“The key to doing well lies not in overcoming others, but in eliciting their co-operation.”
(Robert Axelrod)
“…whatever change we seek to undertake, we are only as good as the relationships we are capable of creating and sustaining.”
(respondent in NHS Highland)
“We are confronting a …foundational moment: one that demands decisive cures, rather than palliatives. These times require… boldness, innovation, and above all… long-awaited action.”
(OECD)
I welcome this initiative by Reform Scotland. It seems particularly important that this discussion is hosted by an independent and credible body, to enable full and frank conversations to be had, received wisdom to be challenged where appropriate and all issues explored without fear or favour. As Paul Gray has suggested, the process (how things are approached) may be just as important as, and will influence, what outcomes are reached.
In offering these comments, I draw on my experience of conducting a review for Scottish Government into allegations of bullying in NHS Highland and my report published in 2019, in which I comment on various matters, including culture and leadership. I also draw on a number of other professional engagements with the NHS in recent years as a mediator and facilitator.
This initiative will require assumptions and preconceptions about how the NHS works to be set aside (together with acknowledgment – and understanding – of the inevitable cognitive biases we all have) and genuine openness to new ways of looking at things. Strategically, this will entail moving away from binary thinking to a deep exploration of the underlying issues (a proper diagnosis), before identifying options for the way ahead (possible remedies) and then arriving at sensible provisional conclusions and a course of action (the prescription for healing).
I suggest that identifying a clear common purpose to which everyone associated with the NHS in 2048 could subscribe would be a useful initial exercise.
This leads into the important topic of leadership. The NHS model of leadership (with echoes in its structure and nomenclature of a military-style command and control, power-based approach) may appear top-down and hierarchical. The NHS is too big and complex to be micro-managed from the top. In my NHS Highland report and elsewhere, I have commented on the danger that fear is a driver: fear of failure, of being criticised, blamed or shamed, of not achieving targets or not meeting expectations, of being made a scapegoat.
This can lead to deferential, defensive and protective behaviour, group think, unwillingness to raise issues of concern, concealment, wilful blindness/bystanding, low morale, increased staff turnover, unhealthy relationships and indeed stress, ill health and individual and collective trauma. In turn, these can also lead to accusations of bullying, where often those perceived as “bullies” also feel “bullied”. This may apply even to the Cabinet Secretary from time to time and in any event can rebound throughout the system. Fear stifles performance, creativity, openness and imagination. Fear kills, ultimately, whether it’s a person, an organisation or a community.
The economists John Kay and Paul Collier capture some of these concerns well in their book Greed is Dead, stating that activities in the public sector world, like health and care, are high in intrinsic motivation but are hard to monitor, so workers are turned into automata, to be monitored and incentivised, rather than trusted for their judgement. Further, as the conflict resolution specialist, Ken Cloke, puts it: “…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.”
I suggest that, from Cabinet Secretary through to ward level, a more enabling, empowering, compassionate, shared and supportive leadership culture would enhance relationships, which are central, and performance, which is critical. A people-centred, rather than a transactional, approach, where everyone feels valued and appreciated, based on mutual trust at all levels, would make a huge difference. Encouragement of a culture of cooperation to achieve optimal outcomes and recognition of shared interests and common objectives, rather than competition for scarce resources, seems key. “Working with” rather than “working against”.
The author Ken Cloke again: “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.”
As an NHS Highland Public Health report put it: “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.”
There are already good examples of such a culture in the NHS in Scotland and identifying and sharing good and best practices across boards and throughout the country is surely an important aspiration. We can perhaps then view the NHS as a vast web of cooperative activity, sustained by mutual kindnesses and reciprocal obligations.
Training and education seem fundamental to all of this. Huge resources are allocated to physical and technical infrastructure. Many of the difficulties in the NHS could be addressed by the allocation of sufficient resources (including time) to developing the skills and competencies associated with building and sustaining constructive and respectful relationships at all levels, dealing with difficult situations, resolving tough dilemmas, making hard choices, and effectively handling ambivalence and uncertainty. These core attributes cannot be taken for granted and can be learned.
This applies at all levels: to senior executives, board members, Scottish Government officials and managers throughout the service. It is key to effective strategic governance and to delivery in the ward. Timely and robust challenge, holding people to account, and speaking up about concerns, is easier and more likely to be effective if individuals have the skills to communicate, listen well, explore issues openly and objectively and be respectful of others throughout.
I would suggest that increased and system-wide use of mediation and facilitation skills would also be beneficial to ensure early intervention in difficult matters and the avoidance of unnecessary escalation, nipping tensions and possible conflict in the bud and offering safe spaces for dialogue. Prevention rather than cure. Focus on learning rather than blame. As ACAS puts it: “What is beyond doubt is that conflict, and its effective management, is a critical issue for organisations in maximising productivity and efficiency. More fundamentally it underlines the link between employee wellbeing and organisational effectiveness.”
Finally, change will be greatly assisted by de-politicising discussion of the health sector and finding cross-party and cross-organisational willingness to work towards solutions which benefit everyone. Much of this is about changing habits, both personal and institutional. We need to reset the neural pathways, both individually and in organisations. This takes time and commitment. Authenticity, humility and courage are vital components. It may also be about letting go of the past, of things that may have defined us and given us a sense of identity. But there seems no other way.
John Sturrock KC is Founder and Senior Mediator at Core Solutions
If you would like to contribute to Reform Scotland’s NHS 2048 forum, please email [email protected]