35. Specific Proposals: Training, Management and HR
Training in Better Conversations and Appropriate Behaviour
35.1. 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. This would help people throughout NHSH, from the grass roots up, to be more self-aware and to take responsibility themselves with confidence to manage differences, difficult situations and conversations with and for each other, in real time.
35.2. Such a programme, which could be multi- and inter-disciplinary, needs to be highly practical and interactive and not theoretical, properly structured and with regular review and reflection. An understanding of the aspects of human nature described in chapter 8 and of the cultural issues in NHS Highland referred to in chapter 16 above seems important in the design. Focus should be on the underlying causes of behaviour rather than merely on the symptoms and on finding proportionate responses.
35.3. In particular, all NHSH staff should be educated about the effects of bullying, on themselves and others, how to handle that and how to avoid entering the condition of "learned helplessness". I suggest that having (or making clear the ready availability of) an informative NHS website on bullying is a useful first step but not a substitute for personal, practical training.
35.4. This could be a prototype more generally for public sector organisations in Scotland at a time when such allegations seem likely to increase. It would fit within the aspirations of the National Performance Framework. Paradoxically, it would probably lead to substantial financial savings owing to improved staff recruitment, morale and retention, in addition to improved quality and safety of care.
35.5. I recognise the resource implications, both financial and personnel. However, this is a major project, akin to building or funding a new capital resource. I suggest that such a perspective is brought to the costs of this initiative, again applying the principles of preventative spend.
35.6. I am struck by this formulation: "The person you work for (your boss) is 90% of the employee experience". 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. This would cover people-handling, managing diversity and difference, handling and receiving complaints, effective communication and teamwork, giving feedback on performance, negotiation skills and multi-professional leadership development, especially for clinical leads and service managers.
35.7. Having the skills and resources to resolve difficult and sensitive situations without resorting to formal processes and being able to separate people from the problem, as well as the self-awareness and resources to accept concerns raised about one's own practice, will be invaluable.
35.8. Viewing and training managers as "facilitators" of other staff would enable a different culture to be developed. Moving from performance targets to continuous learning with psychological safety seems important. A review of the recruitment and promotion process, to ensure that it is robust and objective, would complement these proposals.
35.9. This would sit within a framework of greater clarity about the roles and responsibilities of managers and identification of the support they require to equip them to be effective, with a view to minimising any situations where poor management is perceived as bullying, and/or concerns are not addressed promptly at a local and informal level.
35.10. Mentoring and honest sharing of best practice and operating values across the organisation at all levels (and across Scotland?), with tolerance to discuss when things don't work and a willingness to learn from that, will be very valuable, along with freedom and safety to discuss what is acceptable and what is not acceptable behaviour.
Meetings and Relationships
35.11. Teamwork is so important in the NHS. Encouraging daily contact between managers and frontline staff seems important. Consideration and understanding of the particular cultural issues relating to NHSH, referred to in this report, should form a part of this. Current best practices in NHSH should be identified and replicated wherever possible. The ability to have conversations which feel more adult to adult is crucial to the future.
35.12. For example, the introduction and/or enhancement of well-facilitated team meetings on a regular basis, possibly across boundaries, 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.
35.13. Making sure that staff have adequate facilities and the opportunity to rest, reflect, meet and talk to colleagues away from immediate work pressures and patient-facing environments, will also create a more positive culture. Facilitated conversations over a cup of coffee can be very valuable. I understand that there is a policy of taking time to go for walks; this needs to be encouraged as acceptable and beneficial. In this context, I note the work of the Institute for Health Care Improvement on What Matters to You Conversations and Joy in Work.
35.14. It has also been suggested that there needs to be greater encouragement of social interaction with more of a feeling of a community spirit within Raigmore Hospital and elsewhere in NHSH, with regular and organised local social functions focussed on the community of NHSH.
35.15. Connected to this, it is suggested that there is value in small groups to build relationships, for support, intimacy and openness, and to build a sense of connection and belonging. It is hard to underestimate the value of well-hosted activities like these to help build supportive relationships where people feel secure and comfortable. There is a suggestion of appointing a trained "compassion champion" in each department to whom people could turn for support.
35.16. Related to all of this, as discussed earlier in this report, more generally a new approach to handling internal issues should be adopted, to nip potential issues in the bud wherever possible. I refer to the chapter on mediation and other facilitated approaches.
Social Media Standards
35.17. It has been suggested that staff at all levels should sign up to NHS Highland or NHS Scotland standards of behaviour, including specific guidance on use of social media, which would be co-produced, with an expectation that everybody, including bystanders, could challenge whenever these standards are being breached, regardless of status or grade, and without fear of recrimination. I note the Commitment to Respectful Dialogue referred to earlier as a possible useful starting point.
35.18. Excellent communication is essential at all levels in the organisation and becomes ever more important with increased organisational size and complexity. The age of electronic communication has resulted in a large increase in the volume of communications sent within and between organisations and has encouraged dissemination of information "to all", often regardless of direct relevance. Ironically, the increased volume of information disseminated probably results in an inverse response to or digestion of the information.
35.19. A streamlined and realistic communication strategy should aim to direct material more effectively towards the necessary recipients and be graded in terms of the response required; other material can be posted on websites for interested parties to review.
35.20. More specifically targeted information will increase the actual impact of important messages and help to produce an informed workforce. Furthermore, by making this process more efficient, time will be saved which can be used for more necessary tasks. An effective communication strategy should ideally be led from the top levels of NHSH and be consistent throughout.
Other HR Related Matters
35.21. 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. As noted above, resources may need to be deployed from other regions to assist in the short term but proper resourcing in NHSH itself seems essential, including the appointment of a full-time HR Director.
35.22. 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.
35.23. Work begun by HR in this regard needs to be supported and resourced. I refer back to the proposals from HR in an earlier chapter (and included in full in Appendix 3) and to my own observations in that chapter.
35.24. I note that policies and procedures already exist which purport to deliver many of the goals to which everyone aspires. Again, the apparent gulf between what is written down and what actually happens in practice needs to be addressed. It would be good to make this exercise a collaborative one in which employees and unions feel part of the process. Above all, processes must be experienced as being fair in practice, whatever the outcomes.
35.25. I am also told that the national PIN policy needs revision or perhaps to be better understood and implemented. Consideration needs to be given to the operation of the Datix system and the iMatters recording function so that they can be used safely and with confidence. Training in these matters should be clear and consistent.
35.26. The use of suspension should be reviewed and utilised only in exceptional and clear circumstances and for as short a period as possible.
35.27. In any event, as a last resort, grievance and other formal procedures, when used, must be redesigned to be speedy, transparent and fair to all. Inconsistencies in treatment between staff and lengthy delays must be avoided wherever possible.
35.28. Where two people (or more) separately raise issues which are related, the links need to be made and appropriate steps taken. When there is a pattern of high staff turnover, sickness or frequent themes identified, this should be identified and the chief executive informed.
35.29. I commend the recommendations in the Francis Report on "Good Practice – Promoting a no bullying culture".
Mental Health Issues
35.30. In suggesting that all NHS staff should be educated about the effects of bullying, reference has been made to the trauma model, the Adverse Childhood Experiences study and how people can address unprocessed trauma leading to consequences for the alleged victim and to themselves.
35.31. Generally, awareness of the potentially adverse impact of a return to the workplace in which bullying or other inappropriate behaviour has allegedly occurred should result in outcomes in which people feel protected from anyone who has allegedly bullied or harassed them.
35.32. Consideration should be given to a requirement that the Occupational Health department should ensure that those who appear traumatised are accurately assessed by a properly trained therapist or clinical trauma specialist or consultant within a short period and offered treatment. That assessment must be part of any investigation process. There needs to be a funded fast-track service, given the long wait times for routine psychiatry and psychology services. Mental health supervision is essential.
35.33. It has been suggested that a peer supporter ("compassion champion", mentioned earlier) or "mental health first aider" could be appointed at every layer of the organisation, educated to look for signs of stress and in the trauma model, able to raise concerns and to activate a process to help someone who is experiencing difficulties. There should be a link with the health and wellbeing committee. A staff member trained to a high degree in trauma should be a member of the health and wellbeing committee.
35.34. On the matter of confidentiality, mental health records should be completely segregated from main occupational health records and removed from the E-epos programme. Staff with relatives working in the department should declare any conflict.
35.35. Generally, the adequacy of counselling and other psychological support should be reviewed.
35.36. I am told that BMA Scotland (and the wider BMA) has recently started work to address bullying and harassment issues, and the wider workplace culture in the NHS. Many organisations with an interest in the NHS have also been addressing these issues. For example, I understand that the academies, royal colleges, GMC, and other boards in NHS Scotland itself are all looking at this subject, but possibly independently and in their own ways.
35.37. Efforts to create a more joined-up, cohesive approach to address these issues would seem useful. An honest conversation among all the stake-holders, reflecting on causes as well as symptoms, is likely to reap dividends for NHSH and other NHS boards.