According to The guardian “The Keogh review [published yesterday, 16 July] into high death rates at 14 NHS trusts has not found a disaster on the scale of Mid Staffs, but rather the more banal spectacle of mediocre hospitals, struggling to meet one improvement target after another with little help”.

It reported Sir Bruce Keogh, NHS medical director, saying of the mortality measures, “It is clinically meaningless and academically reckless to use such statistical measures to quantify actual numbers of avoidable deaths”, after there was much political and media hyping of the report. For example, The telegraph flamboyantly claimed, “13,000 died needlessly at 14 worst NHS trusts”.

Today, on BBC Radio4 Today, Evan Davis interviewed Lisa Rodrigues, chief executive of the Sussex Partnership NHS Foundation Trust, following this up.

He asked her “You would really need to have a pretty thorough diagnosis of what is going wrong in an organisation before you know what special measures are necessary. If it’s the leadership that’s wrong, the best thing is not to have special measures—it’s to kick out the leadership, and put new leadership in presumably. If it is the entire staff that have been misaligned to what they should be doing, obviously it would be slightly different.”

I appreciate Davis was playing devil’s advocate, but he was expressing an approach which is prevalent. But it’s unhelpful to think of the problem in this way. Given its apparently common nature, it seems likely that those in charge of these fourteen trusts were, entirely inadvertently, selected for character traits which predisposed them to create working environments in which the behaviours needed to create the outcomes described in the report were more likely to happen.

This might then be overlaid with a system of, shall we say, involvement by politicians (some would call it interference).

It would therefore seem to be a systemic and cultural issue, not one of individual competence. It seems likely that getting rid of one set of “leaders” and replacing them with another will result in the same thing happening again if the same recruitment processes and measures are used. This might suit politicians, of both parties, just fine—but it isn’t much help to the patients. If different recruitment measures are to be used, this itself becomes a systemic and cultural requirement and, if you can’t recruit the bosses well, it’s unlikely you’ll be able to recruit better recruiters well either.

Rather than sacking these people, wouldn’t it be more constructive to build on the experiences they have had? As Einstein did not say, insanity is repeating the same mistakes and expecting different results.

People’s behaviour is driven by their emotions and feelings, and by their thoughts and beliefs. These in turn are driven by the experiences they have had. I would imagine that those responsible for the fourteen trusts (as well as others who must be breathing a sigh of relief) are in their emotions big time right now, and they have had ample help in formulating new beliefs from all sorts of third party. They are perfectly placed to devise new behaviours. Now is the time, with these people, to inculcate a culture of leadership which can actually become the paradigm for leadership in the NHS countrywide.

As a senior manager in the then NHS SW said to me a few years ago, “what we need is a new way of being”. An attitude of leadership which achieves a high level of good enough, compassionate care is what she meant. This will only happen when the NHS and its governmental and political masters understand that leadership is not a behaviour, it is an attitude. Yes, you can talk about the things managers who are leaders do that managers who aren’t leaders don’t do. But it is not the things that people do that make them leaders, it is their being leaders that determine what they do. If it’s good enough for the Royal Military Academy at Sandhurst—whose motto is “Serve to lead” —then it’s good enough for the NHS and for government.

Transcending the political fight

And this brings us to Ms Rodrigues’s eloquent reply to a further question about the quality and tone of the political debate yesterday:  “I can’t have any political views, but I did go on record and say to the secretary of state at the NHS Confederation conference; I asked him a question, ‘Could you please work with Her Majesty’s opposition and people in the coalition and make the NHS something that you work on together rather than something that you argue about…’ … It’s far, far too important for party politics.”

How true. Clearly, both political parties have much to gain from undermining the NHS (and largely the same things to gain, at that). What the NHS management cannot afford to do is create situations which give ammunition to the political parties. In a sense they are colluding in the fight (and it’s a fight between politicians and the NHS, not between Labour and the coalition, whatever the superficial appearance). What is needed is a core of senior managers who get that their purpose is to create a facilitating environment in which each individual member of staff, each team within their trust, and the trust itself can thrive. Managers who, with the appropriate resources and support, but also the right attitude, can then bring that about.

I’ve already argued that, in acute units, board members need to do ‘ward rounds’—extensively. The need to show their face on the wards and in the offices, repeatedly and regularly. It is actually worse to claim you care about people but imply, by your actions, that you don’t, than it is simply not to give a damn. At least people know where they are then. The dissonance between what you say you think/feel/do and how you communicate it is itself demotivating. And lack of motivation leads to poor care, sooner or later.

Since creating a facilitating environment is the main characteristic of a leader, the important question is, to what extent do politicians create a facilitating environment in which the NHS can thrive? After all, they like to be thought of leaders and it’s a fact that they have awful lot of control over the NHS.

I struggle to find even a shred of evidence that politicians do this, or even understand the concept.

Yet it is a truism that any team, however big, emulates what’s going on for the people in charge. That’s precisely my argument in advocating that board members of acute units display a caring, compassionate example to everyone else. Because the converse also applies. If staff in a hospital are judged to be uncaring, it is pretty likely that those in charge are displaying this approach. This isn’t mysterious. People do what the boss tells them to do. The bosses may not be saying, be uncaring. But, if they behave in that way, all day, every day (or worse, come on as hot and cold, caring one minute, not so the next) everyone else will follow suit.

You can predict what the bosses are like by observing the team. Politicians might therefore find it instructive to address the question, to the extent that the NHS is behaving in unwanted, dysfunctional ways, how are we behaving in unwanted, dysfunctional ways?

Since this behaviour and approach patently aren’t bringing about the NHS people need, how sensible is it to carrying on being that way? I agree that it’s too important for party politics, but it’s actually about having a fundamentally, radically different attitude—one that has to come from the top.

Related material:
>  Blog:  Compassionate care
>  Blog:  Friends and family test:  could do better
>  Blog:  NHS reform:  missing something fundamental