33. Specific Proposals: Leadership
33.1. In this and following chapters, I set out proposals both for the present (restorative) and for the future (preventative), with one word of caution: if these are proceeded with in the same pressurised way that has characterised some activity in recent years, the result may be frustration and sub-optimal outcomes. This cannot simply be reactive problem-solving. A merely technical and transactional approach will risk simply repeating the errors of the past. As noted in previous chapters, this is as much about tone, attitude and relationships as it is about procedures.
33.2. This is a time for a measured, thoughtful and coherent strategy. As someone recently said, at a time of uncertainty and doubt: "the winners will not necessarily be the ones that find an answer fast. They will be the ones that find the right questions." And those that take full responsibility for doing so.
33.3. Throughout these chapters, readers will wish to ask the crucial questions: Where are the gaps? What is missing? What is not clear or is misunderstood? How can this be improved upon?
33.4. What I suggest in the following chapters is only the beginning of such an approach and constitutes some of the possible component parts of such a strategy. There is a balance to be struck between moving towards the kind of radical cultural change which will help NHSH to thrive and the need for specific actions to be taken in the short and medium term.
33.5. There are a number of caveats: various other reports (including Gallanders, Polley and Brown, all mentioned in this report, together with others which have been commissioned) have already covered many of these (and other) points and most are useful and helpful. They should be a foundation to build upon; this report may merely supplement them.
33.6. I have not captured all of the points arising in previous chapters and readers will wish to refer back to earlier sections also. I have adopted some proposals put to me by others which seem sensible and adapted others. All of these suggestions are therefore perhaps best viewed as guides.
33.7. There is a Quick Summary of Main Points and Proposals at the end of this section. While it is tempting to offer an order of priority for these, that is a task for NHSH to carry out in the manner I suggest in the following section.
Collaboration and Responsibility
33.8. As steps are taken to work out the appropriate way forward in collaboration with the NHSH community at large, it is worth remembering this maxim of The Phillips Kay Partnership:
"Strategy and policy designed remotely from the people who must deliver is never well implemented. It is better to design well a strategy with the people who must work with it, than to implement poorly a brilliantly thought out strategy that is developed elsewhere."
33.9. Thus, the most crucial recommendation is for the new leadership to adopt the collaborative mindset set out in chapter 30 and take these ideas to the NHSH community at large and work with all the very able people there to build a new culture. Such a participative, collaborative approach to working out the way forward seems likely to be productive.
33.10. In conducting this review, I came across many able people (at all levels, many of whom are not "the usual suspects") who would contribute hugely to the future of NHSH. Together, they could work through these ideas, suggestions and proposals and map out a great future for NHSH.
33.11. To this end, I commend a facilitated early gathering of a selected group of people who have responded to this review, to participate in a three-day retreat to consider this report, assess its proposals and plan the way ahead. I suggest that the Cabinet Secretary could attend on the final day.
33.12. It also occurs to me that a Priorities Task Force could identify and lead on five initiatives which are likely to make the biggest short-term difference.
33.13. I have pondered the appointment of an Associate Medical Director with specific responsibility for overseeing the short-term tasks as one way forward. That person, or the chief executive, could write to all staff and invite them to contact him or her with issues of concern and ideas of interest.
33.14. Thereafter, regular reviews with appropriate benchmarks to assess progress will be essential and a full review in one year's time would ensure accountability. This is an ongoing learning process, asking these questions throughout: What is working? Why? What hasn't worked? Why not? What could we do differently? How?
33.15. I am particularly aware of all of the material with which I have been provided. I estimate that I may have received well over one hundred individual pieces of confidential information that would be of specific use to the senior management of NHSH as they address the issues arising in this review. It would be really helpful if a way could be found for at least the most useful of that material to be utilised by the leadership going forward.
33.16. This might be done by again inviting people to contact the chief executive or an appointed senior person and provide in confidence the information which they have provided me. If helpful, I am happy to work with NHSH as they navigate their way through this difficult area.
Short-Life Working Group
33.17. In this connection, I have noted the role of a short-life working group to look at promoting a positive working culture across NHS Highland. It is proposed that this group "will seek to hear from people across the entire organisation and will aim to ensure that any concerns raised are heard and acted upon."
33.18. While extremely worthy in itself, I am aware that the original composition of the group included people in whom I have heard, from a number of sources, there is a lack of confidence. This is for a number of reasons, including being perceived as having been sceptical about and resistant to the allegations made about bullying in NHSH and not fully to have understood their importance. I refer for example to my remarks about the response to the whistleblowers.
33.19. For NHSH to go forward positively, and given that it is essential that confidence and trust lie at the heart of all initiatives, it seems that real thought needs to be given by the new chief executive (and by the board) to the composition, chairing, remit and design of a group such as this. Again, a proper strategy rather than ad hoc reactions will reap dividends.
A Reset: People-Centred Leadership
33.20. Although there will be much focus on financial matters in the months ahead, as suggested in various parts of this report I suggest that making people the priority will ultimately produce the best outcomes. 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. Effective relationships at all levels are key to the future.
33.21. The leadership team of executive directors and senior managers will greatly influence the future direction of travel and how NHSH is perceived both within and outwith. There seems no doubt that a resetting is needed both in senior management and at board level. There are too many, widely expressed and apparently valid, criticisms of some of those in senior management roles for it not to appear to be essential for changes to occur in order that a new way forward is seen to be both credible and competent – and for real confidence and trust to be restored. There are some very aware and insightful leaders in NHSH who have much to offer.
33.22. It has been suggested that some senior medical staff should revert back to clinical duties and undergo retraining before taking on further management roles. Certainly, ongoing training and support for the new leadership team should be provided in the months ahead.
33.23. I hope that the leadership of NHSH will consider some of the ideas discussed in my chapter on Leadership. There should be much to be gained from taking time to engage actively with other NHS leaders in Scotland and with others in public sector leadership in Scotland through channels such as the Scottish Leaders Forum. Regular support and coaching for the leadership team is likely to be necessary going forward in what will be a crucial and challenging .
33.24. Leaders and others will also wish to reflect on and seek to align how things are done in NHSH with the National Performance Framework and its outcomes, including working to achieve the ambition that people employed by and associated with NHSH:
- grow up loved, safe and respected so that they realise their full potential
- live in communities that are inclusive, empowered, resilient and safe
- are creative and their vibrant and diverse cultures are expressed and enjoyed widely
- are healthy and active
- respect, protect and fulfil human rights and live free from discrimination
- are open, connected and make a positive contribution.
These will serve as useful benchmarks going forward.
The Chief Executive
33.25. Separately, as I have mentioned elsewhere, 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 alive to the human effect of the inevitable tensions and constraints which funding limitations and other challenges bring. Going out and about and meeting people throughout the organisation at their places of work will make a huge difference. He will wish to be seen and recognised at all levels in the organisation (as will other senior managers).
33.26. He will need above all to build, and encourage the building of, relationships. A willingness to communicate openly and with clarity and frankness will be essential too. Ensuring the effectiveness of people-related systems and excellent communication across the organisation will be the key to ongoing healing.
33.27. This will also entail a thoughtful and open approach by the Scottish Government. The constructive interaction of Government with health boards and senior management is an inherent part of the system. Person-centred leadership ultimately comes from the very top. The availability of resources to encourage leadership development seems essential at this time.
33.28. The chief executive needs to be further supported as a leader. 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. It is likely that the chief executive will benefit from high-level coaching and mentoring in this very important role.
Acknowledgement of NHSH Staff
33.29. While the chair of the Board issued a form of apology in late 2018 and the interim chief executive did much good work in his short stint by issuing supportive messages to staff, 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. (I use the words acknowledgement, acceptance, recognition and reassurance deliberately, as each is a component in communicating how seriously matters are now being taken, along with the necessary engagement with staff and explanation to them of how things will be dealt with differently going forward.)
33.30. 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.
33.31. "If only they would say thank you", one staff member said to me. Although there will be much focus on financial matters in the months ahead, I have suggested that making people the priority will ultimately produce the best outcomes. As an indication of this, generally, people need to be, and feel, thanked for doing a difficult job in difficult circumstances. And to be, and to feel, listened to when they have a concern or a problem. Ultimately, we all need to feel valued – and in a way which is genuine and authentic. Achieving this is one of the challenges facing leaders in NHSH.
33.32. This would be a good moment to reinforce these messages in NHSH and to celebrate all the good work which is being done. Simple, clear, consistent and regular messages to all staff should become the norm. I recall one very successful chief executive who would send an encouraging blog once per week to the staff. He was able to convey supportive messages to a widely dispersed workforce. They felt they knew him and that he cared. He did. He also invited suggestions for improvement from all members of staff. In NHSH little things might make a big difference: such as an online "suggestion box"? Or a monthly open forum/drop-in session with the Medical Director?
33.33. Similarly, well thought through and transparent provision of information to the wider community, recognising the difficulties faced by NHSH, should over time help to rebuild confidence. It is unlikely that this is a quick fix, more a longer-term strategy of openness and authenticity.
33.34. It is for consideration from whom these messages should come. However, it seems important that they come from the new chair and/or chief executive, unconnected with perceptions of inadequate responses in the past to allegations of bullying.
33.35. The need for civility and respect at all levels is one of the keys to moving forward. One consultant put it this way:
"...irrespective of any inquiry we should all, immediately, be trying to reflect on how we behave with colleagues and staff generally to ensure we are all truly more sensitive and responsive to the needs of others and cognisant of the risks of not being so."
33.36. 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 (see Appendix 4). The senior management team and the Board could lead the way.
33.37. I refer back to the chapter on Governance where a number of proposals are made.
33.38. 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.
33.39. Review of board appointments, together with training and support for, and provision of appropriate information to, all non-executive directors is necessary, probably at Scottish Government as well as NHSH levels.
33.40. Scottish Government may wish to review governance generally to ensure that candidates with the necessary skills, knowledge, expertise and experience are appointed to NHSH and other NHS boards – and that the size of boards is commensurate with working effectively. Consideration of the appropriate mix of lay, patient and medical members will probably be useful. There is a need for deep understanding of what is necessary in the appointment and support of a non-executive director at all levels of government and the NHS.
33.41. Learning should be sought from other NHS and public sector boards in the short term. Recent independent recommendations to the Board, including by Audit Scotland and John Brown, have provided a starting point and need to be taken forward.
33.42. Specific external support should be offered to current non-executive directors who should be encouraged to continue to reflect on their position and role in handling matters going forward. I refer to the non-executive directors' own recent consideration of matters including how they may appropriately engage and encourage feedback and flow of information.
33.43. In addition to matters already reflected in this report, I endorse their suggestions of (a) an independent person for the non-executive directors to go to if they have concerns that actions are not being addressed after raising these with the chair or chief executive, perhaps following the Senior Independent Director model from England and (b) regular assurance to the Board that there is a robust and working process available for anyone who wishes to raise concerns around bullying and safety.
33.44. Recognition should be given to the amount of time needed and devoted by non-executives generally. If possible, before new board appointments are made, consideration should be given to the specific areas of knowledge and skill which the present Board needs to oversee a budget of some £800 million.
33.45. A forward-looking strategic plan and a shared vision, linked to and taking account of the need for an effective people-centred approach and clinical and staff relationships in light of this review, is imperative.
33.46. Determining the strategic direction of NHSH, including clinical strategy, will be important to bring clarity to decision making, implementation, monitoring and enabling NHSH employees to understand why change needs to happen, what the purpose of the change is and how they can contribute to it. Full engagement of clinical staff seems paramount to the realisation of an effectively delivered clinical strategy.
33.47. Finally, the Board should take primary responsibility for ensuring that the issues raised in this report are implemented and progress maintained in the future and by showing the same constructive, respectful and compassionate approach which they should expect others to follow. They should keep these matters under review on a regular basis.
Clinical Engagement in the Contemporary NHS
33.48. Reassessment of the relationship between clinicians and management seems to be an essential part of building a collaborative and mutually respectful and supportive culture. Apparently, evidence from around the world shows that improved clinical outcomes follow greater clinician involvement in management. Thus, there should be reflection on the manner and benefits of clinical involvement in leadership. This may entail changes of attitude and behaviour for some as they move towards a more collaborative approach.
33.49. 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. It has been suggested that adequate investment in administrative support and communication could enable clinical staff to feel a greater sense of ownership of decisions made by their organisation.
33.50. It has also been suggested that the apparently excellently conceived "Clinical Compact – The Highland Pledge", subtitled "or how we will work better together" describing the relationship and obligations of clinicians to the organisation should be reviewed with a view to actual implementation. This is likely to raise issues of training. For example, clinicians may need training in negotiation and collaboration skills. It has been suggested that there may be scope for a Scottish NHS College.
33.51. A system for addressing urgently concerns/complaints or differences of professional view will be valuable. The use of facilitation and mediation should be considered. The role played by an Associate Medical Director in this context could be critical.
33.52. Similarly, the relationship of GP practices to NHSH needs review and a commitment to mutual understanding and respect. Honesty and clarity about priorities and resources is key, built on the foundation of much stronger relationships.
33.53. The role of trade unions and staffside representation, including the partnership agreement, merits review in order to ensure really effective representation of employees' interests. The unions will wish to re-orientate their approach to NHSH to help assist in creating a supportive culture in which they can objectively identify and promote their members' interests.
33.54. While a non-adversarial approach, and constructively articulating members' interests, seems the only way to help members in the longer term, that will only work in a more rigorous and transparent overall environment. It seems essential that everyone works together to achieve that goal.
Argyll and Bute
33.55. By reason of its geographic and possibly other specific circumstances, as noted earlier, 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.
33.56. 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.