31. Looking Ahead
31.1. It is against this theoretical backdrop that, as noted above, steps need to be taken urgently, both restorative and preventative, to reset the whole organisation.
31.2. As I have noted earlier, there is a desire among some for vindication and retribution. However, 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 and not dwell overmuch on guilt about the past.
31.3. Looking ahead, it will be necessary, however, 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.
31.4. Reassurance will be needed also for those who feel that their careers have been or may be affected merely by standing up for what they believe to be important. And also for those who have failed to match the expected standards of behaviour. It will be a difficult balance to strike.
31.5. As discussed earlier in this report, it seems likely that preservation of jobs and livelihoods has been very important at many levels and has driven behaviour both by those to whom bullying behaviour is attributed and by those who have felt bullied. The various factors which are unique to the area (and identified in chapter 16) suggest that real care is needed in supporting and nurturing inter-personal relationships in NHSH and identifying where these are weak.
31.6. Some grievances will still need to be addressed formally and steps should be taken expeditiously to address outstanding claims as part of a move to make a new start. This will require significant constructive engagement by the trade unions. This will only be relevant if the unions feel that the management and Board have taken steps which fully and adequately address their members' concerns. I expand on this in my proposals in the following chapters.
31.7. Whether all of those who have participated in the events of recent years will be able or will wish to participate in such a rejuvenation is hard to know. The experience of humiliation, resentment, and anger that many people have experienced will not go away on their own and because people say they should. There is the familiar journey to be travelled from denial, through blame and on to acceptance.
31.8. A thoughtful and nuanced approach will be necessary. To what extent a truth and reconciliation approach is necessary requires to be worked out. There is a danger of moving too far too fast for some of those affected. And, as one respondent told me:
"I think the worst thing would be if your report says "we have some learning. We need to do things differently" in a wishy washy way."
31.9. It will be necessary in many cases to draw a line and move on and for many past grievances to be let go of. Individuals will need to decide whether and how they might do so. Adult conversations seem critical. Moving away from the victim/perpetrator paradigm is essential. Generosity of spirit will be necessary, even towards those viewed as perpetrators, who have often also been victims themselves. Bitterness will not assist healing. Freedom only comes with making the choice to move on. "Resentment is like drinking poison and hoping the other person will die," as Nelson Mandela is reported to have once said. And to do this will require a lot of support and help.
31.10. One member of staff with experience in the mental health field said:
"I would observe/add that the legacy effects of working in an emotionally unsafe system, and the culpability that can come from an uncomfortable awareness of having been involved and complicit in something inherently wrong, but where there was no voice, can be traumatic in itself. There will be advantages, if not a need, for people most affected, to have time and space to make sense of, heal and recover even as the organisation moves ahead. If there were a way to achieve this, we might take the learning and wisdom into the future."
31.11. There may be some useful guidance in remembering that, as is often said, small changes may be all that is needed or possible but may themselves result in bigger changes in due course; the past cannot be changed and it may be most useful to concentrate on the present and the future; with the right support and encouragement, people often have the resources necessary to help themselves; in a sense, they are the experts in their own situations and can (re)build relationships one conversation at a time, if they have the necessary support and encouragement to do so.
31.12. There should be little doubt that many of the resources, ideas and skills needed to take the organisation forward exist already in NHSH. These can be identified, released and facilitated. Existing good practices can be recognised and built on.
31.13. A member of staff addressed this in very specific terms:
"More than anything there needs to be a culture of support and value. This cannot be just created by a new initiative, but needs individual teams to start functioning as caring units, valuing each other and supporting each other. The expectation to work well beyond contracted hours needs to be changed, so that a work life balance can not only be achieved by staff, but be valued and used to promote the attractiveness of careers in health. It is so easy for health care staff to be coerced into working above and beyond, because if they don't patients will suffer and staff are by definition caring. The organisation needs to recognise that attention and resource must be put into supporting staff whether this is through addressing staffing levels and acknowledging that with current resources some services may be limited; or providing time for support such as the mentoring scheme for doctors (ideally for all staff), appraisal etc. It would be very encouraging to see the start of an open, honest and supportive culture within this organisation."
31.14. Another senior NHS manager provided this summary:
"It is really sad that the pressure on NHS staff means that managers rarely have time, or skills or training to defuse tension and support their staff and so situations of frustration fester and result in unfortunate situations. What is so bizarre is that these personal attributes that make for good relationships exist - in spades - but are all directed towards the patient and there is nothing left for colleagues."
31.15. In other words, as NHSH looks forward, looking after the people who are looking after the people is central.
31.16. In my research, I came across the example of the Lockerbie air crash and the effect that a profound shock to the system had on the public sector at the time: the local authorities rose to the occasion and developed ways of working together that held good in the future. It is said that shocks can test the resilience of a system and often enable it to come back stronger and more adaptive (not bounce back but bounce forward).
31.17. A crisis can create an opportunity to learn and build a better way forward. The system that will emerge on the other side of the crisis is shaped by those leaders who are able to harness the potential in the moment and galvanise others to act. This emphasises the opportunity now available to NHSH to model a different way of behaving as an NHS organisation.
31.18. I also note this helpful reference to resilience in the context of health in the Annual Report of the Director of Public Health for NHSH on Adverse Childhood Experiences, Resilience and Trauma Informed Care, in 2018, under the heading of a 'sense of coherence' as a route to resilience:
"[Aaron] Antonovsky concluded that a healthy outcome depended on an individual's 'sense of coherence' which was the ability to make sense of, and manage the external environment. Essentially, unless an individual can view the world as being manageable and meaningful, they will experience a state of chronic stress. The former Scottish Chief Medical Officer, Harry Burns, argued that public policy should seek to enhance this sense of being able to control one's life. He puts forward the view that if policy makers persist in defining a population by its deficiencies and problems, then services will only ever be designed to fill gaps and fix issues, which leads to a further feeling of people as 'passive recipients of services, rather than active agents in their own lives.' The key, then, is to pay attention to the emotional, psychological and spiritual resources that allow people to build relationships and establish social networks, so that people have opportunities to find what is meaningful to them, in a way that fosters optimism and control."
31.19. The emphasis on resilience, empowerment, building relationships and establishing thriving networks seems crucial to the future for the workforce in NHSH.
31.20. Finally, one former director emphasises the need for realism:
"Realistic Medicine was introduced by the Chief Medical Officer for Scotland a few years ago and has gained great interest as a method of overhauling the clinical aspects of the health service. I have been suggesting Realistic Communication to be developed as a means of streamlining, and so making more effective, information dissemination at all levels. I would now add to that Realistic Management, as we need to be mindful of delegating realistic tasks ie not raising expectations of implementation with inadequate resources (especially time) which is effectively setting people up to fail and so brings about further disillusionment and disengagement."
31.21. Finding ways to promote the kind of changes commended in this and the preceding chapter while realistically managing expectations will be one of the first challenges for the leadership.
31.22. On the other hand, there is no need to reinvent wheels, rather a need to make them work and move forward. I understand that the NHS Scotland Everyone Matters people strategy has some core and common values (care and compassion; dignity and respect; openness, honesty and responsibility; quality and teamwork) which could readily underpin the kind of strategy I am suggesting in NHSH. As a keen observer commented: "Much of what is suggested is already out there, alongside the good practice that is evident in other boards, which could help to shorten some of the journey time." What a useful point this is.
An Example to Others?
31.23. If the entire community of NHSH can find a way to move forward from the experiences of the past several years, they might provide an example to others who will face similar challenges in adapting to a very different future. There is no choice but to face up to the need for change:
"The framework we use today may have been appropriate in earlier times, but it is no longer in touch with the complex challenges and demands of our time."
31.24. I realised, when reviewing this report at a late stage, that I had not written much about trust. Everything in this and the next section of the report, however, is really about restoring trust. Without trust in the senior management, the board, managers, and each other, NHSH will struggle to move forward. With trust, everything is possible. Trust takes a long time to build. It has to be earned and maintained. "Do as I do as well as do as I say" probably sums up well the need for integrity, consistency and example as foundation stones for a trusting community.