want to be treated at work."
16.16. As one respondent suggested, NHSH would benefit from having a clear direction and momentum, strong clinical engagement and financial realism which comes from more effective organisation-wide communication. I am told by others that communications systems are not "fit for purpose"; that all user emails do not reach (some) GPs, electronic communications and newsletters are not read and digested appropriately and "verbal cascade is patchy".
16.17. A senior nurse observed:
"Senior management wouldn't be known by my staff if they tripped over them in the corridor. They are not physically present. Things being done to you and not with you. That's what I mean by communication issue."
16.18. As noted above, the geographic element has its impact in rural areas. Generally, I heard a number of reports of people in small rural communities being affected by the behaviours of management both locally and centrally. There is a feeling that communities themselves have felt bullied because of promises made and not kept, giving a feeling of being lied to and deceived. Although the evidence is variable, there is a tangible sense that some rural communities feel undervalued and let down by "the centre".
16.19. Poor communication and lack of appreciation/awareness by the centre, in this case "those folk in Inverness", seems to be a theme. One senior manager commented: "There's quite a distance. And we're only five minute's walk away. How must it feel for someone living in Ullapool who must feel very disconnected." It was pointed out that urban health care solutions may not work in rural locations.
16.20. The divergence between Inverness and the surrounding area and the more distant rural communities can seem marked:
"Inverness and the Inner Moray Firth have been transformed in the last twenty years while the outer remoter geographies remain the more vulnerable due to loss of industry, vulnerable rural economies and a changing demography. This can make the design and delivery of services uniquely challenging, particularly when we take the importance of place to the communities we provide services to."
16.21. This from one very rural GP reflects a view I heard on a number of occasions from people who feel on the periphery:
"I am afraid that after the false promises and time that has passed, I do not trust NHS Highland management." "The truth has been twisted throughout this time and I have been badly treated by NHS Highland. I feel as though I have been led on by NHSH management, but ultimately they have turned round and kicked me in the teeth."
16.22. Another GP practice in a remote area (salaried PMS) spoke of a letter informing them of a large cut in budget coming "with no warning, no personable covering letter and made no allowance for our circumstances". They were told to submit a practice plan of how this would be achieved, which they did but subsequently some seven months later, they eventually
"received a copy of a rather meaningless letter …which basically said that we didn't need to bother after all that! We did not even get a letter addressed to us. This second-hand response in no way acknowledged the stress, worry and work that the original letter had caused us and by not even writing to us directly is treating us with contempt. We feel that this was intimidation on the part of NHSH trying to squeeze money from our Practice as a soft and easy target. There was no discussion with us but a complete lack of understanding of our situation and a woeful lack of sensible or respectful communication or indeed any communication to our original plan that we had submitted."
16.23. It is well known in the Highlands that communities far removed from Inverness can feel isolated. It takes hard work to acknowledge that fact and provide the necessary recognition and reassurance.
16.24. I note also the effect of the integration of social care which is unique to NHSH. It appears that the integration of social care has been a particular factor of concern.
16.25. One respondent opined:
"Adult social care was a glass bowl from Highland Council to NHS. It shattered, we cannot pick up the pieces...I would say the bowl being smashed has put an enormous burden on an already overburdened system."
16.26. Whatever metaphor is used, it certainly seems to be the case that integration has placed significant strains on an already stretched organisation and at a time of reducing resources.
16.27. There seems to have been and may still be significant misalignment between expectations within NHSH and Highland Council over social care, at least in some areas.
"Being managed by someone that does not know or understand job role, comes from a different background. Most obvious when Social care and Health care joined forces." "This profession has had a bit of a hard time with managers put in due to integration, who do not understand the profession."
This aspect is beyond the scope of this review but may be important to address.
Importation of Ideas from Virginia Mason Hospital in Seattle
16.28. I heard comments about the appropriateness, effectiveness and transferability of management ideas from the United States. I am not able to comment specifically but wonder to what extent the importation of ideas from one culture to another may have had an impact on NHSH's ability to deal with some of its local issues.
16.29. The impact may be marked: one senior consultant commented:
"NHSH has followed the ethos of the Virginia Mason unit in the USA. Our managers have visited Seattle many times, as recently as November 2018 at significant cost to NHSH. Forming a large part of the Highland Quality Approach, success in Seattle followed confrontation with clinical staff and the active reduction in engagement of clinical staff in hospital management. NHSH has followed this trend and reduced the influence of working clinicians in decision making. Individuals with an alternative viewpoint are marginalised and ostracised and have no recourse to the decision-making apparatus. This has been a management tactic …"
16.30. It is easy for the enthusiasm for a new idea to prevail over the discernment needed to apply it in a way which takes account of local conditions and of changing priorities and pressures. Indeed, having committed to it, with substantial sums of money having been spent and with saving face a possible issue for the proponents, there may have been resistance to challenge on, and review of, these matters. If so, and in any event, it may place in context some at least of what has occurred.
Highland Quality Improvement
16.31. Related to this, it seems that those responsible for programmes to enhance staff and team performance experienced the cognitive dissonance of promoting values and beliefs which were not being implemented in practice by the very people who were supposed to be leading on them. I was told there was emphasis on implementing policies but without empathy, honesty or openness.
16.32. It has been pointed out that there may have been over-reliance on the technical aspects of improvement without the focus on creating the culture and conditions for quality and safety to flourish at the frontline. Quality improvement would be seen as a method that can be used at board level rather than as a method that required distributed leadership and clinical/ managerial engagement in owning the services.
16.33. This is reinforced in this comment:
"There was no time for leadership from senior staff, who were too busy with day-to-day staffing and admin issues, strategic planning and meetings, and did not work with or understand the Band 5 staff's individual roles. Consequently initiatives such as QI were poorly understood on the floor, people, morale was low, and the stronger personalities were allowed to ignore processes that they did not like."
16.34. I was told that:
"The rhetoric within the Highland Quality Approach was merely that - we ticked boxes and encouraged a chosen few to pursue ambitions which often left them burnt out because of too great expectations placed on them."
16.35. A director expressed this view:
"Over-emphasis in past 5 years on financial targets dressed up as quality improvement. This message hasn't worked and has in fact created distrust."
16.36. That said, there are mixed views ("Some love it, some hate it") and perhaps there is still real potential under thoughtful leadership.
16.37. I was interested to note that, during my review, the media reported on a research paper which was published by NHSH which apparently attributed some health problems in the area to the inter-generational impact of the Highland Clearances. Whether that is a factor which would be relevant to this review is beyond its scope, but the very existence of such a view does highlight the fact that there are unique aspects to this part of the world, some of which are not easy to speak about. Indeed, as I conducted my review, I became aware of the importance of research on epigenetic, transgenerational implications of trauma and its aftermath. I explore the issue of trauma further later in this report.
Some Specific Observations about NHSH
16.38. That NHSH is marked out as different is underscored in the following remarks, which tend to corroborate and expand upon some of the factors above, from a member of staff who has experience of working elsewhere in the NHS. Again, this reflects views which appear to be fairly widely held among those who engaged with the review. This employee feels that "there are some stark differences in NHS Highland and the culture, specifically with regards to the management of staff." In outline, these are as follows:
- "NHS Highland has a very insular feeling to it. Everyone knows everyone else, they have a history or are friends. This is made clear to staff. This means that should you have a problem or worry about a situation with your manager then you feel like there is no one else to go to. If you speak to someone senior, then this would be raised with the manager and discussed in what I would call an 'unprofessional manner'. By this I mean it becomes a personal attack on the person rather than a professional discussion about an issue.
- This leads me to my next issue, a lack of confidentiality between managers and staff. I will use an example I have witnessed to explain. The individual had applied for a job and informed his/her manager as per the usual process when looking at changing positions. However, the individual was the congratulated on getting the 'new job' by another member of staff the same day, interviews had not even taken place. It was a case of this individual's situation being discussed outside their confidential meeting with someone else. Though not related to bullying this has now created the feeling that information shared with managers is not confidential. This has broken the trust between staff and managers and made individuals feel as though they cannot speak openly to their manager for fear of who else this may be shared with. This creates isolation and leads to people keeping quiet about many things for fear of how this will be handled.
- Gossip – I have heard managers gossiping about other staff, passing what I would call derogatory comments and making their feeling of dislike for the staff quite clear. I also relate this to the point above, staff's private situations and discussed with other staff members who are their 'friends'. A level of gossip and chatter amongst staff, especially junior staff is common, and when working in close quarters you are inevitably going to overhear things you would rather not or shouldn't hear. However, when these come from managers and staff are seeing managers gossiping, it creates a culture that this is unacceptable.
- Discrimination - I feel that processes/ policies are implemented for certain staff when they feel the need, but this is not uniform across all staff. I have witnessed in certain situations staff are asked to take annual leave whereas others are offered compassionate or special leave, sickness policy implemented with some staff and not others despite these staff having significant sickness. This inequality between staff leads to low morale and bad feeling between staff. This feeds into the gossiping and that circle is continued.
- Lack of support – generally my feeling is that there is a lack of support for staff. There often seems to be a lack of management in office, a lot of staff complain about a lack of induction and this creates problems going forward, it also makes staff feel 'neglected' and unsupported. Staff needs in terms of supervision is limited and supporting staff development and growth is not a focus of management. There is a lack of career development and minimal support for staff in seeking these opportunities.
- Communication is poor at all levels. Concerns that are raised never seem to be fully appraised and what I would call 'placating emails' are sent to try keep staff happy for the interim. This makes challenging issues difficult as you have followed process and nothing has changed or been actioned, a dead end is reached."
16.39. A well-informed respondent offered these views about some of the causes:
- "There is a clear disconnect between the top of the organisation and the service delivery parts of the organisation.
- Lack of clear direction for departments, with lack of clarity about budgets and resource constraints
- There is no clinical strategy. This translates further down the organisation as a lack of clarity about what NHS Highland should or shouldn't do, will or won't provide.
- There is a weak clinical voice at the top of the organisation.
- Reactive approach to issues is commoner than pro-active; this starts at the top and is replicated down through all of the organisation
- Crisis management causes an increase in likelihood of interpersonal conflict or bullying.
- Lack of ownership at department level of issues/problems/challenges.
- Ineffective or under-effective organisational meetings structures, and people attending them do not properly represent or participate, people attend unprepared and uninformed.
- Behaviours. Many people do not behave well in meetings. This applies across the board. The underlying cause of this is a mix of personal conduct, poor chairing and a lack of defined proper behaviours.
- Managers are given responsibility for department performance even though it is invariably clinical outcomes which are being measured.
- Learned helplessness of clinicians at all levels but most importantly at senior level.
- Incomplete leadership structures in hospital plus vacant management posts, high manager turnover, eclectic/odd management portfolios."
Contrasts with Other NHS Bodies
16.40. Finally, the view that the experience in NHSH is different from elsewhere is reinforced by others:
"Appalling, environment toxic, people could do what they wanted, disjointed, so unlike other NHS bodies, much worse, no collaboration…"
"I now work for [another NHS body in Scotland]. I am confident that if these behaviours occurred there they would be called out for what they are and would be managed."
"I have observed the management culture within Highland and contributed to quality management reviews in Boards throughout Scotland…. This experience tells me that while NHS Highland may not be alone in having problems of morale, the gulf between management and clinicians within the Board is deeper and wider than I have seen elsewhere in Scotland."
"I have faced stressed/upset/angry/depressed colleagues throughout my career, both as a registrar and in my current post amongst more senior physicians. But in the Highlands, and only there, did I see many of them slowly change over the years. Their posture changed and they developed this shell shocked, wide-eyed look about them and clearly didn't know which way to turn anymore."
16.41. The problem was summed up by one NHSH employee in a rural area with personal experience both of bullying and unsatisfactory treatment for a family member:
"With all the bullying allegations, recruitment problems, stress and pressure on staff within NHS Highland one has to wonder if the shortage of staff and ridiculous waiting times within some departments are a consequence of these long term problems within NHS Highland and is due to the style of management and an inadequate board who are unwilling to listen or adapt. Potential new staff will not apply or accept a post within a region with a poor reputation and bad treatment of staff. Word of mouth is very powerful in more rural areas."
16.42. A full time official for one of the Trade Unions wrote to me about his experiences of NHSH:
"On a general point I do sigh when I hear that a member has a problem within NHS Highland as I know it will be a long tortuous process. There is clear evidence of unnecessary delays in any investigation process and with issues around bullying and harassment it means that, regardless of any outcome, the professional working relationship is beyond repair. Highland does have a raft of policies the same as any other Health Board, however it is a continuous fight with management and HR to actually follow these policies. In particular timescales are drawn out whereby investigations take place 9 months after allegations of bullying have been submitted in writing, no one is trained on a particular policy (Gender based Violence), members do not hear about a complaint that has been lodged 4 months prior, contact with managers and HR are ignored and often members and myself are passed from one person to another and even then the answer that comes back is inconclusive. This always leads to an escalation and lack of faith in the Board to deal with anything….
"In my role, I cover the whole of Scotland for the last 17 years, I have had to deal with more allegations of bullying and harassment in NHS Highland than all the other health boards put together."
16.43. I pick up the themes of the management, board and HR in subsequent chapters.
16.44. On the peculiarities of NHSH, this was offered as a summing up:
"I love living in the Highlands and have enjoyed working for NHS Highland, however it is struggling both financially and staffing wise. In all areas, ageing staff are retiring, recruitment is difficult and remaining staff are struggling to deliver a service with fewer resources. People become stressed and frustrated so it's easy to see why these allegations come about."
16.45. For those who wish to look forward and rejuvenate the organisation and enable its staff to flourish, these words should not be a conclusion but a challenge to change things for the better.