23. Senior Leadership
23.1. In trying to understand what, if any, cultural issues have led to any bullying, or harassment, and a culture where such allegations apparently cannot be raised and responded to locally, I note that the senior leadership of NHSH has seemed to many with whom the review engaged, though not all, to have been characterised over some years by what has been variously described as an autocratic, intimidating, closed, suppressing, defensive and centralising style. It appears, at least to some, that challenge was not welcome.
23.2. It is said that there was pressure on senior management to conform even if individuals felt uneasy. Perhaps understandably, self-protection seems to have been the norm for some senior managers. People felt unsupported. I was told that attempts to change things failed and people lost jobs.
23.3. I was told this may have resulted in an unwillingness to speak frankly and that people felt helpless, trapped, unhappy and, at times, scared at work. I was told that power and control appear to have been concentrated in a very small group and exercised in a particular way, with limited sharing of information. I recall the words of Professor Charles Vincent, mentioned in an earlier chapter, summing up "culture" as meaning ""how we do things round here", "here" being anything from a small group or team, to a whole organisation…"
23.4. Associated with this view, sadly, one of the more significant issues of concern brought to my attention has been how some respondents have viewed the apparent influence over a period of time of the recently departed chief executive. Given that departure, it is not useful to report in detail on the specific examples I was given from a variety of backgrounds in the organisation but it is important to seek to learn from this. Indeed, with the passage of time since my appointment and gathering of information, the organisation has to some extent already begun to move on. I am conscious of not wishing to impede that momentum.
23.5. I am also conscious that I have mentioned more than once in my report that one should assume that people are trying their best in the circumstances in which they find themselves. I am also aware that I am reporting on views expressed which have not been tested forensically. I remind the reader of the caveats set out earlier in this report.
23.6. However, I feel I would not be fulfilling my remit if I do not mention this leadership issue, as acknowledgement to those who came forward and for those who told me of their experiences and who expressed the view that this cannot be allowed to happen again. That, I suggest, is the key point and I also cover aspects of this in my sections on governance and management.
23.7. A former non-executive director commented that:
"I feel that unless one addresses the culture, it'll all fall off again. I think the culture element is that the culture is set at the top. What they don't tolerate/promote. Unless one changes those values, we will not change the way in which this organisation is run."
23.8. It is important for me to acknowledge that the former chief executive feels that she has been unfairly treated and that the actions of others have been very damaging to her and the organisation and that she herself feels she was the subject of bullying. I also acknowledge the view that some of the issues raised in this report may have been evident before she came into post. One senior management representative said that they did "not believe that the management culture at NHS Highland has been created by one person or that it emerged under the recent and current leadership".
23.9. I note the view of one board member:
"I don't think there is any way that [the chief executive] as one person can set a culture that applies to everyone. The culture is something that grows and develops itself."
23.10. Another senior manager told me:
"I don't think of it as possible or credible that one or two individuals of an organisation like the NHS could have that degree of influence. I don't think so. Cannot pin the reputation of an organisation of this size on a very small number."
23.11. A former senior manager noted:
"I believe the Leadership team has shown considerable strength and commitment in its drive to improve quality and safety. I understand that in taking forward such significant change, there will be some who remain unconvinced of the direction of travel and may even feel aggrieved by it. However I firmly believe that the organisation has followed due process in relation to any concerns raised."
23.12. And a more nuanced view from a board member:
"The board is perceived as an omnipotent top of the pyramid, but it's not like that. It's much more collegiate. That's really challenging to do. I think [the chief executive] has her faults, as we all do. I think she's incredibly committed. She's a driven person who can see a way forward and make change. Very focused on the needs of people, the political pressures, budget. Very complicated to deal with. I think that might lead to perceptions that she just drives ahead regardless and if you don't agree you better get out of the way. There might be that type of perception/feeling."
Inability to Speak Up
23.13. I reported at an earlier stage that a feature of the general situation in the organisation was unwillingness to speak up. It also seems that some people in senior management positions did not feel able to speak up, even collectively. I put this down to a perhaps understandable culture of learned behaviour – a degree of self-protection.
23.14. "Learned helplessness" is a recognised symptom of simply staying where you are when you have no control over your situation. It is important to note that it appears that those who sought to resist or challenge the situation as they perceived it felt side-lined, marginalised, undermined or intimidated.
"People in senior positions knew what was happening but there was nowhere to go."
"I could see that senior managers disappeared or moved sideways. I would ask where they went. It feels like it you're not part of it... you're either in or you're out."
"…if you rock the boat you are a marked man and you wouldn't do it twice"
"who did I think would say no…? It would be career suicide."
"Victims of bullying are often made to feel that they are the problem, or have a problem. I feared that I would be undermined."
23.15. Many who were concerned at director and senior management level and themselves experienced bullying behaviour have left the organisation. I was also told that some people have been very damaged by the experience. Others, allegedly bullied, adopted bullying behaviour themselves. One senior manager who was herself the subject of specific allegations of bullying behaviour, reported that she had also experienced fairly horrific behaviour directed at her. The pressure to perform, conform and survive seems likely to have produced a vicious cycle. "If the best way to manage is to yell and threaten that may percolate to all levels," as one put it.
23.16. I am aware that some now regret their inaction, experiencing what is described as bystander shame or guilt: "I find that so sad because if we don't care about people, we're finished. Why didn't I put my hand up?" "I thought I was the only one."
23.17. A person close to senior positions told me:
"I saw many bullies go unchallenged. I feel the culture of NHS highland supports bullying behaviour and treats it as normal and acceptable. The culture is toxic and is harmful to staff and I am sure this in turn is harmful to patients. I am ashamed I did not play a part in bringing this to a close."
23.18. One said:
"I feel disgusted that bullying of this level can be allowed to go on when so many people at the top are aware of it." Another described helplessness: "despite it being common knowledge no one helped."
23.19. All of this, of course, reflects the themes highlighted by Dame Laura Cox and Sir Robert Francis in their reports referred to earlier. And, as NHSH moves on to a new stage, this needs to be learned from and then left behind. I refer to my final chapters.
Leading by Example
23.20. The relationship between behaviour at a senior level and behaviour more generally was commented on by one senior manager:
"It's contaminated through senior management this aggression that was never there before. It's an aggression – a feeling of people don't matter, results matter. It's evidenced by the number of members of staff who have become patients. People talking about their fear and literally shaking when they have to have meetings …"
23.21. Overall, in assessing what, if any, culture exists where allegations apparently cannot be raised or responded to locally, from what I have heard and with the important caveats already referred to, I understand why some have concluded that what was being experienced at the top of the organisation led to a situation in which identifying and addressing inappropriate behaviour was difficult.
23.22. In seeking to discern to what extent the way in which leaders behave influences an organisation, I note the Bowles report into NHS Lothian at paragraph 3.2:
"Complex organisations have many sub-cultures, depending on a range of factors such as geography, sector, values and mission. In the NHS there will be very different cultures particularly in relation to healthcare professionals who have their own ethical standards and codes with which they need to comply. Nevertheless there will be an over-arching culture which is predominantly created and shaped by the Chief Executive and the senior leadership team."
23.23. I note that Sir Robert Francis expressed the same view that "culture starts at the top... and filters down through all levels of leadership and management to the front line…" and that willingness to speak up is influenced "not only by what is said by the leadership team, but also what they do and the signals they give."
23.24. The Bowles Report goes on:
"The role of leaders in setting or undermining avowed cultures
Leaders of organisations have a pivotal role in setting the tone and style of the over-arching organisational culture. From EMT downward through the management hierarchy, employees look to their managers to role model the espoused values of the organisation, and to guide them on the path to understanding and interpreting the culture so that they do things in the right way.
In any organisation where the behaviours and leadership styles of any of the leadership team are at odds with the avowed values of the organisation, it can cause a cultural disconnect, with layers of disaffection, poor engagement patterns and inappropriate behaviour throughout the workforce. The old adage... 'Don't do what I do, do what I say'... if in evidence and repeated throughout the management hierarchy can cause personal and organisational tension in terms of lost output, poor morale, stress, sickness absence and retention issues."
23.25. From what I have been told, I have formed the view that this analysis is relevant in NHSH also.
23.26. Generally, for future appointments and to address these issues, it seems important to consider in general terms what drives leadership behaviour. Some of it may be personal and personality-driven; indeed often fear will be a factor. It is possible for example that sub-optimal outcomes of a programme such as quality improvement, and the need to make it appear that everything is working well, could be an influence.
23.27. Reputation, fear of loss of face, or appearing not competent in a job may well play its part for so many under pressure in senior roles. A need to be (or at least to be seen to be) in control is another recognisable feature.
23.28. It must also be recognised that inappropriate behaviour can be attributable to a number of external factors including the pressure of the serious financial situation and fairly constant, and perhaps understandable, interventions from government. As a senior executive observed: "The relationship with Scottish Government is one of command and control."
23.29. A senior consultant put it this way:
"The bullying seems to start at the top with the SG giving CEs an impossible job. It is not just about the lack of money. We have too many hospitals in NHSH and yet the politicians have been unsupportive at attempts to rationalise and close hospitals that need to close. The problem has been that our local NHSH management has been insufficiently strong to challenge this, but I appreciate how difficult / impossible it might be to do so."
23.30. It is a complex, multi-layered situation. While one can only speculate, and some of the factors outlined here may help to explain, the real value lies in seeking to ensure a different approach and outcome in the future.
23.31. The new chief executive will wish to take NHSH to a different place in terms of relationships and behaviours. I comment on this in my later chapters covering leadership and in my proposals.
23.32. As a senior director put it,
"We need new leadership and a new culture to be adopted. We'll need a very capable CEO in terms of their people skills, their leadership. That's critical. I think that we need to change how we engage with our staff (we haven't done that properly or well)."
A Note of Caution
23.33. I am alert to one of the dangers I mentioned at the outset, that of scapegoating. In the comments above, I have tried to be respectful of the views expressed to me and to ensure that these are acknowledged. However, these words of a senior staff representative bear repetition:
"Scapegoating individuals will not resolve many issues. It is important for every employee to take personal responsibility for her/his own behaviour, to be the best version of her/himself, to be able to apologise if s/he has had a bad day which may have resulted in less than desired behaviour, for the apology to be accepted and for everyone to move on. It is important that employees feel safe to identify behaviours – their own and others - they would like to discuss and resolve in a positive, balanced and adult manner, to know that such a request is welcome and discussion is possible. The ability to self initiate the words 'I'm sorry' is powerful, especially when the person offering them is already aware that words will be accepted and respected. It brings greater peace of mind, trust and security. The worry of a grievance being lodged is stressful and can lead to ill health and time away from the workplace.
There are undoubtedly bullying behaviours evident within NHS Highland over a long period of time. HR practices and processes have often required challenge by members with our support. Rather than the responsibility of an individual employee, workplace cultures of bullying are an organisational wide issue and change requires an organisational intervention – it cannot be left to individual employees to challenge decisions and change the culture on their own. That said, every employee has responsibility to avoid it as a chosen behaviour for the workplace, to challenge unfairness, bullying and harassment when it occurs and have this fairly resolved. It is important that when employees raise concerns that they are not ignored, unfairly removed from post, blamed for someone else's perception or told that the behaviour they are experiencing is not happening, the phenomenon known as gaslighting."
23.34. The challenge now is to create an environment in which these laudable aspirations can actually be met.