I went to a meeting recently to discuss the relationship between the patient and professional; the topic was essentially ‘what prevents people being patient focused?’  The facilitator was deliberately provocative and came out with some astonishing comments; at least I thought they were astonishing until I reflected on them.  The one which I found the hardest to digest was the notion that managers in the NHS are, or often can be, driven by fear.


As a result I spent time reflecting on whether staff, particularly managers, in the NHS are driven by fear: the fear of (your hospital or department) not performing, of breaching one of the core performance standards, significant concerns regarding patient safety, being in deficit, the list goes on and will obviously be different depending on the level you work at.  


When initially challenged with this my reaction was to completely disagree. I don’t recall ever working so hard out of a fear of not delivering, but more the genuine desire to do the best job I could for the group of patients that attended the services which I managed, together with the fact that as an employee we have a responsibility to the organisation where we are working. Yet the more I thought about it the more I think that the fear factor is very real but that we don’t necessarily think of it in this way.   


No CEO or Ops Director wants to go to the Trust Board and no Senior Manager wants to go to their Senior Management Board having to report serious infection control issues or breaches, being overspent, having not identified or delivered cost improvements etc.  It can be a very uncomfortable place.


The more I’ve reflected on it and the more I think about the conversations I’ve had in various organisations this year with colleagues, together with my experience, the more I think that health service staff are driven by both the genuine desire to do a good job for patients, but also by varying degrees of fear.


I was interested to read in last weeks HSJ about Monitor working with the Royal Military Academy Sandhurst to develop a specific leadership programme for Chairs, CEOs and Medical Directors.  Whilst I remain sceptical about whether a one day programme is the right approach and / or going to crack it, I strongly agree with some of the principles behind it.   It’s not just Foundation Trusts though; managers in all NHS organisations need to overcome fears, we need the intuition to know when to ‘go against the flow’, we need to manage and take calculated risks and set stretching goals.   We all need to understand the context in which we are working, we need to have the freedom to be able to make decisions that we see as sensible whilst being held to account fairly.   I don’t mean some groups of staff, I mean all groups.   Holding to account doesn’t have to be an authoritarian approach.  


Perhaps it is back to who is on the bus in the first place.