2. Summary of the Report
2.1. NHSH is and has been for many a great place to work. There are thousands of well-motivated, caring and supportive people providing excellent caring services to thousands of patients in the area served by NHSH, often sacrificially and well beyond the call of duty.
2.2. This has been a very hard time for many employees of NHSH and those connected with NHSH. It may be that focus on the primacy of patient care and safety in recent years, through quality and performance initiatives, has not been matched in all situations by care for those delivering the services.
2.3. Patients and others in the NHSH community need to be reassured that the day to day work of the organisation is designed and able to do the very best it can for all concerned.
2.4. The only way to optimise the use of limited fiscal resources is to draw upon and acknowledge the deep well of goodwill that exists in the NHSH workforce. That goodwill has been seriously tested in recent years for a number of those working in NHSH.
2.5. There is a great opportunity now to create an open, safe and inclusive organisation in all of its component parts, perhaps even to be a leading exemplar to other organisations. If real learning can be taken from what has happened, and if kindness and compassion can be restored in NHSH, there is a great opportunity to build a new kind of organisation.
2.6. There may be no greater leadership challenge in 2019 than to help people under pressure to feel valued and for everyone to appreciate the benefits which come from rebuilding strong relationships, bringing out the best in each other and enabling everyone to be more effective in every way.
2.7. It seems necessary, at a deep level, to explore and understand why individuals and organisations behave as they do, especially when under pressure, and to find enduring remedies, not transient sticking plasters. Current research into behavioural psychology and neuro-science provides an excellent resource to draw on.
2.8. This is an organisation with an £800 million budget funded by the taxpayer. The current situation merits serious analysis. This report reflects a stage in a longer journey of consideration and discussion about these important issues.
2.9. Of the 340 people who made contact, the review engaged directly with 282 respondents in face to face meetings and in written form. They came from a broad cross section of the staff employed by or associated with NHSH, from most departments, services and occupations, mostly current and some former.
2.10. In total, the review has enabled a total of 186 individuals to express their views personally on a one to one basis or in a group setting. This was not easy for many. Most people expressed satisfaction with the opportunity afforded to them.
2.11. Those coming forward in response offered a wide range of views, from those who wished to say that they are not aware of bullying in NHSH at all to those who provided details of their own and others' experiences of bullying behaviour, both individually and collectively.
What the Review was Told
2.12. The majority (66%) of those responding to this review wished to report experiences of what they described as bullying, in many instances significant, harmful and multi-layered, and in various parts, at all staffing levels, and in many geographic areas, disciplines and departments of NHSH.
2.13. There are issues common to the whole of NHSH, some which are particular to the Inverness area and Raigmore, and some which are particular to more rural areas and to Argyll and Bute. These affect wider communities too.
2.14. A significant minority of respondents expressed views with varying degrees of firmness to the effect that there is not a problem, or at least that there is no bullying culture as such, and that any conduct of concern is nothing other than what might be expected in any similar organisation with day to day pressures. They have been hurt and angered by the adverse impact of the allegations which have been made, on patients, staff and local communities.
2.15. A significant majority of those with whom the review engaged have, over a number of years suffered, or are currently suffering, fear, intimidation and inappropriate behaviour at work. The issues raised are also wider and more complex than "bullying", however that is defined. Bullying cannot be assessed in a binary way.
2.16. While it is not possible to conclude conclusively that there is or is not a bullying culture in NHSH, it may be possible to conclude that the majority of employees of NHSH have not experienced bullying as such. Having said that, extrapolating from the evidence available to this review, it seems equally possible that many hundreds have experienced behaviour which is inappropriate. That seems far too many.
2.17. The number of individual cases in which people have experienced inappropriate behaviour which falls within the broad definitions of bullying and harassment described earlier is a matter of the utmost concern. Many appear to have suffered significant and serious harm and trauma, feel angry and a sense of injustice and want to have their story heard.
2.18. A number of those against whom bullying allegations have been made are also, or have been, the subject of inappropriate behaviour themselves.
2.19. Many people have been afraid to take steps to address issues internally or to speak out, currently and over a period of many years. Many feel that no really effective, safe mechanism to do so has existed.
2.20. A significant number of employees, at all levels of seniority, have resigned, moved to other jobs or retired as a direct result of their experiences in NHSH and inability to achieve a satisfactory resolution, some to their financial detriment.
2.21. Themes emerged for staff who feel they are not valued, not respected, not supported in carrying out very stressful work and not listened to regarding patient safety concerns, with decisions made behind closed doors. They feel sidelined, criticised, victimised, undermined and ostracised for raising matters of concern. Many described a culture of fear and of protecting the organisation when issues are raised.
Understanding the Cultural Issues
2.22. 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 matters locally.
2.23. Some factors could be described as cultural and are possibly unique to the specific local and geographic circumstances of NHSH and its employees. 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 be common to all large organisations.
2.24. These are explored in detail in this Report.
Management and Leadership
2.25. 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, and relate also to the effectiveness of the governing body to provide effective oversight.
2.26. A significant number of respondents expressed concerns about the role of senior management. The senior leadership of NHSH has seemed to many, though not all, to have been characterised over some years by what has been described as an autocratic, intimidating, closed, suppressing, defensive and centralising style, where challenge was not welcome and people felt unsupported.
2.27. A significant number of managers who engaged with the review reported operating in circumstances in which they felt 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.
2.28. It appears that the intersection in decision-making between management and clinicians is not working well enough and is a cause of much frustration and sub-optimal performance.
2.29. Issues were raised about appointment, recruitment, promotion, training, diversity and relationships of managers.
2.30. Many who were concerned at director and senior management level and who themselves experienced bullying behaviour have left the organisation. Some people have been very damaged by the experience.
2.31. It is understandable that 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.
2.32. For a number of reasons, including inadequate provision of information to the Board which was not conducive to effective and informed decision-making and a culture which tended to discourage challenge, it appears that the Board has not functioned optimally in its governance and oversight role leading to a situation where allegations apparently could not be raised and responded to, adequately, locally.
2.33. Over a period of time, concerns have been expressed about a style of management and type of behaviour which many contended was not acceptable in a large and complex organisation. It seems clear that people in leadership positions were or should have been sufficiently aware of the concerns expressed as late as mid-2017 and probably earlier.
2.34. Both the Board and the Scottish Government were, or should have been, sufficiently alerted by developments to act more decisively at an earlier stage.
2.35. In a public service with a budget of £800 million, new leadership should look seriously at the learning arising from what has occurred, especially in connection with holding to account. If this is done, it should be possible to assess and respond to allegations, such as those of bullying, more fully at an earlier stage.
2.36. The absence of a proper strategic vision with specific goals and timelines seems to be a contributor to the current sense of lack of direction.
2.37. The governance structure seems extensive and impenetrable to many. It does not seem conducive to open, transparent and effective operation.
2.38. The role, appointment, training and support of, and provision of information to, non-executive directors appears not adequate in practice to meet the needs of the Board of a large publicly funded organisation with an £800 million budget.
2.39. Unless people with the necessary skills, knowledge, expertise and experience (and ability to ask the right questions in the right way while understanding financial, risk and other management issues) are appointed to NHS boards, there is a danger that governance will not be effective and national policies will not be implemented effectively.
2.40. Many people expressed their concerns about the partnership agreement for staff involvement in decision-making and the role of trade unions and staff-side representation, which appears to many employees to have failed adequately to represent the interests of employees of NHSH in regard to bullying claims.
HR and Other Processes
2.41. It appears there has been, and continues to be, serious delay in addressing many of the issues of significant concern to members of staff in NHSH. This is often because of failures and delays in recording, reporting and investigating, and in grievance and other procedures and policies for dealing with complaints and other concerns (including the inconsistent and inappropriate use of suspension and capability assessments, breaches of confidentiality and perceived loss of impartiality).
2.42. While there is a lot of criticism of "HR", that may be a catch-all which conflates management roles and the HR function and does not fully acknowledge the wide-ranging nature of the dysfunction across management generally.
2.43. The view has been expressed that there is a strong need to improve diversity awareness and bring the NHSH culture into line with attitudes and practice in the rest of the UK.
2.44. It has become clear that mental health should be a major management issue for the NHS and NHSH in particular. A significant number of people employed in NHSH have suffered and some continue to suffer from significant mental health issues as a result of their experiences, many of which can be described as traumatic given their repetitive and intrusive nature in disruptive and damaging situations.
2.45. There are a number of more specific concerns which the report comments on in some detail.
2.46. Senior officials in Scottish Government were aware of the dysfunctional situation with the Board and at senior leadership level for a considerable period of time prior to matters becoming more public in the autumn of 2017.
2.47. There is a tension for Scottish Government between intervening and encouraging organisations and individuals to deal with issues themselves. Government is often accused of over-involvement. Yet, when things go wrong, it is held responsible. Judging when and how to intervene is not easy.
2.48. The Scottish Government is an essential part of the system. How it acts and reacts also impacts on those in NHS boards and executive positions in local areas. Now seems like a good time to review this relationship.
2.49. Those involved as whistleblowers genuinely felt they had no option but to do what they did and that this was the only way to address matters, even with the costs which arose. None of this would have been necessary or would have developed as it did had the Board and management appeared to be open to a full exploration of the issues. The report's findings are not hugely influenced by the whistleblowers' allegations; they were ultimately a catalyst for others to come forward.
2.50. Many people have been hurt and feel misrepresented and offended by what has appeared to them to be a brutal step by the whistleblowers. Individual reputations in a close community have been adversely affected. There seems little doubt that certain assertions were too broad and without the support claimed.
2.51. The existing system for whistleblowing does not seem to have functioned as effectively as it needs to.
Ways Forward for NHSH
2.52. In NHSH, steps can be taken, both restorative and preventative, to reset the whole organisation and to promote an institution-wide healing and reconciliation initiative, supporting and liberating the workforce. This is likely to have a positive impact on patient care and outcomes too.
2.53. Better staff relationships will lead to better clinical outcomes, especially when the tasks are complex and interdependent. To achieve this, there is an urgent need to collaborate and work together rather than to compete, based on a deeper and wider understanding of the shared interests that allow people to cooperate more effectively and efficiently to find solutions.
2.54. This necessarily entails a move away from trying to control everything to a more distributed, multi-disciplinary or collective leadership and decision making.
2.55. There needs to be an enabling culture from the top. Culture change needs to be owned by the leaders. That means leaders who are not afraid, who have high self-esteem and a great deal of humanity and compassion. Kindness is a critical component of the leadership which will be needed going forward.
2.56. A new style of people-centred leadership will be crucial, with a more effective and competent management team and board, and a more compassionate, honest, courageous, humble, empowering culture, open to respectful challenge, communicative and accepting of the realities of operating in a very pressurised and financially challenging situation. Fear cannot be the driver.
2.57. An honest conversation is needed more generally in the NHS, and with the general public and employees, about realistic expectations and the perhaps inevitable tensions between clinical delivery and financial reality.
2.58. Fault-finding and a culture of blame will not be a productive way forward. Wherever possible, NHSH will need to look forward constructively to the future.
2.59. Looking ahead, it will be necessary to find ways to acknowledge the circumstances of the past, to recognise the impact on individuals, processes and services, to demonstrate acceptance of some personal responsibility, to show that lessons have been learned, to reassure staff and indeed the general public that there is a genuine willingness to grasp the need for change and that things will be different in the future, to rebuild confidence, and to move forward with greater competence in the years ahead.
2.60. More attention should be paid to early intervention, when a difficulty or conflict is first identified. Nipping matters in the bud is critical. This can be addressed by education and training, by empowering those affected and bystanders to raise concerns early, and by introducing other different approaches which move away from adversarial or binary processes.
2.61. Many of the issues currently being addressed through conventional grievance and other procedures may be amenable to, and more effectively resolved by, early intervention through mediation and other facilitated conversations.
2.62. The time has come to place mediation firmly at the centre of a preventative strategy in the NHS in Scotland. That could start in NHSH.
2.63. Leaders and others will wish to reflect on and seek to align how things are done in NHSH with the National Performance Framework and its outcomes.
Leadership, Governance and Management
2.64. It seems essential for the new chief executive to exhibit an ability to engage with people at a personal level, to listen well and to seek to understand, to value contributions from all parts of the organisation and to be alert to the human effect of the inevitable tensions and constraints which funding limitations and other challenges bring.
2.65. He will benefit from the support of like-minded and like-acting colleagues who can help lead by example and demonstrate real empathy, insight, self-awareness and vision in practice. He will need the support of an appropriately qualified Board chair who has a similar mindset.
2.66. There is a real need for an authentic, meaningful acknowledgement and acceptance of how serious matters have been for many people in NHSH over a number of years, together with recognition of the impact on them of these circumstances and a reassurance that matters will be addressed now with rigour going forward.
2.67. At the same time, there should be recognition of the impact on those who have not experienced adverse behaviour but who have been affected by the fact that the allegations themselves have been made. Healing can only occur if the different experiences are recognised and acknowledged.
2.68. Whatever procedures and policies are available, they are unlikely to be effective unless people are civil to one another, especially when under pressure. This comes from the top and cascades through the whole organisation. Consideration might be given to adopting something akin to the Commitment to Respectful Dialogue of Collaborative Scotland.
2.69. The Board must be able to hold senior executives effectively to account, in the sense of supportively enabling and ensuring effective leadership rather than blaming or coercing. A review of governance structures, the committee network and culture will enable the kind of clear communication and taking of responsibility which this report commends. Allied to this, the Board will wish to oversee a review of the management structure also.
2.70. Other detailed proposals regarding governance should be acted on, particularly in connection with non-executive directors.
2.71. Reassessment of the relationship between and among clinicians, GPs and management seems to be an essential part of building a collaborative and mutually respectful and supportive culture. There should be reflection on the manner and benefits of clinical involvement in leadership.
2.72. Clearer management structures, a better understanding of the needs and motivations of both management and medical staff and a positive approach to the greater good, will all benefit staff and patients alike.
2.73. The role of trade unions and staffside representation, including the partnership agreement, merits review in order to ensure really effective representation of employees' interests.
2.74. By reason of its geographic and possibly other specific circumstances, a separate review in and about the functioning of management in Argyll and Bute should be commenced, conducted by a person or persons from outside that area.
2.75. In so far as staff have any specific concerns about patient safety, these should be referred to the chief executive or to a specified independent person if preferred.
Support for NHSH Employees
2.76. Support is needed, in a number of ways, for individual employees in NHSH (at all levels), who have experienced inappropriate behaviour and who have suffered distress, harm and other loss. This should include providing safe and independent spaces for many current and outstanding physical, emotional and psychological issues to be addressed fairly urgently.
2.77. It is likely that these initiatives will result in a need to address specific complaints, disciplinary matters and grievances, many of which appear to remain outstanding and/or unresolved. The cooperation of the unions, especially the GMB, will be important in this. A strategy to resolve the many outstanding cases as speedily as possible should be devised.
2.78. Other specific proposals are made in this Report.
Training and HR
2.79. Longer term, a carefully designed ongoing comprehensive training programme addressing appropriate behaviour (including a well communicated, simple and clear definition of what constitutes bullying and harassment, together with diversity and discrimination awareness) could have a profound impact.
2.80. There is a need to rebuild confidence in and of managers. A programme of action learning, training, review, coaching and support is essential at all management levels, including for those preparing for recruitment, induction or promotion into management positions.
2.81. Among a number of specific recommendations to build relationships and confidence, the introduction and/or enhancement of well facilitated team meetings on a regular basis, possibly across boundaries on an inter- and/or multi-disciplinary basis, with opportunities to express concerns, to brief and debrief safely, and review events and experiences in a supportive culture, could help greatly. Managers could be trained and encouraged to undertake and facilitate these.
2.82. There needs to be an organisation wide clarity about and understanding of the role of HR, and its limitations, and it and Occupational Health need full-time direction at the highest level. Appointment of a full-time HR Director is essential.
2.83. All HR and other policies and procedures should be reviewed, updated and simplified, in the context of national reviews – and properly publicised. Systems for accurate and robust recording of complaints about alleged bullying and harassment should be maintained so that understanding of the extent, nature and distribution of bullying and harassment in the organisation is improved.
2.84. Grievance and other formal procedures, when used as a last resort, must be redesigned to be speedy, transparent and fair to all.
2.85. It is suggested that all NHS staff should be educated about the effects of bullying, the trauma model, the Adverse Childhood Experiences study and how they can address unprocessed trauma leading to consequences for the alleged victim and to themselves. Other steps to address dealing with trauma are recommended.
2.86. While one would hope that the steps above would minimise the need, and that "whistleblowing" would be very much a last resort, further steps should be taken to provide a properly functioning, clear, safe and respected wholly independent and confidential whistleblowing or, more helpfully, "speaking up" mechanism.
2.87. All staff should be aware of how to use this and in what circumstances its use is relevant so that individuals with concerns are able to express these confidently in the future.
2.88. Provision of an independent, confidential, trained "guardian" or guardians seems essential both for those who experience and wish to report inappropriate behaviour and for those against whom such behaviour is alleged.