The People Manager
The snowy white peaks that range across the NHS has been the subject of recent articles in the HSJ. Those urging the NHS to have a more diverse group of leaders do so on the assumption that having more black managers in senior posts would make a difference. I am not convinced.
‘Look no further than the president of the US, often referred to as the most powerful man in the world yet unable to make even modest changes in his country’s health care service’
In the US they have achieved this goal. Both in corporate America and in the public sector, black people are represented in key senior posts. Many major cites in the states have a black mayor, a black chief of police and prominent black politicians. However, whether it is housing, education or health, inequality persists. Life expectancy is lower and unemployment higher among the black and ethnic minority communities.
To those who claim appointing a small number of black people to leadership posts would send out a positive message to ethnic minority staff within NHS trusts and the communities they serve, I say not if their experience of the service is colour blind, not if they still find it harder to get promotion than their colleagues, not if the service continues to fail to recognise cultural and religious differences, and not if people continue to feel that managers, doctors or nurses are judgmental about their lifestyle.
It’s not just about race. A few high profile black leaders will not change the culture within NHS trusts.
If you remain unconvinced then you need look no further than the president of the US, often referred to as the most powerful man in the world yet unable to make even modest changes in his country’s health care service to benefit the disproportionate numbers of black people on low incomes who endure poorer health and shorter life expectancy. His efforts are undermined by the prevailing culture, just as those of a black chief executive of an NHS trust would be.
By all means let’s make every effort to have a fair recruitment process and take steps to ensure boards reflect the diversity of the communities they serve but the goal is not to have more black people in senior posts, it is to have an NHS that is capable of providing a service to the whole community and has the confidence of all sections of the community.
In business there are no ideal partners.
When it came to drugs, Walter White, the lead character in Breaking Bad, had the technical skills and knowledge. He was the “chemist” but he knew nothing of the street, his customers, distribution methods or dealing with the competition. He did know he had a quality product. He needed someone with experience of the commercial side of the business and the contacts to go with it which is why he stuck with an unreliable, disorganised and occasionally panicky partner: his former chemistry pupil Jesse.
‘When one partner is more cautious and the risks are not shared evenly − then you get into trouble’
They started off small trading on the outstanding quality of the product. However, they soon realised they had to deal with some volatile, unsavory and untrustworthy big players who had no qualms about exploiting and intimidating them. They tried going it alone but their inexperience made them vulnerable to being taken advantage of by the big boys; their only option was to do a deal with a really big operator with a national network.
Whiter the white?
Two problems: their new partner demanded a bigger share of the profits and in an unequal relationship their new partner insisted on full disclosure, whereas they knew nothing about their new partners’ other business interests.
‘Partnerships are tricky and across the public and private sector divide that is doubly so’
Walt’s motives were honourable: he didn’t want to force his family into debt to pay his medical bills as he died of cancer, especially as he knew that even successful treatment would only buy him a few more months. He was well motivated and quickly realised if he wanted to provide a secure financial future for his family in the time he had left he needed to expand the business. His original partner’s motives were simply to make some money and his ambitions were more modest: a flat-screen TV, a newer car. Expansion certainly meant more profit but also more risk. And in this business we are talking life and death.
When one partner is more motivated, more ambitious; when one partner is more cautious and the risks are not shared evenly; when being disorganised and unreliable goes from an irritating trait to a serious threat to the business − then you get trouble.
Partnerships are tricky and across the public and private sector divide that is doubly so.
Politicians and certain sections of the media would have us believe the world is divided into strivers and the skivers. In my experience both exist in the world of work but they are in the minority.
‘An effective manager needs to invest in getting the best out of the majority’
In any organisation about 10 per cent of staff are very ambitious, self-motivated and talented and 10 per cent are incompetent, over-promoted and not delivering. The majority are just doing enough, no more no less.
They see no reason why they should volunteer for unpaid overtime. They have a lunch break and go home on time. They think “going the extra mile” is just another example of managers expecting more than they are prepared to pay for. They are not driven by ambition but by the need to pay the mortgage and the desire for two weeks in the sun. They are not trying to impress the boss by getting into work early or taking work home and they are not after extra responsibility − they don’t need the aggravation.
Yet this is 80 per cent of the workforce. As a manager you don’t need to do much managing of the high flyers − just keep giving them more work and new challenges and accept that they will soon be off to bigger and better things. The incompetent and difficult already take up too much of your management time. An effective manager needs to invest in getting the best out of the majority.
So what tools do you have to do so? The annual appraisal doesn’t offer much for this group. The high flyers get the recognition they crave for by exceeding expectations and the underperformers have it confirmed and documented as they move a step closer to the exit.
You have in your gift training opportunities which the high flyers are keen to access but hardly need, whereas those who are in greatest need of training find any excuse to avoid it, leaving little opportunity for the rest.
The keen ones get the extra work and interesting projects they desire and the useless ones can’t be trusted with anything but the most straightforward tasks, leaving the biggest burden on the majority. There is the option of team building, but the trouble is that high flyers are not team players and neither are the skivers.
Therefore, your best bet is one-to-one supervision. In this case, supervision means more than support and guidance. It starts with positive feedback as this is where individuals start to feel valued, get inspired and see their contribution to the future. Most people give of their best when they are happy at work – and what makes people happy is getting on with their teammates and feeling appreciated by their boss.
The Monty Python reunion is an excuse to retell the one about the lumberjack who sang about his fondness for cutting down trees and putting on women’s clothes. To remember how we laughed at the ridicules attempts of a pet shop owner to sell a dead parrot to an increasingly incredulous customer.
‘John Cleese as the customer − or patient − would represent the increasingly incredulous public’
It was funny because we couldn’t believe anyone would be so persistent and so adamant in their attempts to con the public. Is it so funny now we know that the police have been routinely fiddling the crime figures, hospitals have been caught manipulating waiting list statistics and ambulance trusts have been guilty of falsifying response times?
In other words, leaders have been trying to convince us crime was falling, waiting lists reducing and ambulances arriving on time when it’s simply not true.
‘I wish to register a complaint’
Since success is measured by performance public sector leaders have focused on improving the figures rather than improving the services and when the figures have not told the right story they have simply been changed. The appearance of continuos improvement is maintained and careers advanced until someone points out that the parrot is in fact dead.
The whole NHS transformation programme could be seen as the Monty Python team doing a reworking of the dead parrot sketch. John Cleese as the customer − or patient − would represent the increasingly incredulous public as the pet shop owner or private sector tried to convince him that the exotic import was going to breathe new life into the NHS and far from being dead it was simply asleep. While doctors and nurses yearn for a brighter life as a lumberjack.
Polly Toynbee asked the question why so few people speak out in The Guardian, as the departing head of NHS England, Sir David Nicholson, says the emphasis on competition has bogged down the NHS in competition law that is making millions for lawyers, while preventing cooperation, creating bureaucracy and stifling initiatives.
‘The view at the time was “better to be at the table influencing decisions than outside shouting objections through the window”’
It was a similar situation a few years ago when the previous government split social services into adult and children services, which effectively put child protection under the direction of education. They didn’t want this poisoned chalice. And the directors of social services did not ask for their departments to be divided and their roles downgraded.
The Association of Directors of Social Service, up until this point considered a strong and effective voice for social work, was in public very quiet. Yet privately directors saw it as an attack on the profession and an attempt to weaken a critic of many government policies.
As predicted, it has not proved a success and many local authorities have gone back to a combined service under one director.
Why the silence?
When I asked the chair of the new Association of Directors of Adult Social Services why so few of his predecessors spoke out, he said the view at the time was “better to be at the table influencing decisions than outside shouting objections through the window”.
Not only did this turn out to be a tactical error but senior people in the NHS appear to be repeating it, as he admitted to me once at a table where he found himself surrounded by government advisors and representatives of the private and voluntary sector, who effectively drowned out his voice.
So what does this tell us about leadership in the public sector? Clearly, to influence a government you must have access as well as trust and credibility; but one thing above all else that sets leaders apart is the courage to stand up for what you believe in – even if it won’t make you popular, do your career any good or get you in the New Year Honours list.
Almost as shocking as the allegation that the chair of the Co-operative Bank buys cocaine was his performance in front of the select committee that revealed he didn’t know much about his bank, or indeed, banking. Or was it?
‘The chief executive and directors ran the show, the non-exec directors were for show and the chair’s job was to keep the show on the road’
There has always been a tradition in both the business sector and the voluntary sector of appointing people for their standing in the community rather than their expertise.
The government has itself been introducing people with commercial backgrounds and business experience into NHS boards to “strengthen” them, while the chief executive and directors provide the professional expertise.
Chairs who don’t interfere
A large housing association I worked for was a typical example. The chief executive approached people of good standing to be on the board, the full board met twice a year to approve the budget and that was it. The chief executive and the chair were careful to recruit board members who would take an interest – but who would not interfere.
In other words, the chief executive and directors ran the show, the non-exec directors were for show and the chair’s job was to keep the show on the road (and non-exec members in line).
‘Board members are responsible not just for the budget but also for quality of care’
The chair got the status and the chief executive had the power in this set-up. It appears this model is still in existence in the City.
Whether it’s a housing association or NHS trust, reductions in government funding mean organisations have to look to review their activities. Boards are required to be dynamic, more prepared to take risks and find new ways to fund developments.
Board members are responsible not just for the budget but also for quality of care. They need the experience, skills and confidence to challenge executive decisions. But does strengthening the board inevitably weaken the position of the chief executive and senior management team?
Once you have a board that is up for a challenge, you may find that they don’t think the chief executive and senior managers are.
What the NHS needs is not more nurses but more prison sentences. This is heath secretary Jermey Hunt’s view and the reason for a new law under which doctors, nurses and NHS managers face up to five years in jail if found guilt of neglecting or mistreating patients.
This is a recommendation from Don Berwick’s review of patient safety − in which he also called for an end to the blame game towards medical staff. Since physical abuse, neglect and mental cruelty of an individual in your care is already a crime for which care staff have gone to prison, why is it necessary to have a new offence specifically for those working in the NHS?
I predict it won’t be senior managers or doctors who find themselves at risk of a prison sentence but the lowly, overworked, underpaid nursing auxiliary. Is this the moment when Hunt jumps the shark? A desperate gimmick to try and revive what has been a disastrous attempt to transform the NHS.
Here’s a question: how many NHS senior managers have been made redundant following a reorganisation only to be appointed to a senior management post in another part of the NHS? The National Audit Office found it was one in five.
About 2,200 senior managers were reported to have been re-employed soon after had being made redundant with large pay-offs. And the cost to the NHS is estimated to be £430m.
‘It has been suggested senior managers taking redundancy packages over £100,000 should be banned from applying for a post in the NHS for 12 months’
Many of these pay-outs involved a one-off payment of over £100,000. Good luck to them, I say. It’s very unpleasant being made redundant, worrying about how you will pay the mortgage and whether in the current climate you will find another job.
Here’s another question − in light of the fact this is not the first major reorganisation of the NHS in the last 10 years − how many senior managers have had multiple redundancies and received a big payout every time, before being re-employed? Now, that’s not a sensible or financially justifiable use of an NHS budget that is under severe pressure.
Putting the ‘N’ back into NHS
The big issue is not the size of payout; the issue is that given the “N” in NHS stands for “national”, why are senior managers not offered redeployment elsewhere in the NHS? If they turn down a reasonable offer of a comparable post then they would not be entitled to redundancy.
No doubt some people would say uprooting family, changing schools and selling a house to move to the other end of the country is unreasonable but these are senior managers − this is exactly what they do in pursuit of promotion and the route most of them followed to become a senior manager.
It has been suggested that senior managers taking redundancy packages of over £100,000 should be banned from applying for a post in the NHS for 12 months. This would seem an unfair restriction but it does raise the question that if we need so many managers, why did we let them go?
Of course, the real answer is to stop costly reorganisations and spend the money on employing doctors, nurses and carers − not paying staff to leave.
Should we have a law to punish those who fail to report the abuse of children? The former director of public prosecutions thinks so.
‘If the proposed new law had been in place at the time Mid Staffordshire hospital was failing, would all the ward staff either be guilty of abuse or of failure to report abuse?’
If health workers, teachers and nursery staff were to be prosecuted for failing to report abuse of children then presumably nurses, home helps and care staff would be prosecuted for not reporting abuses of older people.
Yet there is already detailed guidance to professionals on the need to immediately report any concerns to social services. So what additional safeguards would be provided by the threat of a witch hunt after the event?
The current concerns are a reaction to the scandal of the establishment cover-up around the Jimmy Savile case and the admissions of the Catholic church hierarchy.
The government has said organisations should support and protect whistleblowers because this is how cover-ups are exposed.
If the proposed new law had been in place at the time Mid Staffordshire hospital was failing, would all the ward staff either be guilty of abuse or of failure to report abuse? How would you prove your innocence?
Who would believe someone who claimed not to have seen anything, not to have been told anything and not to have heard anything? The only way to shrug off suspicion would be to accuse someone else.
Rather than draft a new law we should be asking why the existing laws have not been used to prosecute those in the BBC, the Catholic church and the police who failed to treat allegations of sexual abuse seriously, who did no investigate rigorously or who covered up abuse.
Surely to cover up an illegal act to protect an individual or organisation is already a crime.
It’s not a new criticism, but a report co-authored by MP Ann Clwyd and former nurse-turned-NHS chief executive Tricia Hart confirms that NHS hospitals are bad at dealing with complaints. The report was commissioned following the inquiry into the failings at Mid Staffordshire hospital in response to the concern that this was not a one-off.
‘Defensiveness is a state of mind that will not be dislodged by policy and procedures’
In the case of Mid Staffordshire, the inquiry found that complaints about the care of patients had been dismissed, denied or ignored. They were either not properly investigated or were responded to by standard letters offering insincere apologies.
While senior management and the board had a clear understanding of the budget position, received regular financial updates and took a close interest in actions to address overspends, they did not show a similar interest in patient care, management information on complaints, lessons learnt and changes implemented.
The report characterises NHS trusts’ responses to complaints from patients and relatives as “delay, deny and defend”.
If past experience is anything to go by a comprehensive and complicated complaints system will be put in place that covers informal and formal complaints. No doubt there will be a requirement for every NHS trust to have a detailed set of procedures, which include how to complain and how complaints should be investigated and responded to.
It would include various escalating stages to appeal or take the complaint to a higher level, should the complainant not be satisfied with the outcome. It would be bureaucratic, off-putting, time consuming and ultimately not achieve the desired outcome.
This would be accompanied by a policy statement from the board that makes clear that all complaints should be treated seriously, investigated rigorously, that lessons learnt should inform changes and that the trust should be open and honest about failings.
But defensiveness is a state of mind that will not be dislodged by policy and procedures.
‘Apologising and putting it right straight away means dealing with a complaint informally’
You can’t defend a member of staff being rude; you can only apologise. You can’t defend staff leaving a patient in a soiled bed; the question to ask is, “Did someone do something about it when it was brought to their attention?”
Apologising and putting it right straight away means dealing with a complaint informally. As a senior manager I was tasked to get involved when situations had escalated because the initial response was considered unsatisfactory.
This would involve an independent investigation, a report that would be shared with the complainant and a meeting with me as a senior manager to receive our apology.
This might have involved explaining what action was being taken to ensure the issue didn’t arise again, whether that be instructions to staff or ensuring adequate cover for staff off sick.
Often the issue was further complicated by complaints arising out of the process such as complaining about the response of the person who they first raised the issue with; complaining about a perceived lack of independence of the investigating officer; or complaining about the length of time taken to conduct the investigation.
If the person complaining was still not satisfied they could take it to the ombudsman. If the ombudsman upheld the complaint in full or part, then the organisation would be required to make a formal written apology that would usually involve a commitment to actions to ensure the incident would not happen again.
The chief executive was required to present an annual report to the board that summarised all complaints received, broken down into informal, formal and ombudsmen stages. The nature of complaints were grouped and any actions taken as a result were identified; for example, this might include new guidance given to staff or issues to be covered in staff development.
The overall lesson to be learnt was that on almost every occasion, if the initial response had been to acknowledge the concern and do something to address it, patient and relative would have been satisfied.