Cultural issues related to allegations of bullying and harassment in NHS Highland: independent review report
An independent review report looking at cultural issues related to allegations of bullying and harassment in NHS Highland by John Sturrock, QC and mediator.
30. Leadership: Creating a Collaborative, Compassionate Place of Work
30.1. In this chapter, I explore some of the general theory underlying the leadership challenges and opportunities for NHSH as it looks ahead. In following chapters I discuss what this might mean in specific terms.
30.2. The following quotation, adapted from a recent speech by the Prime Minister of New Zealand, Jacinda Ardern, sums up the way ahead.
"…one priority will be to support the mental wellbeing of all employees…. From a purely economic perspective, there are clear benefits to supporting positive mental wellbeing, including enhanced productivity. From a kindness perspective, the modern age places huge stresses on all people, which affects their ability to live full, meaningful lives. Confronting this will make us a better [organisation]".
30.3. In summary as put by another observer:
"Once staff become safe and are treated well, you will have a workforce that is happy. A happy workforce is a motivated and productive workforce."
30.4. One respondent to the review observed:
"Your report acts as an urgent prompt/warning to help us redesign and reengineer NHS Highlands into a kind, compassionate, fair and caring organisation for both us and patients."
30.5. Others had similar views:
"We need to care for the carers as we do for the patients."
"We all need healing; it's the nature of the human condition."
"I hope that the outcome will encourage a thriving, happy, well led organisation which provides excellent patient care and looks after the people working within it."
A Better Way
30.6. History is full of examples of situations where focussing on the people who form the workforce has transformed an organisation. Research shows that when people do what they love, work feels more like play and they are more likely to keep going when the going gets tough. They end up being more productive and effective.
30.7. If leadership can be inspiring, visionary, energetic and attractive, people will deliver more. Perhaps this is especially true in public service, especially in the NHS, where people often act over and above the call of duty in order to serve. The converse is likely to be true if leadership is constraining, dictatorial and fear-based.
30.8. A recent example can be found in the fortunes of Manchester United Football Club. The writer, Matthew Syed, whose book Black Box Thinking contrasts safety in the health service with the aviation industry, has pointed to the shift from fear-based and fear-inducing leadership, characterised by criticism, confrontation, blame and buck‑passing, which impacted negatively on performance, to a joyful, supportive, liberating approach which has released players (the staff) to see things more widely (literally as well as metaphorically, as the brain responds differently), and to become more creative, responsible, and engaged. There is less fear and more interaction. More confidence and fun in what they do. Interestingly, the new (and, at the time of writing, interim) manager has also visited backroom staff and shown interest in how they support the playing staff.
30.9. I note in passing that, in the aviation industry, this is not just about a "no blame" culture; more it reflects a "just" culture, where the difference between what is acceptable and unacceptable is understood. This entails another shift in mindset, moving from culpability and shame to acceptance of fallibility and vulnerability. This presents another useful challenge to NHSH thinking.
Resetting the Organisation
30.10. In NHSH, I believe that 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. Better staff relationships will lead to better clinical outcomes, especially when the tasks are complex and interdependent.
30.11. No doubt, this may take many months or even years. New thinking and fresh attitudes take time to embed. Changing habits requires conscious effort. As one respondent to the review observed, "to turn round this liner, you need lots of people going in the same direction with confidence in those on the bridge – this will take time." Someone else suggested that the better analogy is with a flotilla of boats all heading in broadly the same direction. In any event, there is a transition stage to be undertaken. Another senior director told me:
"We need to work through, we will be working together for a long time. It's going to take time. People have tried to sort our issues through one-off interventions. This is going to take years of counselling."
30.12. Another manager told me:
"I think people, managers, NHSH need to look at a way to work together rather than be in competition. Integrate properly. Add to that, the struggles I come across with the people I have professional responsibility for, I looked at a way to increase access. Managed to increase resources, but people need to work smarter. But there's resistance there because they feel under attack. Management think they do communicate well, but I'm not sure they communicate effectively. They need to be more open with the struggles NHSH is facing. Rather than coming up with immediate solutions, they need to work towards developing a shared vision and get people on board."
Collaboration and Interdependence
30.13. 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. No man, woman, doctor or manager is an island; there is a mutual interest in supporting each other. Interdependence is the watchword.
30.14. This has its own challenges, given the geography:
"[Management] didn't come together very well in multiple sites. Now you have chief of medicines for various hospitals. It's about achieving the balance of accountability and responsibility by site and also having the ability to work collaboratively and influence in the greater interest in the organisation in other sites. Joining these sites up without losing the individual strengths."
30.15. It is likely that all of this will require an overall strategy which focusses on full engagement and openness, and the enhancement of effective working relationships throughout the organisation. This will help to build a culture of cooperation and respect which is founded on a deeper understanding of the differing roles and viewpoints of various groups such as clinicians and managers, to take an example. Inviting colleagues to participate in a rebuilding exercise will reap dividends. A coherent, integrated approach is necessary. Working in any one part in isolation will be challenging if the values are not shared by other parts of the chain.
30.16. As the consultants, The Phillips Kay Partnership, put it,
"To make sense of complex social systems requires many perspectives to be brought together. No one person or group could ever understand the whole environment. To release the collective intelligence in the system we must build strong and open relationships."
Process and Relationships
30.17. Put more broadly, I believe that this is an opportunity to encourage a different way of dealing with the inevitable stresses and strains of providing health services in the Highlands and to apply some new thinking, to the benefit of all concerned. It is, as Phillips Kay remind us, all about the how, the process, the journey: "The process you use to get to the future is the future you get."
30.18. The key to survival as an organisation is cooperation. Arguably, in order to overcome the chronic nature of any dysfunctioning body, there needs to be a shift from paradigms which are power-based (resting on hierarchy and status, win/lose, operating by command, with an expectation of obedience) and/or rights-based (resting on bureaucracy, operating by control, with a high expectation of compliance) to one of mutual interests, with shared vision and openness, where power and decision-making is shared, and distributed, wisely and thoughtfully. What might that entail?
30.19. As Ken Cloke puts it in discussing the points made in the previous paragraph, we need to develop better attitudes, behaviours, processes and relationships with skills and capacities which help to reduce resistance, overcome impasse, build trust, encourage participation, value diversity and dissent, redress injustices, encourage feedback and evaluation, and which accept ambiguity and complexity. A tall order but it needs to be done for a complex organisation to thrive.
30.20. He explains:
"If the content of the problem is successfully addressed and the relationship is constructive, but the process is ineffective and unfair; or if the content and process are successful and effective, but the relationship is competitive, adversarial and untrusting, chronic conflicts will arise that can prevent even the best solutions from being implemented. Yet nearly all of our focus in solving ...problems and making decisions is on the content, and comparatively little is devoted to improving either the processes or the relationships. This is often because of pressure to deliver, achieve results, under great pressure. Short term gains [but] with longer term losses." 
30.21. He points out that: (a) the substance or content of the problem must be successfully identified, discussed, addressed and resolved; (b) the process for solving problems and making decisions must be inclusive, transparent, effective and fair; and (c) the relationship between the people who are impacted by the problem, or trying to solve it, or make decisions about it, must be respectful, constructive, trusting and collaborative.
30.22. Thus, as one senior NHS executive put it:
"All improvement begins with relationships. And by that I mean good, trusting and empathic relationships. Add reliable processes to this and as long as you are using the right measurement to steer your progress then improvement will happen."
30.23. Another commented:
"I passionately believe that the people of the Highlands deserve a better health service and that this will only be achieved if we can foster better working relationships between clinical and operational staff and create a working environment where decisions can be made more promptly so that the standard of care is improved."
30.24. Another put it succinctly, "whatever change we seek to undertake, we are only as good as the relationships we are able, or capable of creating and sustaining."
30.25. If relationships are not strong, respectful and open, no amount of procedural changes or micro management will lead to the kind of cultural change that is required in NHSH. The Scottish Government's Collective Leadership initiative also reminds us that: "We cannot make this kind of change by telling people to do it. We need a clear appreciation of the power and importance of relationships to enable our work."
Command and Control to Collective Leadership
30.26. This necessarily entails a move away from trying to control everything to a more distributed, multi-disciplinary or collective leadership and decision making. NHSH is probably too big and complex an organisation to control in any event but, in trying to do so, the trouble may have been that relationships have sometimes taken a back seat as one-off transactions seem a more efficient (or easier) way of operating. This turns out to be hugely inefficient and costly, however. A more holistic approach is needed, acknowledging complexity, ambiguity and uncertainty.
30.27. This also requires an approach to negotiating distribution of resources and addressing other potentially contentious issues which is based on interests rather than positions: the Getting to Yes model. Ironically, perhaps, this helps to create more value. We are reminded that "[h]elping people create more value on their own represents one of the highest forms of respect."
30.28. Many factors interact and conventional management approaches will need to give way to greater collaboration. In a sense, one is looking for a move from heroic leadership to post-heroic, as the jargon describes it. This is likely to apply both to senior management and to clinical leaders. Delegation and empowerment do not, however, mean abdication and senior leaders will still need to take appropriate responsibility. I note these words from the NHS Education Scotland Leadership Behaviour and Qualities Guidance Notes:
"The model of 'heroic leadership' is no longer appropriate. What is required is 'engaging leadership': "a commitment to building shared visions with a range of different internal and external stakeholder…[which] exploits the diversity of perspectives and the wealth of experiences, strengths and potential that exists within the organisation, and with partners and other stakeholders"." 
30.29. Peter Senge and others commented on the leadership style of Nelson Mandela:
"Perhaps the most transcendent example of Mandela as a system leader was the Truth and Reconciliation Commission, a radical innovation in the emotional healing of the country that brought black and white South Africans together to confront the past and join in shaping the future. The simple idea that you could bring together those who had suffered profound losses with those whose actions led to those losses, to face one another, tell their truths, forgive, and move on, was not only a profound gesture of civilization but also a cauldron for creating collective leadership. Indeed, the process would have been impossible without the leadership of people like Bishop Desmond Tutu and former President F. W. de Klerk."
There are clear signals here for a different way to approach NHSH. Where are the Tutus and de Klerks?
Compassionate People-Centred Leadership
30.30. Such a pro-active approach requires resources and skill, of course. It needs 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. This is not some kind of passive, acquiescent, permissive approach but active engagement in building, encouraging and sustaining excellent personal and professional relationships.
30.31. As I mentioned in earlier in this report, and with reference to the NHS Highland Senior Manager and Executive cohort annual appraisal, humility, honesty, openness and self-awareness are all desirable characteristics. People-centred leadership in other words.
30.32. This is a profoundly compassionate approach. And I believe that it was Bishop Tutu who said in his inimitable way:
"Compassion is not just feeling with someone, but seeking to change the situation. Frequently people think compassion and love are merely sentimental. No! They are very demanding. If you are going to be compassionate, be prepared for action!"
30.33. Commenting on this, a colleague observed:
"And you simply can't be compassionate at the same time as being judgemental. When you judge you look down to get a clear view but when you feel compassion you are sitting beside someone looking at what they are looking at through their eyes with your arm round them - and you can't be in those two different places/mindsets at once."
30.34. Research backs up the compassionate approach. The University of Edinburgh Global Compassion Initiative reports that:
"Mounting evidence from the new science of compassion demonstrates that it is key to: improving personal and organisational performance (in cooperation and productivity, resilience, employee commitment and retention), enhancing effectiveness (creativity and innovation, navigating change, collaboration, addressing conflict); supporting well-being (physical and mental health, engagement at work, and welfare); and building reputation (credibility)." 
All of these are highly desirable outcomes for the new approach to leadership which NHSH has the opportunity to embrace.
30.35. The challenge for NHSH is to find the right kind of leaders. One senior consultant who regretted his own unwillingness to step forward told me:
"… we seem to have promoted within the organisation those who either have a thick skin or those who just don't care. I feel sorry for the former group as they don't seem to understand the qualities of leadership that are needed. We desperately need others to step forward. How we encourage people with those skills to do so is unclear to me."
This report is a call to action for people like this consultant.
Understanding and Complexity
30.36. I sense that 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. Seeking real understanding is a key to all of this. How well do people really understand what the underlying issues are and where others are coming from? How can that be addressed?
30.37. As has been pointed out: "If we assume too readily we can see things from others' points of view we end up seeing them from merely a variation of our own.". So we have to go further than simply stepping into another's shoes to see what things look like: we need the competence to try to understand the context in which things are being seen by them.
30.38. That context is complex and multi-layered. I note the approach commended by the International Futures Forum (IFF):
"We follow the OECD definition that 'competence in complexity' is not an abstract achievement but "the ability to meet important challenges in life in a complex world…"".
30.39. This resonates with the emerging work on systemic organisational constellations, drawn to my attention by my colleague Liz Rivers who assisted in the review:
"Systemic constellation is able to reveal embedded patterns that would otherwise be very challenging to understand and change, or simply impossible to access. Even if we intellectually recognise the patterns of negative behaviours and destructive relationships, it is in practice extremely difficult to transform these patterns. Through systemic constellations, we see the complex web of interconnection reaching into our society, organisations and individual life. Experiencing this interconnectedness can have a powerful effect in our organisations and gives the possibility to transform unhealthy systems."
30.40. I was struck by this comment about what is called "Eco-Leadership" which is "very much the environment where we are concerned with emergent change, where we are no longer leading change in a traditional sense, but creating the leadership capacity under which we can handle ambivalence and uncertainty. In this situation, the leadership role is increasingly about interpretation and sense-making for the organisation."
30.41. This may all make sense as an appropriate underpinning for a 21st century NHSH and resonates again with the issues of complexity, ambiguity and uncertainty identified in the National Performance Framework referred to in chapter 4. And, of course, it fits in well with the Collective Leadership approach also promoted by the Scottish Government:
"Critical to working in this way is recognition that it is about "in here" as well as "out there" – we need to develop the skills and attributes to be able to work collectively within both the individual and groups for greatest impact on the system."
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