Neil Goodwin’s report clearing NHS East Midlands of bullying highlights issues of management and regulation. Failure may be about more than poor local leadership, says Nigel Edwards
The investigation into allegations of bullying against NHS East Midlands exonerated the strategic health authority but made some recommendations that deserve wider attention.
Objective information is useful but it is not a substitute for judgement - we already have too many examples where the rules get in the way of sensible decision making
In particular, Neil Goodwin, the independent consultant and former SHA chief executive who carried out the investigation, identifies important issues about management and leadership in the NHS and significant errors that are frequently repeated.
Identifying potential failure is difficult in the commercial world and even harder for health providers. The performance regime is a reasonable attempt at removing some of the subjectivity, patronage and inconsistency that used to plague the process. Many years ago some of this was done with little more than corridor conversations, anecdote and sometimes a degree of prejudice, favouritism or malice. But current measures are some way from perfect and there are limits to what formal measurement of this sort can achieve.
- First, they are retrospective and so may not give sufficient warning of impending failure. This means the chance to intervene early is likely to be missed.
- Second, they concern day to day performance, which may not relate to the fundamental health of the organisation.
- Third, there is a major difficulty in distinguishing random noise from important signals.
- Finally, longstanding issues may damage current performance.
A lot of research in this area suggests it is not possible to design measures to identify organisations about to fail without generating a large number of false positives. This means much effort will be spent intervening and potentially causing harm in organisations that do not need help.
New ways to fail
At the same time any measurement system risks missing organisations that have found new ways to fail. The fallout from Mid Staffordshire Foundation Trust - rather like the problems in the banking industry - is leading to a major exercise in closing the door of the empty stable.
The pattern of time consuming reviews, followed by hundreds of recommendations which often would not have prevented the original problem, followed by a different problem arising is a common feature of both professional and organisational regulation. This adds complexity and work but may do little more than create the illusion of assurance, and may even increase risk by distracting managers’ attention.
We might do better to look systematically and objectively at the organisation’s capability and leadership. Monitor takes a governance and managerial approach - the concept of organisational health - looking at culture, leadership, the use of knowledge and resilience.
Objective information is useful but it is not a substitute for judgement - we already have too many examples where the rules get in the way of sensible decision making. There is an unavoidable problem here. Those making these judgements need to be close enough to the problem to understand the context and issues. But this closeness carries the risk that they bring prejudices and even personal interest - in some cases their own decisions may be part of the problem. The illusion that judgement is better higher up the management hierarchy is a hazard which can lead to unhelpful interventions.
Mr Goodwin suggests that in some cases the decision to intervene “may be driven by [an SHA’s] senior management’s personal experience, judgement and intuition”. This is true but further thought about how to offset some of the dangers of this is needed.
A serious problem in the NHS’s approach to failure has been a tendency to attribute it entirely to the leadership of the organisation. A much more subtle approach is required to distinguish between failure because of poor management and processes, failure because of a major cultural problem and failure because of problems with the wider system. Each requires a different solution, and only in the first case will changing the leadership be sufficient.
For this reason it is helpful that Mr Goodwin’s report recognises the importance of the wider system. His proposal that systems should produce a plan which maps out how they are moving forward is an interesting one, although if the system cannot write a shared plan then it is probably already in trouble.
The emphasis on behaviours is also important. The proposal to revise the code of conduct picked up in the Department of Health response seems sensible and has been adopted by NHS chief executive David Nicholson. It certainly needs to align better with the NHS constitution but the real question will be how it is enforced, the sanctions used and how far it permeates the culture. Anecdotal evidence suggests the current code of conduct has had limited traction and has not been incorporated into contracts.
Mr Goodwin makes important recommendations about the way challenging chief executive posts and other key executive director roles are filled in organisations with major problems.
There has been a distressing tendency to appoint people who may never have been a chief executive to the most difficult jobs. Chiefs of challenged organisations report that word spreads and good people are reluctant to risk their reputation in organisations with a major problem. In one case it took three attempts to recruit a finance director. I am amazed at the tenacity and courage of the people running these difficult organisations but I can see why others might not want to do it. This blight extends down to consultant, middle management and clinical jobs.
Recruiting good people is made even more difficult by a tendency for them to be seen as part of the problem. Good people become associated with where they work. The report says “there may be reluctance from those appointed to lead challenging organisations to accept proposals for help on the basis of pride or because they relish the satisfaction of putting things right without external support. This reluctance should be resisted”. This seems optimistic and might be mistaking fear for pride.
So Mr Goodwin’s call for a much more strategic approach to these posts is right. In his response to the report Mr Nicholson says he is already developing a list of the most challenging posts as part of the work of the National Leadership Council. This is welcome. The lesson here is that “challenging” should not automatically be equated with size or teaching status - these are important roles but there are trusts both large and small with longstanding problems which need to appear on the list. If organisations that have had many chief executives or finance directors over short periods of time are not on the list then there is problem.
The response also mentions support for the leaders of challenged organisations. This will be important but support tends to be patchy, of limited help, short term and too often consists of reporting what is being done rather than being of direct assistance.
Not all the recommendations are picked up in the DH’s response and some would be better adopted locally.
The missing dimension is time. When new people go in they need to be given the time to make a difference. As Cally Palmer, chief executive of the Royal Marsden Foundation Trust, has pointed out, managerial stability and time are crucial. Newcastle United has had 25 changes of manager since 1977, the hospital has had one. No prizes for guessing which is doing better.