18. Management Roles and Behaviours
18.1. I have found this and the following chapters among the most difficult to write as so much of what I heard in my review focussed on perceptions of inadequacies in management throughout the organisation. I am sure that there are many sides to this and, while I seek to capture some of these here, I am equally sure that those better informed than I am will be able to identify other aspects to this and indeed point to misunderstandings on my part. So be it. This is a contribution to be built on.
18.2. I have sought to identify specific areas in connection with which concerns have been expressed and where many managers and others have felt unable confidently to carry out their duties. The views expressed here also help to explain why the concerns about bullying have become so prevalent.
18.3. At the outset, I am concerned that many of the difficulties experienced in recent years in NHSH are said to be attributable to a management style which has not been effective in the challenging circumstances of the modern NHS. This poignant summary captures much of what I have heard about the management of NHSH:
"I've just left a meeting where a colleague I hold in considerable regard has effectively collapsed as the ineffective organisation and culture in the … management team leaves him vulnerable to a colleague who can only 'react out' rather than face their weaknesses. This person already has an unresolved staff issue with a team member off work … because of ineffective systems to manage them out of the service. He now faces another charge of bullying that is unlikely to stand scrutiny.
This is what plays out in real time when systems… are managed by people who lack the insight and perspective to manage well. In effect, a collective failure of both leadership and management. Where individuals who are unable to deliver the tasks required of their role are chronically undermanaged because they create fear and confusion for their managers. They perpetuate harm on others as the only way they can stay 'safe' is to 'kick back.' It becomes a tangled mess of chaotic if not bullying behaviour, culture and practice with judgements of Solomon required to make sense of it.
I do not think it unreasonable for civil servants, senior managers and directors to be able to demonstrate such awareness, skill and competence in managing these scenarios.
It bothers me to watch these situations play out in full sight with an organisational culture of inertia as to how to respond. Something needs to fundamentally shift for NHS Highland to move on. We diminish service delivery and perpetuate harm on the majority when a minority in positions of power and limited awareness (insight, integrity, perspective, compassion, empathy) hold sway."
These are telling words. I explore aspects of this "fundamental shift" in a chapter on leadership in the final section of this report. Meantime, I explore further perceptions of the current situation in this chapter.
18.4. More simply, perhaps, one specialist in Raigmore Hospital emphasised that poor management rather than bullying itself may be a significant cause of the present situation:
"The greatest issues which have been expressed to me by colleagues in medicine in Raigmore Hospital…is of poor management of bullying, and staff not being listened to. I think the consequences of poor management may well outweigh the distress caused by the initial bad behaviour….staff feel they have concerns and these are not registered or understood. This could be because the options which they wish to follow are not achievable or are unrealistic, but without documented reason, and/or registering of the decision, individuals seem to feel disempowered and undervalued. This then affects teamwork and morale. I do not think this is an intentional policy, but may to some degree be a cultural or historical issue."
Concern about Senior Management
18.5. I need to record that a significant number of respondents expressed concerns about the role of senior management and its ability to recognise and address the issues which have arisen in connection with inappropriate behaviour in recent years. Some senior managers are viewed with suspicion and resentment. I have had concerns expressed to me about a number of director level executives and their ability to function coherently, individually and collectively.
18.6. I do not go into detail but I am told that many people feel that, unless there are changes at that level, much of what has been occurring will continue. That may be associated with a view that executives "are not visible, rarely at the coal face. Who are they? Disconnect, not understand, done to not with". "Done to, not with" is a telling remark. It signifies the feelings of a large number of those who responded to the review.
18.7. A commonly held view is expressed thus:
"Many believe the senior medical leadership are complicit in the development and maintenance of the ongoing issue of bullying within NHS Highland and it is perhaps inappropriate for them to be leading on the restorative work that will be so very necessary going forward."
18.8. I comment further on this in my proposals for the future. Clearly, a demonstrable change in leadership is necessary and has, of course, already begun.
18.9. An employee in a rural community commented on the perception that this is a pervasive tendency:
"NHS Highland management were more than aware of multiple policy failures and continual breaches of them. They allowed for multiple staff member(s) to repeat the same as the staff member(s) before. NHS Highland management themselves became bullies and harassers by isolating me and by covering up the bullying and harassment that I was subjected to for so long. They have tried to cover everything that had happened up and tried to encourage me to just forget all about it. This was not limited to just the .. original bullies/harassers named in grievance one, but by all the management involved, right up to senior management; I was passed around from pillar to post, told conflicting and contradicting information each and every time. It has all been a horrific nightmare and sadly I don't believe I am the only staff member in which has been subjected to this kind of behaviour."
To be clear, I offer this view not for its factual accuracy but for the perception it expresses, in the hope that doing so will help in the healing process going forward.
18.10. Describing intimidation, fear and reprisal against NHSH staff in a number of settings, a GP told me (prior to recent senior changes):
"I fear that unless those few individuals in Senior management are called to task over their behaviour and leave their posts that nothing will change. The fact that until recently they denied there even was a problem but are now wanting to meet together to improve things fills me with despair that by pretending to work together to solve the problem they will be seen in a different light."
18.11. Perception is so important as I discussed earlier in this report. Making a few superficial changes is unlikely to be sufficient to restore confidence.
18.12. One director astutely summarised the position:
"If I managed people the way I'm managed then we'd be in a lot of trouble."
18.13. An experienced team leader wrote in these terms:
"Within the HSCP we have a few senior managers who have what could be described as an autocratic approach to management, I have personally been in meetings where there has been an audible gasp from the room when someone has challenged ideas put forward by certain senior managers. Some seem to revel in their public image as cold and ruthless managers which negates any 'open door' policy they may profess to have. There also seems to be a lack of clear strategic planning with many decisions being made hastily in response to the latest reports of potential quick fix solutions. As a result, the overall image of senior management from the clinical staff is one of ruthless determination to make saving at any cost."
18.14. Autocratic, fearful to challenge, ruthlessness, lack of strategy, undue haste: these are all powerful images which reappear in later chapters. Further concerns and the effects are captured in the following paragraphs.
18.15. An occupational therapist described the situation in this way:
"Although I do not feel bullied as an individual, I do have to engage with processes and systems which I find uncomfortable both ethically and professionally. Many systems and processes are being introduced which are not effective and have a detrimental effect on clients, service and staff. I personally feel that it is incompetent senior management and the lip service which is given to consultation and feedback from front line staff which is the problem. Senior management seem to devise systems which as well as not being effective, waste resources and staff retention and recruitment are a major issue."
18.16. A long-standing clinician said:
"… you should be aware that these issues have had a very significant detrimental effect on patient care and in my case have also impacted on my own health and personal life. I think there are two main problems at play here
1. Dysfunctional management structure, with very limited clinical input to board level.
2. Behaviour and attitude of senior management.
I think this combination has resulted in a disconnect between the front line staff and senior management leading to the former feeling disenfranchised and powerless at best. I have been a consultant here [for many years] and can honestly say how saddened I am by the current state of affairs."
18.17. Another long-standing observer, this time a GP, described experiences and observations of mishandling of complaints in this way:
"Perhaps the institutionalised incompetence and arrogance has led to a rise in bullying. As I said – I have never seen it. However, I have seen a progressive deterioration in what was once a great Board to work for, to a Board that does not care about its staff."
These words capture the underlying nature of many of the concerns about a deterioration in management and governance which many have experienced.
18.18. This from a now-departed consultant bears upon the bullying allegations:
"To conclude, I believe that NHS Highland has a leadership culture which does not wish to hear views which differ from its own. It gives privileges to those who say what they want to hear and it is willing to allow people with hierarchical privilege to abuse their position. Lastly, the managers of NHS Highland do not know how to recognise or to address bullying when it occurs in the institution."
18.19. The impact can be serious and the implications resonate with the findings in this review:
"It is very hierarchical and senior management (above grade 8B) are always believed and supported. This leads junior staff to feel too scared to raise concerns. Any concerns are dealt with through a formal process of investigation, when a more informal conversation or approach could foster better relationships.
There is reluctance to challenge or deal with people like x because it will take so much time, cause major disruption to senior management and would perhaps encourage more staff to make complaints, taking more time.
This leads to people behaving like bystanders, almost glad that it's not them or hoping that the situation will resolve itself."
18.20. Some of these concerns are picked up elsewhere in this report; I am mindful for example that these points could equally arise in the earlier chapter addressing why people feel unable to raise concerns.
18.21. The problems with the management culture are summarised here:
"I've worked for the NHS for [many] years now... Over the last 10 years, I've seen significant changes in the behaviour of senior management, some of the attitudes towards staff has been of a bullying nature. This 'top down' attitude has become more prevalent since HSCPs were established legally, I fully appreciate the financial pressure however that does not, nor should be an excuse for treating staff so appallingly. It's almost become an accepted organisational culture, primarily because staff do not feel able or willing to challenge it.
Staff morale everywhere is the lowest I've ever witnessed. I am aware of a few individual members of staff who have spoken privately about being subject of inappropriate behaviour. Some have been close to submitting formal grievances however they have been worried about the ramifications of doing so to the extent they have either sought employment elsewhere or they just learn to tolerate it which does little to encourage people to perform effectively or indeed support their health & wellbeing. In one instance, a member of staff felt 'leaned on' to prevent a grievance being submitted.
This was quite a common tactic used by NHS management: they isolated one person to discuss an unpopular decision and then went silent until everyone involved simply gave up."
18.22. It is difficult not to conclude that a new "management culture" is essential if NHSH is to thrive and the behaviours and effects experienced by many are to change.
The Medical Director
18.23. The role of Medical Director is clearly a pivotal one. As one respondent put it: "...a Medical Director is a highest link and connecting position between medical colleagues and the Board." It is a role which requires sensitivity, confidence and real leadership, and a combination of skills and aptitudes which are not necessarily easy to exhibit. It is necessary for me to say that a number of specific concerns were expressed by a number of respondents about the way in which the Medical Director has handled matters over a number of years. These were summed up by one respondent:
"If I had concerns, I could not take them to the Medical Director."
18.24. The role has not necessarily been an easy one; as ever there are differing views:
"He's extremely well motivated. He finds it very tough. He's been wilfully misrepresented. Deliberate traps set for him."
18.25. The Medical Director has intimated his intention to retire and I judge it unnecessary to go into these matters in further detail. Suffice it to say that, in later sections in this report on the future and leadership, I describe the attributes of openness, engagement, listening, empathy and support that seem essential in the key management roles to take NHSH forward into the future.
18.26. Just as the workings of senior management are a matter of regular commentary by those with whom I engaged, there was awareness of the challenges for those in middle management roles.
"I've always had the sense that something wasn't quite right. This comes through in comments made, awareness of staff turnover. Sense that middle management are given tasks to implement without any sense they can be listened to. Command and control approach."
18.27. A retired consultant said:
"Hospital managers have a difficult task. Several competent and conscientious managers have been forced out over the last 15 years. Medical staff often don't hear the details until much later. One technique employed in NHSH is to create another tier of management and to hold the manager below you to account for failing to meet targets and so create a scapegoat."
18.28. One consultant, with many years working elsewhere in the NHS and who recognises issues in NHSH to an extent that he has not previously experienced, told me:
"Middle-management (clinical and service) are not empowered to effect changes and defer to senior management on the majority of issues. When combined with a lack of senior management presence (clinical and service) this leads to a lack of transparency and a feeling of not being heard amongst consultant staff. Service Managers continue to be given unrealistically high workload and only have time for fire-fighting. Service manager illness rates appear to be high with the knock on effect of covering for missing colleagues significantly impacting the remaining managers' workload."
18.29. From a rural GP practice, the impression of top down, command and control is reinforced:
"Our experience over that last 15 years has been of a good deal of incompetence, and a great deal of lack of engagement from NHS managers with us as a practice. We have not found that management see their role as enablers of clinical practice, but of reducing budgets and meeting targets. This has produced a very negative culture in which it has been difficult to thrive.
It is my opinion that the middle management of the NHS in Highland are in general underqualified for the work that they do, and that although in the main good people they lack the experience in management to provide effective support to clinical staff. This means that decision making is often deferred, that lines of communication are indistinct and that the organisation is very "upward looking" rather than responsive to the opinions of front line staff. There is a "top down, centrally driven" culture."
18.30. The difficulties for local and middle managers were captured in this way by a director reflecting on a particular situation to illustrate a point:
"What respect does the clinician have for the local manager? They see them as administrators rather than managers. That poor local manager, who's trying to do the best they can, has a group of staff they have little influence over. The dynamic we have is that now is that every manager who has been trying to manage doctors thinks "oh hell, I have no chance now". Those middle-managers now feel completely disempowered. Anything they try to "force through" will be perceived as bullying.".
18.31. Another respondent was concerned that I should make clear that the voice of these managers needs to be heard in the current discussions. This further comment reinforces that point:
"That group of people – service managers – not senior people but do an important job to keep things together and making it all happen. Some of the hardest working people in the organisation who are asked to put up with a lot. They don't have a voice."
Vulnerability of Managers
18.32. This leads on to the issue that a significant number of managers who engaged with the review reported operating in circumstances in which they feel unable to manage effectively because of the uncertainties and pressures presented by the current situation. There is a real concern that allegations of bullying can be used to avoid or deflect appropriate management of performance and other difficult issues.
18.33. I mentioned earlier that many managers feel that the situation places them in a vulnerable position as exemplified by these remarks:
"Because NHS Highland is currently in the position it is in, the stance feels along the lines that managers must be at fault and need to improve as opposed to supporting managers who find themselves wrongly accused. I feel that I am a very vulnerable position."
18.34. Two senior managers expressed the anxiety of many managers that allegations of bullying serve to disempower them from carrying out their roles effectively:
"Managers and clinical/service leads within the NHS have a designated responsibility to keep others accountable for their work. If poor performance exists then one must address this as part of Clinical Governance. This would also apply to situations where there might be a lack of transparency about what a person is doing in their work – the leader or manager may need to ask questions to ascertain whether the working practices of that person need to be changed in some way."
"I am concerned that I and others will now be limited or defensive in the difficult and challenging context for [this department] in particular and health services generally in having appropriately assertive, adult and honest communication for fear of being accused of bullying."
A Very Real Concern
18.36. Loss of confidence, disempowerment and distrust underline the linkage between cause and effect:
"I feel a significant amount of damage has been done and for those that are expected to provide leadership, support and application of organisational policies, there will I feel be a lack of confidence in the support that will be provided by the organisation where managers are applying policies and doing their best to manage difficult situations.
The biggest issue we are possibly left with as a result of the way in which this has been raised and handled is to rebuild a trusting and safe environment for staff to both work and manage in. We have significant risk and there has been a significant disempowering and shattering of confidence at senior manager and senior HR level in the organisation. This may add to the current feeling of lack of direction which I think has caused the current situation."
18.37. A senior management representative captured the vulnerability of, and danger for, senior managers in the exposure which is now occurring:
"My concern about the complaints made against senior managers at NHS Highland is that they are public, would appear to be designed to name and shame the senior managers, to stigmatise them publicly, cause division, and encourage blame. There is no opportunity for the employees both those named and those associated to take the issues levelled against them and discuss and resolve them in a fair, open and adult manner.
There are very many excellent dedicated senior managers within NHS Highland, past and present yet they have been attacked without chance to defend themselves. This behaviour is profoundly unfair and I would hope if you are able to make recommendations about the importance of following NHS Highland policies and raise concerns with dignity, integrity and a degree of confidentiality in the first instance. We are concerned that there has been a tendency to use the media to attack colleagues in public. Staff side and management agree policies to enable better communication and manage expectations between one another and it is fairer to all if these are used. A future public shaming must be avoided. If employees feel they are not listened to by their employer then it is best to agree a secondary link with the Scottish Government where concerns can be escalated and acted on. The print and broadcast media is not the best environment for this at all."
18.38. It is important to recognise the significance of this contribution among all the comments and criticisms which I have been bound to record. The thrust of these comments probably provides the only sensible way forward.
18.39. Looking ahead, however, it will be necessary to find a way to address these complex issues. The serious issues raised in this report will need to be faced openly, directly and clearly. I discuss some of this in later chapters.
18.40. I was interested to hear the point of view of those who have operated within the current structure. The forward-looking approach of the following remarks is helpful to note and is indicative of the type of radical thinking that is perceived to be needed to create meaningful change. A consultant told me:
"There is a continuous thread of management inefficiency, bullishness and a culture of not listening and giving in to narrow tribal considerations. Only a root and branch reform of the management structure would be able to move this organisation from a 'blame the individual' to a 'just culture' where people can work with confidence and deliver the best healthcare possible to the local population."
18.41. A former director made a number of apparently useful suggestions to address suboptimal performance:
"The present deployment of the Medical Directorate is suboptimal in terms of cohesive working, clinical-strategy development and interchangeability of roles. Addressing these issues would strengthen the team and in turn bring greater robustness to bear in leading… At both territorial board level and at national level this network is currently functioning sub-optimally, due in part to inadequate or poorly timed engagement over issues of substance relating to strategy and delivery.
Furthermore, adequate investment in administrative support and communication could enable clinical staff to feel a greater sense of ownership of decisions made by their organisation and could be a vehicle for reporting dysfunctional or adverse culture and/or behaviour which was not being satisfactorily dealt with by other (eg HR) routes and thus would provide an additional safety-net.
All along the health service continuum, from Parliament/Government right through to every clinician, one of the major factors which increases stress levels (in turn potentially increasing dysfunctional behaviour) is real or perceived inadequacy of time to perform tasks or deliver outcomes properly or satisfactorily. If NHS cultural values are taken seriously then there should be an onus to share or co-operate over the delegation of new work and tasks at all levels in order to establish how the additional capacity for implementation will be found. Such additional capacity can be found by either relinquishing another task, working differently or allocating more staff hours to the new task.
Establishing this as the normal modus operandi will reduce stress at all levels."