27. Other Concerns about Behaviour
27.1. Some specific concerns were raised in connection with a number of departments, disciplines and services. I raise these here, along with some commentary and observations about what may be needed. Again, I wish to reinforce that I have not tested these matters forensically but include them as they are indicative of what can be worked on to set NHSH on a different path in the future.
Concerns Regarding GPs
27.2. I was made aware of a number of difficulties in relationships between some GP practices and management/central services and concerns about how some GPs are perceived to behave. It seems that the relationship between many GPs, as independent contractors, and the organisation itself at senior management level and through support systems, is often rather strained. These comments capture the concerns expressed:
"Whilst the majority of GPs are excellent to work with, there are some that prove to be more challenging, disrespectful and on several occasions I find intimidating and passive aggressive. The only intimidation I have ever experienced has come from certain GPs."
"What I do recognise and have experience of, both personally and directed towards people in my own team, is a culture of disrespect and intimidation from some GPs and some GP practice employed staff towards NHS managed service staff. I believe that some GPs have no recognition that the way they speak to and treat staff can be intimidating, threatening and bullying."
"Some GPs appear to have no respect for the roles and professional responsibilities of other professions and have an attitude that, as GPs, they should be in a position to command and control what other professionals will and won't do and to dictate demands to us. This is far from the collaborative and multi-disciplinary approach to patient centred care that many of us strive to achieve. I have seen and heard many examples where staff have been made to feel humiliate and belittled by GPs."
"As well as individual GPs having no recognition that they behave in such a manner there is also no accountability for them to improve their behaviours. As independent contractors, the Dignity at Work Policy does not apply to them and, in any case, they do not recognise the concept of dignity at work. Until recently I would also say that there has been a reluctance in NHS Highland to recognise and to try and address some of these issues. When I/we have raised such incidents with managers, I perceive there has been an approach that, because it is GPs, there is little that can be done and that we just have to live with these unacceptable behaviours. I do not think this should be the case. When we have challenged individual GP's behaviour it often does improve in the short term but then reverts back."
"Unless the culture amongst some GPs changes, I am very concerned that we see some very experienced and highly valued staff members leave, directly as a result of how they are being treated."
27.3. The impact of this on some senior managers is reflected here:
"This behaviour has not been dealt with, not because there is a culture of bullying but because as an organisation (and as senior managers in this organisation) we are afraid to do anything that would upset these individuals or would make the situation worse. There is an imbalance of power in favour of those who display this behaviour (particularly when they are clinicians such as GPs and consultants) which also creates a climate of fear."
27.4. A different perspective comes from one manager who understands the tensions:
"I still have tough conversations with GPs. One meeting where they were bordering on disrespectful. But for me, that's part of the process. They need to push the boundaries to get across their point. I can understand why people could believe there was a culture of bullying, I personally don't think there is, but I could see why they feel that way."
27.5. On the other hand. I heard from a GP that he perceived an anti-GP ethos and felt picked on by management:
"They'll pick that up and infer you're a trouble maker if you keep challenging what they're trying to implement, like effectively withdrawing the district nursing practice in my area."
27.6. There is a perception about management interference, for example in prescribing practices, in order to reduce cost. Another GP expressed concerns about a bullying approach by NHSH managers towards GPs. Yet another GP described experiences she has had which have left her "feeling ever less valued and in tears (over years) despite a tremendous work ethic and a recognised loyalty to patients and their care."
27.7. As ever, contradictions abound. Issues around the new GP contract and its impact in the Highlands add a further layer of complexity.
27.8. An astute observer posed this question:
"When we work for an organisation like that health service, we care for one another and care for those in lead. There is a recognition that we must nurture each other to keep doing what we do. We do have a corporate sense of responsibility. I've spoken about subcultures. I don't always get that sense of corporate responsibility from general practice. It's the way that the service is set up, it's a microcosm focussing on their own enterprise in that area. GPs are good clinicians but… I wonder if the action of my four colleagues: is it about their lack of access to leadership and support? If we are better at interdisciplinary working and access to leadership and support services, would we have got to the position we are in?"
27.9. What is clearly needed is a new and open set of relationships with a new and collaborative approach to leadership and negotiation about use of limited resources. This will require people-centred skills and attitudes on all sides.
Nairn GP Practice
27.10. One GP practice, Nairn, featured significantly in this review. It is clear that there have been serious issues between Nairn and the Board and managers for a number of years. I heard concerns expressed on both sides. However, again, the way of dealing with this is said to have been through implied or direct threats and intimidation. This is not sustainable.
27.11. Nairn is, I am told, innovative and different. It may not necessarily fit the expectations of some decision-makers. That issue could be faced up to directly and respectfully. I was encouraged to think that a quantitative analysis of clinical effectiveness would help to achieve an objective way forward.
27.12. In any event, urgent work seems to be needed to achieve a deep understanding and common ground between the Board and Managers and the practice. I believe that skilled independent mediation would offer a start.
27.13. I was made aware of serious concerns regarding this important department. It has not been functioning as it should over the years. There have been tensions between senior radiologists and management and within the department.
27.14. There has been concern about locum provision and risk to radiology services, especially interventional. I was told of an apparent unwillingness on the part of the Board/chair/senior management to listen to concerns over a number of years. I was told that dealings with the senior management team and the Board have been frustrating and that the severe problems around recruitment of senior medical staff to Radiology have been essentially ignored until latterly. I also heard that this has fuelled discontent so far as Radiology is concerned.
27.15. However, it seems clear that there are many sides to this story and indeed I heard of real difficulties experienced by some senior clinicians who provided the interface between the service and management. Senior managers have also expressed concern about disruptive behaviour by some senior radiologists. "The Radiologists never embraced change willingly or took a lead on this... The culture in the department was difficult with a huge amount of undermining and disrespectful behaviour on-going."
27.16. This whole situation has been unhealthy and would benefit from an urgent rigorous independent assessment and review (and possibly mediation) which takes account of all points of view and not only the strongest voices. Indeed, I would suggest an overall review of the future of Radiology to ensure confidence in the vital working relationships and decision-making the department needs to ensure the delivery of safe, effective and high-quality services to their patients in the Highlands. Could it be recalibrated and become a world-class centre of excellence?
27.17. Whatever the outcome, this could be an excellent example of where having an overall clinical strategy at Board level would be really constructive and beneficial for the future. And where deeper understanding of the real underlying issues from all perspectives might build a foundation for a more effectively functioning service.
27.18. I have been made aware, from a number of sources, of internal leadership issues, including allegations of bullying, connected with the chaplaincy service which, it is recognised by a number of people, does much good work and could do more in the counselling area. I am told that staff have sought to raise awareness over many years but feel that little has changed in managing concerns.
27.19. Again, this seems to exemplify what many employees of NHSH are saying. As one observer put it: "A more robust approach in dealing with concerns raised could have stamped this out 10 years ago."
27.20. I suggest that a review of the leadership of the chaplaincy function may be necessary.
Mental Health and Other Departments
27.21. I heard a number of concerns expressed about management in various areas of mental health including neurology, neuropsychology, psychology, psychotherapy and psychiatry, especially an apparent lack of respect for clinical judgment and needs: in one context, a consultant told me:
"Many acts of overt and covert attempts to destabilise and deconstruct the department, with direct impact upon individuals including myself; unprofessional and inaccurate, displaying a fundamental lack of both knowledge about what we do, but also lack of concern about stating that we as a professional group are not cost effective."
27.22. Another concern expressed was that a service lead for mental health banned the phrase "clinical governance"; "however, clinical governance is the cornerstone to robust lines of accountability and appropriate practice. The Francis report clearly identified failings in clinical governance that led to multiple deaths and a very top down, blaming culture."
27.23. These views are replicated by others with concerns about intimidating behaviour, harassment, belittling of services, avoidance of key issues, failure to address bullying by a head of department over many years, inappropriate management, poor clinical governance, loss of staff and failure by the union to act appropriately.
27.24. I also mention paediatrics, orthopaedics, dentistry and maternity as areas where specific concerns about bullying have been raised. I cannot go into further detail in this report for reasons of confidentiality.
Belford Hospital, Fort William
27.25. I have the sense that a review at Belford would be useful. There are concerns about its isolated nature, burnout/longevity of senior staff, the relationship with other hospitals in NHSH and some inappropriate behaviours. I suspect that these will be well known to senior management.
Argyll and Bute
27.26. A number of respondents came from Argyll and Bute (A&B). There is no doubt that the geographic spread of NHSH creates unusual situations. It was put to me that "A&B within the context of NHSH, in many respects 'manages its own smoke', although there is clearly a corporate link with the 'north'. A&B is a different place to 'north' NHSH, as all secondary care referrals go to Glasgow, and so there is no 'clinical link' with 'north' NHSH which includes Raigmore Hospital."
27.27. Initially it seemed that the circumstances in Argyll & Bute were such that many of the concerns in the north might not apply there. But, as evidence came in, similar concerns were raised, especially about management behaviour and inconsistency, and inadequacy in training of managers, appointment and application of policies and systems.
27.28. In the time available, I was not able to conduct as full a review of Argyll & Bute as of the north Highlands. Thus, I fell into the position which is often the subject of criticism by those in the west and south, with justification, of not seeming to be as interested in that part of the organisation as elsewhere. I fully appreciate that there will be much more to learn.
27.29. However, I was concerned to hear from a number of sources about particular problems in some of the island communities and of a management culture located in Lochgilphead and Oban which seems to have created significant tensions and resulted in poor relations between managers and frontline staff.
27.30. This is one example:
"Thank you for listening to my concerns. When a working environment becomes toxic over a period of time, what is non acceptable behaviour becomes normal and suddenly it's embedded. For staff on the frontline in Argyll and Bute defensive and intimidating behaviour is normal practice that we endure on a daily basis, it corrodes confidence and lowers morale but we keep on caring for people and their families. The calibre of frontline staff is immense and they are a credit. The solution to financial pressures is within them if senior management stop and listen properly and start to work with senior nurses and staff instead of treating us like the enemy. You save money by helping people to work more efficiently through workable IT and systems not by cutting nurses, services and beds."
27.31. The key areas of concern were described by one respondent as:
- Intimidating behaviour individually and as a team by [certain senior managers]
- Aggressive body language and facial expressions.
- Making negative or derogatory comments.
- Changes in decision making leaving people on the back foot and ill prepared.
- Making decisions affecting individuals without consulting them and announcing them widely.
Other respondents described unacceptable treatment in a small community including ostracisation, victimisation, harassment, humiliation and rumour-spreading.
27.32. This observation summed up concerns: "A culture of undermining, intimidating and pressurising operational managers has developed within the A&B HSCP." I am persuaded that a specific review of management practices in Argyll and Bute is necessary and, because the nature of some of the allegations implicate management at a very senior level, consideration should be given to this being conducted by someone from outside the area who is viewed as wholly independent. Consideration should also be given to greater integration with North Highlands.
27.33. I am aware that there is new director level leadership and I hope this will help in the process of resetting matters in this part of NHSH.