The Four Rings of Leadership in Healthcare

I went to London a couple of weeks ago for the IHI (Institute for Health Innovation) conference in London – Quality Forum 2017. The focus was on Quality and Safety in Healthcare, with some hugely surprising and refreshing perspectives from around the world. It was absolutely great and I learnt loads. I’ve tried to distill my learning from the time into a single sheet diagram. My hope, over the next few blogs is to unpack this a bit more, but here is a very brief summary:

If we want to have excellent, safe and financially sustainable health systems, we need four key ingredients, with the patient and their family at the heart/centre. The most important factor in providing safe and high quality care is a CULTURE OF JOY! I love this. I love that an institute based in Harvard, with research from across the world, is able to say this so clearly. If we have happy teams, we provide the best care. It’s simple! A culture of joy has three key elements: firstly the team needs to have a sense of camaraderie (we’re in this together and we love each other and take care of each other), secondly the team needs a sense of purpose and thirdly the members of the team need to feel trusted to do their jobs.

Alongside this culture of joy, there needs to be a SOCIAL MOVEMENT, both within the staff and in the wider society. A social movement relies on structures in which power is ceded and personal and corporate agency (responsibility and action) can flourish. There also needs to be a sense of CONTINUOUS LEARNING, in which all partake, every voice matters and no question is too stupid. In Toyota the staff make over 2.5 million suggestions each year! No wonder they are continually improving. And fourthly, there needs to be an agreed focus on QUALITY AND SAFETY, which entails several aspects.

All of this depends on a new kind of leadership that is first of all humble, able to cede power and deal with significant complexity and ‘not knowing’. When financial constraints are tight, or huge savings have to be made, it can be tempting to start rationing and cut services deeply. This may balance the books, temporarily, but it destroys every thing you are trying to build, demoralises staff, ruins your culture and breaks trust with those you are trying to serve. The challenge is to begin to hold our nerve in the midst of extreme pressure and do what we know is right, backed by the best evidence available to us – and this, believe it or not, actually makes us financially sustainable. I am going to really enjoy unpacking this more and revisiting my learning over the next few blogs, but the above should hopefully fuel some thinking in the mean time.

Building a Culture of Kindness in the NHS

My morning surgery began today with a patient of mine, who works as Health Care Assistant (or Band 3) in our local acute hospital trust. As we find across the board in the NHS right now, there are pressures in her department with under-staffing and a very high and demanding work load. She started her day in tears, telling me about the sleepless nights, but even more so about the lack of support she is feeling in her work environment. She feels unable to understand why huge fees are paid to find locum consultants, when posts are not covered, but money cannot be found for the absence of staff at her level, when the numbers are down, leading to an increased pressure and low morale.

Now, this is not a criticism of the acute trust we partner with every day, because I actually know all too well the situation here, how complex it can be and just how dedicated to caring for staff the leadership of the trust are. However, when we read in the press today about sickness absence for stress among paramedics, and if I were to detail more stories about the number of cases I am currently dealing with as a GP about stress in the workplace for ALL grades of staff in the NHS and social care setting, then we have to face up to the fact that we have a problem. Stress in the workplace and low morale in our teams is not a problem we can afford to ignore. It not only causes high sickness rates, which then increases the pressure on teams, with knock on financial implications to the system; it also causes significant compassion fatigue (i.e. staff are literally less able to care about or for their patients), because they are emotionally overwhelmed, under-resourced and therefore become more numb, disengaged and unkind and this is detrimental to patient care.

The problem is actually really complex, but it is, in my opinion, primarily cultural, and particularly affects the lower pay-grades of staff, because they feel and are in fact less able, to influence change. If we do not develop a culture of kindness towards our own teams and have a sea-change within our working environments in terms of how we care for each other, we will only see the problems go from bad to worse. So, how do we create a culture of kindness, a culture of honour, a culture of wellbeing?

I would like to suggest six things (all beginning with H – the 6Hs), which are fairly simple, but make a massive difference to how teams function and therefore the morale within those teams:

Humanity – First, we must recognise that hierarchy has the inbuilt tendency to de-humanise us. As we get higher in the pyramidal systems in which we work, we can easily lose our humility and compassion towards others as we have to cope with the greater demands from “above us” and if we’re not careful we can turn into slave drivers. Top down, controlling leadership is detrimental to good morale and stifles teams from working effectively. There is a famous, ancient parable (told in the New Testament) about an unmerciful manager, who owed a huge amount of money to his master/CEO. The CEO called him to account and threatened to fire him. However, he begged for mercy and the master cancelled his debt and gave him a fresh chance. However, this same manager then went and found all the people who owed something to him, and instead of paying forward the mercy he had received, treated his own debtors shamefully, despite their begging and pleading for mercy. When the CEO found out about this, the manager was duly fired. I wonder how often we tolerate ‘bullying’ by managers, because they ‘run a tight ship’, without calculating the cost of this style of management on our teams and the patients we serve? Changing culture is hard. Even if the CEO sets a good culture, any one of us can bring a negative influence in the area we work. We have to make a conscious choice to keep our kindness switched on. As we climb the ladder of responsibility, we must continue to act with humanity. We must also remember that it works the other way round – we can start dehumanising those in leadership positions ‘above us’, or those who work in different teams. We make terribly unfair assumptions about people all the time. A little bit of understanding, kindness and compassion goes a HUGE way in treating each other with kindness instead of suspicion.
Humility – For those in leadership, there can be a tendency to forget that when we were in in ‘lower’ positions, we often felt the same low morale and pressure from those ‘above us’. Leadership requires that we keep our love and compassion switched on towards those who we now lead. This means we must really learn to listen, and that means having the humility to recognise where we have been getting it wrong. If we are not prepared to change, then we are not really listening. It takes courage to create a culture in which we can receiving a challenge from those in our team and be able to make a change and not just use our position to squash the person who dared to speak out. It takes even more guts to admit where we have been wrong, say sorry and move forward differently.
Help – one of the very worst things that can happen in any team dynamic is when we hear the words ‘it’s not my job’. I hear it so often and it makes me sad! We must never think we are above any task – whether that is cleaning up a mess, wiping a patient’s bum or picking up some litter. We must simply help each other out. But we also need the humility to admit when we are struggling and actually ask for help. We encounter terrible and unspeakable trauma at times, or may simply be going through tough personal circumstances. Sometimes, we need the humility to recognise where we are not coping, where we are struggling, when we’re not functioning and ask for help. And when we ask for help we need to have the confidence that we will encounter the humanity of those around us to help us at our time of need.
Honour – Sometimes a situation may not be able to change, but in these situations the very worst thing leaders can do is close ranks, shut communication down and raise the levels of demand. No, vulnerability, openness and honesty, sharing the reality of the situation and communicating clearly why things cannot change currently at least allows the team to pull together and face the situation as one. However, there must be a very clear challenge here – Yanis Varoufakis puts it so well in his book “And The Weak Suffer What they Must” – we have to remember just how crippling powerlessness can be. Like my patient this morning, she has no access to the ‘powers’ or to the ‘purse strings’. She cannot up and leave, she simply can’t afford to, and so she works under huge pressure for very little pay, powerless to enact change, other than to put in place her own boundaries. A cultural shift towards a culture of kindness is to ensure that those with the least ‘honour’ are treated the most honourably. Leadership is about being able to take the hit, not self-protectionism at the cost of ones team. It is absolutely amazing just how far the words ‘Thank You’ can go, to keeping this sense of honour alive.
Health – (by health, I mean wellbeing in its widest sense) – we have to actually care for the people around us. We have developed a culture in the NHS and social care where we will do all we can to care for our patients/clients, but will break the backs of ourselves or our teams in the process, which is actually entirely self-defeating! It is impossible to care for others well, when you are feeling exhausted and broken! I have said it on this blog before and I will say it many times again: we have to develop a sense of the health and wellbeing of the people in our teams. We need time in the craziness and business of each day to stop the mad rushing, be still and take notice/be mindful/be heartful. We all need time to get up off our chairs and stretch and be more active – #runamile every day (it only takes 15 minutes). We need time to connect with each other (do we really take time to know the people we spend an inordinate amount of time with and alongside and check they are actually doing OK?), to eat well, stay hydrated and keep learning, so we don’t feel overwhelmed. Building these as an absolute priority into our daily work routines is vital, especially as pressures increase. The tendency is that when the going gets tough, our health gets significantly worse. We must learn to protect this in the midst of our business, or we will suffer the consequences in multiple ways.
Hope – there is an ancient proverb that says: “hope deferred makes the heart sick, but hope coming is a tree of life.” Hopelessness takes root when we feel that nothing can ever change and we feel powerless to influence anything. Hope is born when we develop ways of working in which teams can work together on solutions to the problems they are encountering, rather than being dictated to from on high in a unrelational way. Hope is about being able to sense that the future is alive with possibility. It is a life line when things are tough, when the tunnel is long and dark – just a little glimpse of light – and then faith builds that together we can get there.

Not difficult. Actually pretty straight forward. We don’t need unkindness or low morale in our work places. We don’t want to be suffering with compassion fatigue because we are physically and emotionally drained and running on empty. We really can create the kind of culture we want to see and experience in the NHS and social care – a culture of kindness – sounds nice doesn’t it?! All it takes is for us to remember humanity, humility, help, honour, health and hope.

3 Keys for the Future of Healthcare

This week I traveled to London for an interview. The lovely team that I work with have nominated me for the HSJ Clinical Leader of the Year award. Unbeknownst to me, this meant presenting myself before a panel of experts and leaders in the field of healthcare to talk about the work we have been doing. It was a privilege to get to do this. One of the questions gave me an opportunity to explore with them what I have learnt that has the capacity to bring transformational change….another was about the nature of leadership (which I will blog on next time).

So, for what it’s worth, here are the 3 key things which I consider to be vital to unlock the future of sustainable healthcare, just in case they are helpful!

Culture Change

Much has been written in the press (and quite rightly so) over the last few years about some of the toxic culture that is at work in the NHS. Sometimes the toxicity is to do with power plays, competition, hierarchy, bullying, low morale and substandard care. But in other cases it is to do with a lack of compassion and care towards those who work in the system which causes the other negative behaviours or leads on to emotion fatigue and poor delivery of service.

When I moved into my role as “lead clinical commissioner of maternity services” (we love long titles in the health service!), three and a half years ago, it was just as Sir Bill Kirkup was publishing his report into the University Hospital of Morecambe Bay. It highlighted the failings we had in our maternity and neonatal services that had lead to some extremely sad and unnecessary losses of life. It targeted the negative culture within our teams and directly challenged some of the behaviours. Morale was understandably at an all time low. But there has been a significant change in culture over the last few years. Cultural shift is absolutely possible but involves a willingness to look stupid at times, to persevere when things feel awkward and remain hopeful when the task seems impossible. I believe the secret lies in rehumanising team meetings, connecting at a relational level, being vulnerable with each other, learning from mistakes, challenging unacceptable practice but creating an atmosphere of grace in which people can reflect, learn, grow, develop, change and discover each other with a deeper understanding and eyes that choose to look with kindness. I refuse to start any of the team meetings I chair without checking how people are doing, giving them space to tell a bit of their story. I want to give space for people to encourage each other, say what they love about each other and what they most appreciate about one another’s work. It’s not rocket science. It’s called connection and compassion! I’ve seen it work here in maternity teams, in our health and wellbeing teams and it really can happen anywhere. Without giving it space and time, nothing will change. But where there is a real sense of togetherness and hope, many more things become possible.

2. Community Partnership

Part of our problem in healthcare is our level of expertise. We know far too much. We “know” what’s good for people. We “know” what people and communities need. We “know” what will make them better. BUT we have not yet really learned to LISTEN. I have found it to be a very humbling and necessary experience to shut my mouth, quieten my need to fix and really listen to the people and communities I am looking to serve and live amongst. When our team hosts conversations to listen to people here around their dreams for this area in terms of health and wellbeing, they don’t talk about extra appointments at weekends or shorter waiting times. They talk about dog poo, safe playing spaces for kids, singing, looking after elderly neighbours, help with exercise and eating well, safe places for people with mental health problems to get together and be understood and many other things. I have found that listening builds partnerships. It creates trust. It means that with our communities, we can co-commission things, and we can do things together rather than the experts doing things to them.

If we are going to see the social movement we need around health and wellbeing in this country, we are going to have to let go of some of our “knowing” and be humble enough to learn. We are going to need to partner with people and not do things to them. We are going to need to focus more on prevention than treatment. We are going to need to work differently. Without the vital engagement and listening with and to our communities, we will never achieve the holy grail of a sustainable health service that remains free for everybody. Together, many things become more possible, and we can learn to live in peace.

3. Collaboration

Every organisation is strapped for cash. It doesn’t need to be this way, but it is the reality of our current economic model. Collaboration and the sharing of resources between partners and organisations is the only way forward. I love sitting in team meetings that involve healthcare – in its different guises – primary, secondary and community services, with social care, the police, the fire service, mental health teams, the voluntary sector, the faith sector, the city and county councils. Creating new cultures, letting down barriers, discovering shared vision, pooling ideas and resources – seriously good for the soul and definitely the future we are looking for.

What Lies Beneath?

Do you sometimes wonder what is really going on? As the furore around the planned 5-day strikes by junior doctors unfolds, with all the clamour and the noise, the positioning, the power plays, the arguments and the counter-arguments, I wonder where is the truth amidst the madness? How have we reached a stage in which the government and an army of medics, surgeons and psychiatrists are at such loggerheads? What lies beneath all of this?

Theresa May, our Prime Minister tell us that “doctors have never had it so good” – I wonder when she last shadowed a Senior Registrar for Acute Medicine on a Friday night in an understaffed hospital? Jeremy Hunt tells us that he is a modern day Aneurin Bevan (I wonder what AB would think of that?!), whilst his shadow counter-part, Diane Abbott retorts that this is a ridiculous suggestion. The PM and the Secretary of State for Health both agree that the junior doctors are playing politics, something the other side refutes, but all agree that this is a disaster and patients lives may well be put at risk. The right wing press tell us it is all about pay and that the doctors are being greedy, whilst the left wing press tell us it is all about an underlying agenda to privatise the NHS. The Junior Doctors admit that some of this is about pay (who would want a significant pay cut for working long and unsociable hours?) but that it is more about resisting a policy to deliver a 24/7, 7/7 NHS, which they believe to be unaffordable and unstaffable due to shortages in funding and recruitment. Senior colleagues appear to be split down the middle in terms of support for the strikes, patient groups are understandably concerned and yet a solution does not appear to be forthcoming.

Shouting, anger, fighting, noise, name-calling, power-plays, hate and hollering. So, who will seek the welfare of the people and the nation? Who will make for peace? Both sides tell us this is what they are doing and this is why they stand their ground. The government apparently want to deliver the same standard of service throughout the 7 day week. The Junior Doctors say they are the ones really standing up for the people by resisting that which is unsafe and unfair.

So, let us learn from the peacemakers to find a way through. In apartheid South Africa, peace was not reached through hate and vitriol. It took deep courage from men and women to expose lies, to speak truth to power, but most importantly to tell their stories. It was not about the one man, Nelson Mandela, but the many together waking up to an alternative future that was fairer for everybody. In the battle for civil rights in the USA, a nation was awakened to the reality of injustice within its own borders. The story of one woman, Rosa Parks, who refused to be humiliated on a bus became a people movement as numerous as the stars, shining together for an altogether different day. In Rwanda, after the appalling genocide, those who lost everything, found a voice to communicate to their very oppressors, those who had raped and murdered their own families, not only their story, but forgiveness for the atrocities caused and found a way through to a new future. If we want peace and a better future for everybody, then we need to face up to our reality, be willing to really listen and then find that together we can embrace a new future.

We have an apartheid of globalisation and free market capitalism across the entire world. Every day, the gap between the rich and the poor is widened. Our entire economic system, founded on the oppression of Empire through expansion (via military violence), the creation of debt (through an errant banking system) and the rule of law (held in place by the state of the exception) is no longer fit for purpose. We see it in the plight of refugees stuck between war and barbed wire fences in a land they cannot call their own. We see it in the disproportionate imprisonment of Black American males in the USA. We see it in the vile island detention centres of Australia. We see it in the slums of New Delhi, the townships of sub-Saharan Africa and the Favelas of South America – in the eyes of children dying from such ridiculous things as diarrhoea and starvation. We encounter it in the streets of Athens and the public squares of Madrid. And yes, we find it in the midst of our NHS and social care system. Our world as we have known it is broken and no matter how much sticky tape or wrapping paper we apply, the centre simply cannot hold. The core is unstable. Everything is shaking. We must have the courage to let go of what we have known and embrace an altogether different future, a future that is fairer for everybody, where things don’t simply trickle down to the poorest, but in which the balances are re-set.

We have become slaves of the ‘free market’, fodder of the beast that requires ever more of us. What lies underneath the row over Junior Doctor pay and the forthcoming strikes is a great gaping hole that scares the hell out of many of us. Oh, we can sling mud until the cows come home, but it’s not going to get us anywhere. Top down, pyramidal, heroic leadership that stays its course and demands it’s own way is simply not going to cut the mustard. We must have some brave and difficult conversations about the detrimental effects of making policy from the safety of ivory towers, and learn to really listen to the stories of those affected. We have so much to learn from the Leeds Poverty Truth Challenge, the Homeless Charter in Manchester, the Community Conversations in Morecambe Bay, the Cities of Refuge initiative, the Civil Rights movements, the Mediation work done in Rwanda…..we don’t have the answers right now. The problems facing the NHS are fare more complex than trying to ensure an undeliverable manifesto promise is outworked. We need humility on all sides, collaboration and partnership.

It goes deeper than people right across the UK needing to manage their own health and wellbeing more effectively. It is more complex than needing to recognise where there is waste and dealing with it. It isn’t just as straight forward as needing to talk about chronic under-funding and under-recruitment. We face an existential crisis, an ontological question about the future of humanity together. Resting back onto familiar ways of operating or antiquated leadership styles will simply not work for us any more. The black hole we face is either a death or the opportunity for re-birth. A squeeze that will force us into something new. We can’t keep dancing around it forever. We must take the plunge, accept that there is no going back and see what new creation we might just co-create with Love on the other side. Don’t be afraid…….there is light at the other end of the tunnel.

A Co-operative Future for General Practice?

imgres If you take the work of Steve Peters (of “The Chimp Paradox” fame) seriously, which I do, then you can see Chimps at work everywhere in the NHS right now (and I’m not taking a cheap shot at Jeremy Hunt). For those of you, who have no idea what I’m talking about, then do read the book….but a brief precis is this: each of us are two people – we are both simultaneously an emotionally driven, primal chimp and a more rational human being. When faced with difficult circumstances, our chimps all too easily take over and our behaviour is driven by our emotions, because our human also feels insecure and we lose hold of our values (the computer part of our brains) which is able to alter our chimp behaviour.

I’m not making a judgmental criticism, I see it in myself. I see the raw emotion of how I imgres feel about what is happening in General Practice, Community Nursing/Therapy and indeed the NHS at large and it becomes easy to function out of raw emotion, heading into ‘rant mode’ or a strong defensive posture with the rest of my pride. But I have found it brings division. It pits my practice against another or General Practice at scale against the Hospital Trust or the government or whoever. But it doesn’t actually solve anything. It stares the problem in the face and hollers at it or throws faeces at it, and other than being cathartic (which has it’s place for a while), it doesn’t engage with a creative or collaborative process about how we face the future. The facts are right in front of us, and there is some thought about how to make General Practice strong enough to survive, be that through giant mergers or the formation of federations. Here in Morecambe Bay, we are experimenting with both those options and also trying to work in Integrated Care Communities (incorporating all our community partners) according to geographical locations.

However, I’m not sure we are facing up to the realities we see creatively enough. Whether we like it or not, General Practice as we have known it is unsustainable. There simply aren’t enough doctors coming through training, there aren’t enough doctors choosing to be GPs and there certainly aren’t enough GP trainees wanting to become partners.The partnership model as we have known it, is over, and the sooner we face up to this, the more creative energy we will be able to harness to find solutions. The formation of federations or the advent of the ‘super-practice’ will go some way to stop the gap, but it is the structuring of them that deserves some attention. Integrated working with community teams, be that district nursing, mental health, community therapies or social services calls for a wider and deeper system change. But here is the very difficult thing for GPs to let go of: the idea of the autonomous self, being in charge.

Co-Op-Principles If we are going to find solutions to the needs of the people we serve and develop together (no matter what is being shaped from the centre) a future healthcare model that works, GPs may need to let go of our power, as we have known it and embrace a different way of being. I think a possible solution lies with the co-operative movement as this would allow a truly integrative model to develop that benefits all our workers, no matter what their role, giving us the cultural environment in which innovation, excellence, learning, creativity and compassion could really flourish. Due to the nature of co-operatives and the principles at their core, a powerful force could be released which provides alternative solutions for a more equitable society.

What would a co-operative model be like? Well, there are different options and different images styles, from John Lewis to Mondragon, or the model adopted by Jos de Blok in the Netherlands. But the reason I like it so much, is that it takes power from the few and shares it with the many. It allows for a different style of leadership and a different mode of making decisions. Collaborative conversations and compassionate care of one another in providing care to the wider community becomes the order of the day with leadership that is both clinical and managerial but modeled on financial benefits for everybody and cooperation of wider teams of people.

images There are draw backs and co-operatives are not perfect, but they are a solution that should be seriously considered as General Practice tries to navigate itself into the future. They can be complex to set up, but I would argue that complexity is worth it when it offers a solution that lasts longer than a more straight forward quick-fix that may not make it past a decade or two. Are we brave enough to explore solutions that dis-empower us for the sake of a better future for everyone?

Time to Face the Music

We have yet to really face up to the crisis we are in. We keep on pretending that by making a few alterations here and some adjustments there to how we deliver health and social care, we might be able to save the NHS. But this simply isn’t true. Last weekend saw a crisis conference for GPs nationally as 38% think they will be forced to leave the profession in the next 5 years due to severe under-resourcing and increased stress (that would be a loss of 10000 GPs throughout England, with government plans to recruit only 5000 by 2020). Yet again our Emergency Departments are at breaking point, Junior Doctors are staging further strikes, Public Health Services have been decimated and although new partnerships are being forged with social services and (to some extent) the education system, deep cuts in both those areas mean there is little time or energy left to find new ways of working for the future health of our population. Throw into the mix a need to save £22 billion through “efficiencies” and couple that with the crippling debt caused through programs like PFIs in our acute hospital trusts and we really do have a problem.

Complicating this picture is the stark reality that 1 in every 5 pounds spent in the NHS is as a direct result of our current lifestyle choices and we have believed a lie that the NHS is “free” and therefore we can treat it however we like and live however we want and it will somehow magically sort us out. On top of this we have an ageing population with increasingly complex health needs and an ongoing under funding of the entire system (only 8.9% of GDP).

And we cannot we forget the financial crash of a few years ago which was a major warning sign to us that we are living in a broken system and the god that is
images the Nation State is beginning to crumble all around us. Let me just repeat that difficult statement in another way. The grandfather that is the Nation State is now utterly riddled with a cancer and it is dying. The cancer, like all cancers needs ever increasing growth in order to sustain it’s life and our economy is set up to feed it, but even built on the pyramid of power, control and debt, it can no longer survive. Like any dying man, it is holding on for dear life and as it does so, it puts the squeeze ever tighter on to health, education and other public services, pretending it is still powerful, controlling public services through the slashing of budgets and ever tighter and undeliverable targets whilst not actually dealing with it’s debt issue at all, but telling us all a story that it is. And the mouth of this dying beast, the media that has become utterly complicit with it all, spouts out tale upon tale of how mighty the State remains, “punching above it’s weight” on an International scale (using violence and threat where necessary to do so), but tightening it’s belt to ensure economic sustainability. Am I being dramatic? Listen, when 85 people now have more accumulative wealth than half the world and when the 50 richest global corporations are richer than the 50 richest Nation States (and are therefore powerful enough to tell them what to do), the facades must come down. The Emperor has no clothes on.

And so it is time to face the music. Once we realize that the centre cannot hold, we can permission ourselves to find new ways of being. There really are alternatives to what we have now. there are other ways of being. Life will go on. We can learn to dance to a different tune, we can sing a new song and begin to reimagine a different kind of future. We can learn to live differently. There are some tough conversations to be had. But, as the old systems begin to pass away, what might emerge instead? What brave or holy experiments might we try without letting go of the wisdom we have learned? What might it be like if politics and economics were just part of a collaborative and cooperative world rather than assuming the role of dominant sovereignty over every other sphere of society? What if we can’t have everything we want right now, learning some new and more effective boundaries around the ways we live? What might we prioritise? How might we move towards a more peaceful world? How are we going to live in a way that is sustainable and leaves the environment as a gift rather than a burden for the generations to come? How might we develop an economics of equilibrium (the state of a healthy body) rather than one of continual growth which requires us to feed its ever hungry belly with our own lives? What might we recover in education? How could we shape regional wellness services? How might cities and regions gift their expertise to one another? How might we choose to protect the most vulnerable in society and provide for the most deprived, keeping love at our core over self-preservation, greed, fear or hate?

Truthfully, we can no longer afford to avoid these conversations or hide away in our business. If we want things to remain exactly as they are, then so be it, but what will we leave for our children’s children? In the NHS we spend our lives trying to preserve and prolong life at all costs. But we must learn to face death, because there is life the other side of it. There is life the other side of the Nation State as we have known it. There is still ethical, free, safe, sustainable and accessible healthcare for all the other side of the NHS in its current form. It might become a National Wellbeing Service. Or it might be more regional and cooperative. It will mean some different lifestyle choices and some more effective partnerships. It will mean changing our attitude towards how and where care is provided. But I’m sorry to say that unless we make some radical choices to either pay a lot more tax or not renew trident and spend all of that money on healthcare, there are some deep cuts to be made in the mean time. It is going to be a very painful few years ahead. We must not imbibe ideologies that protect the rich and punish the poor. But we have to be brave enough to let go of the good we have known in order to embrace a future that is better for everybody together.

And that calls for a different kind of kenarchic leadership. We need leaders who will serve and collaborate with communities in open and honest conversations, so that cuts do not happen in an isolated boardroom, but wit Unknown-3 h and among the communities most affected. Leaders must learn to ‘hold the space open’ for the new to emerge. It will mean understanding that we must make choices about which targets we do and don’t decide to meet, prioritising some services over others and taking better care of ourselves individually and in community. But it is not a time to lose hope! There is much goodness to come, much rediscovering to take place. Much creative reimagining to enjoy. Many songs to be sung. So, let’s face the music and dance.

A Different Kind of Leadership for the NHS

Over the last few weeks we have seen the unfolding story of a health secretary in a battle with Junior Doctors (of which there are 53,000). Under-girding the entire debate is a manifesto promise made by the Conservative government that they will deliver a 7/7 NHS. There has been a misuse of statistical evidence by the government to inform this position and indeed we do already have a 7/7 NHS.

In order for this promise to become a reality, the government must face up to certain facts, which are obvious for all to see. Firstly, the NHS is underfunded and rearranging pay agreements with junior doctors who are already underpaid is grossly unfair and will not achieve the desired affordability. Secondly, the NHS is understaffed (we already have one of the lowest doctor to patient ratios in the EU). Thirdly, morale among NHS staff is low, and much of this is due to staff being used as fodder to drive the system, rather than cultivating a system in which they are cared for, can flourish and can influence change in the system where it doesn’t work. Pushing more work for less pay will not drive up morale! Fourthly, the slashing of local government budgets is causing a social care crisis that has huge implications on the ability of the NHS to function. Fifthly, public health budgets have been reduced to a bear minimum at a time when we know we need to have wider conversations with the citizens of the UK about how to take greater care of their own health and the health of their communities in order to make the NHS sustainable. Sixthly, the problems with weekend care in our hospital systems are a result of a lack of support staff and services available over weekends and a crumbling social sector which blocks up hospital beds. Needless to say, the situation is complex.

And so, given such a complex problem, how should the system be lead and managed? With an iron rod? With bullying, top down hierarchy? With “visionary” leadership that knows how to do the “right thing”? With the defeat of the ‘militant’ junior doctors? What kind of system is the NHS? It is not a linear, predictable system, but rather something far more akin to a human body, a living, organic system. Meg Wheatley in her book, “Leadership and the New Science” writes powerfully about the folly of trying to manage complex systems as though they respond to the theories of Descartes and Newton – they simply don’t behave that way. And so, this kind of system cannot and will not respond best to competition, targets, inspections and beating its members into submission. No, it will respond best to collaboration, to the right environment in which people can thrive. It requires the kind of leadership that will listen, that will work in partnership, that will host good conversations and find a way through together. I do not see that kind of leadership from the department of health.

The NHS is a national treasure. Yet, this government, with only 36% of the national vote, from an antiquated and unjust ‘first-past-the-post’ voting system, is driving through ideological changes that it has no true mandate from the people to execute. This kind of political behaviour exposes more than ever the abuse of sovereign power and the need for something totally different. We need leadership, but we need a new kind of leadership, a leadership that is loving, compassionate and kind, collaborative, listening and releasing, a leadership that believes for the best and a leadership that invests in the kind of health service we need to deal with the health inequalities we see. We need that kind of leadership now. We need a different kind of government and a different kind of politics now. It is emerging in the margins, but we need leaders at the centre with a new kind of heart.

Changing the Culture of the NHS

I had the very real privilege of listening to and interacting with Prof Mike West of the Kings Fund as part of a Cumbria Wide learning collaborative a few days ago. It was utterly engaging and inspiring. His basic strap line is this: “The vision of health and social care is to deliver continuously improving, high quality and compassionate health care to all in our community.” The problem is that we’re not doing this, and we’re not doing this because there is something deeply wrong in our culture. And so how do we change a system, especially when it feels that the odds are seriously against us? How do we recover compassion? How do we envision a floundering workforce and help them to believe? Why are there some beacons of light in each organisation and some really dark holes? Why are we not learning more readily from areas of good practice and challenging those that are way below par?

There are some seriously problematic things for us to face up to, and although I love to take a ‘solutions-focused’ approach, I do believe that sometimes you have to face up to your reality before you decide to move into a different kind of future. We could talk until the cows come home about the potential dismantling of the NHS, the low morale of staff and this ‘black hole’ of debt. But what I want to focus on in this post is the cultural deficit. Previous governments have tried to address this with targets, competition and inspections, but each of these, although I think introduced with good intentions, have backfired spectacularly and driven morale lower without improving the culture at all.

Stress is defined by Mike West as a poisonous concoction of high work demand, low control and poor support. Chronic high stress levels are significantly higher in the NHS (26.8%) compared to any other sector (17.8% on average). High stress is detrimental for people’s health and a well known cause of early death. And so in an organisation in which we have 1.4 million people spending on average 80000 hours of their lives caring for other people, we are literally killing them by not caring for them. This is a paradox in an organisation which is supposed to have compassion at its core. And yet we know through significant evidence that the lower the morale and health of your team, the worse the outcomes for patients will be. Stress in the NHS and the lack of compassion with which we treat our own staff is a more significant health risk to the population than many of the issues that we give far more attention to.

So, what can we do? Are we doomed to serve systems that de-humanise people and devour them like bread? Must a system be driven by what Foucault calls ‘biopower’, ie using human beings as the fodder to drive the machine? Can the systems be harnessed and redeemed and made to work for us rather than served by us? Yes! I can say that this is happening here in Morecambe Bay and I see evidence of it in many areas. Nationally, we can take comfort from 2 things, in particular. Firstly, although the truth about our current culture is uncomfortable, the truth is now available to all, so change really can happen. Secondly, the vast majority of people genuinely want the culture to change and the dominant minority in the centre of toxic cultures can no longer hold. Mike West says systems can change, and he has gathered some good evidence to back this up. But it takes time (5-6 years), it takes focus and it takes consistency. He breaks cultural change down into 6 key elements that are well worth exploring.

6 Key Elements of Cultural Change

1) Vision, values and strategy. It is absolutely vital in order for a culture to change that the direction of travel is obvious to all. Salford Royal Hospital in Manchester have for years had the same vision statement: “To be the safest hospital in England”, and they have done it! A vision has to be clear, it has to mark ambition for the future and be able to guide and inspire the whole organisation towards change. However, it takes 5-6 years to embed this through an organisation. So those who communicate a vision to staff and then wonder why they haven’t got it yet need to understand that a paradigm shift in thinking doesn’t happen overnight. A change in direction of the rudder doesn’t turn the ship in one go. The vision needs to be communicated multiple times in multiple ways to multiple audiences. It needs to be inspiring, owned by all and makes clear commitments to the direction of travel.

2) Clearly aligned goals at every level. If a vision is to be cast, there must be measurable goals along the way, so that a team knows they are heading in the right direction. These goals have 2 key elements. Firstly they must be clear and achievable (so not more than 5 or 6). Secondly, they must be aligned to vision, measurable and challenging. People must be challenged to reach an objective, so that the process is both stretching and fun, and there needs to be celebration of goals being reached along the way. Problems emerge here when leaders don’t want to hear about problems that are being encountered. The team needs to be responsive to barriers. For example, there is no point wasting time and energy on collecting data for the sake of it. We want to collect data that actually helps improve patient care or helps staff do their job more effectively. If we want our staff to treat people with care and dignity, then we must treat our staff with care and dignity and that means listening to them and responding to them as we head into uncharted waters.

3) Leaders need to manage and engage with their staff well to gain high quality care. The high level of chronic stress in NHS staff proves that this is not happening as well as it needs to. The Kings fund have discovered some key themes from their research in this area: a) patient satisfaction rates are far higher where staff have clear goals and are working together as a team to achieve them, b) staff views of their leaders is directly linked to patients’ views of care quality, c) staff satisfaction/commitment predicts patient satisfaction, d) if staff feel high work pressure, low control over this and low support then patients will also report low staffing numbers, insufficient support, privacy and respect, e) poor staff health and well-being is directly linked to high injury and mortality rates, and good HR practices lead to lower and decreasing levels of patient mortality. Another key factor is the reduction of hierarchy. The John Lewis Partnership has consistently had the highest level of staff morale for the last 180 years. one key factor is this: there are only 3 levels of hierarchy – CEO/board/partners. Staff/partners feel empowered to make changes and they are listened to.

We are not managing our staff well in the NHS. 24% of staff report regular bullying by ‘management. Discrimination is higher especially for those of Black-African and Black Afro-Caribbean descent. It is still high for those from Asia and 18 times higher for Muslims than for any other group and is also high for those who are not ‘heterosexual’. If you have white skin, you are three times more likely to be promoted into senior leadership positions, when account for numbers is made. And despite the suffragettes we continue to see discrimination against women in certain specialties, most notably, surgery. This is not an acceptable culture. We need to change the culture. Leaders need to learn to be present for their team. Mike West puts it so well: “Leaders need to learn to listen, with kind eyes, full of care and fascination (just as we would want our patients to be listened to). We need to learn empathy, to communicate well and take intelligent action.” Engagement with our teams is about really engaging at an emotional level and this takes trust. Our management styles must change towards being far more inclusive, empowering and under-girded with our values and integrity. For staff to feel happy, there needs to be a sense of a stable senior leadership team. There should be a real sense of anger about how badly staff in the NHS are currently treated but a clear positive attitude towards affecting change. Leaders must help process negative emotion in their teams and deal with quarrelsome, disruptive behaviour that spoils the hope for a different future. Poor performance and attitude has to be challenged if we are to create the kind of culture we need and want to see.

There are many situations and systems in which an entire culture can be toxic, with top down bullying as the order of the day. Creating resilience in our teams is not about toughening people up to go back into toxic situations until they finally break. No, we need something far more creative than this. It is impossible to change a culture as a lone shark. Mike West talked about gaining ‘minority influence’ – good examples of this are found in the Feminist movement and the Green Party. A small group of committed and determined people can accomplish an incredible amount. But if the culture will not change, then wipe the dust off your feet and go and give your energy elsewhere. Systems can change if there is desire enough to change them. There are hospital trusts in the UK that report significantly higher staff morale than anywhere else. We must learn from places like Salford Royal, Royal Wolverhampton Hospitals, St Helen’s and Knowsley, Bedford and Frimley Park. Here in Morecambe Bay, where the maternity service has been at rock bottom, we are part way through an incredible cultural shift and many other departments throughout the country are beginning to turn here and ask us what we’re learning in our journey of change.

4) Learning, Quality Improvement and Innovation. This is a very straight forward point, but one to which we do not pay enough attention. Learning organisations facilitate the learning of all staff and the system itself to continuously improve. If we’re not improving, we are going backwards. We must learn to learn from failures and create a culture where this is acceptable. Learning organisations are characterized by systems thinking with information systems that can measure performance. In such a system, staff are encouraged and motivated to focus on improving quality (why would we want to do a shoddy job?). Learning is done in teams and crosses the boundaries of role and specialization and there is always dialogue going on around this. Prof West says that a key question to continually ask is this: “What do we need to change around here to enable you to be able to do your job more effectively?” We must make a promise to learn and a commitment to act. Where staff have a focus on continually improving patient care and this is embedded in the culture, targets become obsolete. Reflective practice and learning becomes endemic. All staff are accountable and all staff are enabled and empowered to bring about change.

5) Team working. Teams need clear objectives, roles, communication and learning. In the NHS, 5% of people say they do not work in a team. 40% of people feel they work in an effective team. That leaves 55% of people who consider the team they work in to be dysfunctional. Stress, injury, bullying and errors are all higher in ‘pseudo-teams’ and the mortality rates are significantly lower for patients who are cared for by teams that function well. Interpersonal conflict is a disaster for effective team and inter-team working. The Kirkup report into Morecambe Bay and the Francis report into Stafford both highlight the appalling and detrimental effects of the breakdown of relationship between consultants and hospital departments. It is estimated that up to 30000 deaths per year could be prevented by more effective team working. This conversation really matters! We have to change our culture.

To develop good teams, we must encourage positive and supportive relationships, resolve and prevent conflicts, create a positive group attitude to diversity, be attentive and really listen to our teams, encourage inter-team cooperation and nurture team learning improvement and innovation. Our teams must develop reflexivity. Teams are more effective and innovative to the extent to which they take time out to reflect upon their objectives, strategies, processes and environments and make changes accordingly. The best response to pressure is not to work even harder, but to stop, take a step back and reflect. This is true even in emergency situations, as evidenced by the pilot who handed over the controls to his co-pilot whilst he took time to assimilate his options and decide on a strategy to land US Airways flight 1549 in the Hudson river in 2009.

6) Collective Leadership. Leadership is the responsibility of all. It is for anyone with any kind of expertise to take responsibility where and when appropriate. Leadership is shared in teams across the whole community. It is interdependent and collaborative, working together to ensure high quality health and social care. This is our experience through Better Care Together in Morecambe Bay. It needs to be both clinical and managerial. The more hierarchy there is, the less opportunity there is to innovate. There are lessons for us to learn from more collaborative leadership styles like ‘The Art of Hosting’. We would do well, to take heed and learn some vital lessons from teams daring to do things differently.

Mike West finished his lecture with a very beautiful summary: Health and Social Care is about the core value of compassion. We want to create compassionate communities that listen with fascination and are empathic. We have to begin with ourselves. We need to take intelligent actions around this so that we can create the kind of cultures we want to see.

Morecambe Bay – Better Care Together

Morecambe Bay

Known for it’s fast moving tides, mud flats, quicksands, islands, rare birds, natural gas, submarine building and nuclear power; Morecambe Bay is a place whose motto is “where beauty surrounds and health abounds”. The first part is true – it is a place with some of the most spectacular views on offer in the entire UK and hidden treasures of wildlife and wonderful walks. A place where I live with my family and I now call home. But it has some of the worst health outcomes in the country, sitting bang in the middle of the North-West – the worst place for health per head of population for any of the regions in the UK. We are the worst for cancer rates, the worst for heart disease, the worst for respiratory problems and the worst for early deaths. And please avoid the rhetoric that would have you believe that it is because of low aspiration and poor choices made by the people here. The North-West is underfunded in terms of health training, according to Health Education England, to the tune of £19 million every year, when compared head to head for other regions. And given the fact that health outcomes are so poor here, it is fascinating that 94% of all health research monies are spent south of Cambridge.

Looking at the health system here, it would be easy to be disheartened. The recent Kirkup enquiry into drastic failures at the University Hospitals of Morecambe Bay Foundation Trust, to which the trust has responded with humility and learning, highlighted just how much change is needed here. We also face the vast complexities associated with local tariff modification. And as if the local challenges are not enough, we have the added recruitment crisis that is affecting the entire country (worse in rural areas), the undermining of our junior doctors and their pay, the berating of nursing colleagues from overseas who don’t get paid enough to remain here, severely low morale in the system as a whole, and a maltreatment of General Practice in the National Press at a time when the profession is on the ropes; then there is the huge debt of the hospital trusts – compounded by the PFI fiasco and the creeping privatisation of our services, which has led to the shambles that is out of hours care and staffing issues due to agency working. And all that is on the background of a hugely underfunded healthservice, with only 8.5% of GDP spent on health compared to the 11% most other OECD countries spend. The truth is, we simply do not spend enough of our GDP on health care for it to be sustainable in its current form, and the government knows this.

For the last three and a half years, I have been working here as a GP, having previously spent 14 years in Manchester. Three days a week, I work clinically in my practice, and the rest of my work time is given over to being part of the executive team for the Lancashire North CCG – I am the lead for Health and Wellbeing. Although the odds are stacked against us, something really wonderful is stirring here. I would go as far to say that believe it or not, Morecambe Bay is one of the most exciting places to be involved in health and social care anywhere in the UK. Let me tell you why I feel so hopeful (and why you should consider working here)!

Understanding the Purpose of Healthcare

A chap called, Phil Cass, who is an (unmet) hero of mine in the medical field, lives in the state of Ohio. He has been been doing some work with local communities to try and make healthcare affordable for everybody – a truly noble quest in a country where 50 million people cannot afford any. He took the conversation out to the community and they tried various questions, but found they weren’t really getting anywhere. He and team of people then realised that they needed to ask a better question. The question they needed to get to was “What is the PURPOSE of our healthcare system?” – Once the communities began engaging with this question, something remarkable happened – time and again, the same answer came through – the answer was this:- “to provide OPTIMAL healthcare to everybody.” The word optimal recognised that every person would achieve different “levels” of health depending on age, underlying health problems, genetics etc, but the vision of the community became that they wanted every individual and the community as a whole to live as well as they could. The community then realised that in order for this to be achievable, they had to fundamentally change their relationship with the healthcare system and this then made care much more affordable. Here in Morecambe Bay, we are taking a similar conversation to the 320000 citizens who live here.

Starting and Finishing with People

The NHS has become a horribly target driven culture and amidst the stress and strain, in which staff themselves often feel dehumanised, it is easy to forget what we are here for – human beings. Putting people (rather than patients) at the heart of how we think about health is a vital starting point.

So, we are learning to truly engage with and listen to the people here. With the help of an amazng team, I have been hosting conversations here in Carnforth, in the form of ‘World Cafe’ discussions (a fantastic way to ensure every voice is heard). Our hope is that from Millom to Morecambe, we will see conversations springing up as we talk about how Morecambe Bay can become the healthiest place in the UK. And by being healthy, we do not mean just physical health. We are talking about mental health, social health (there really is such a thing as society!) and systemic health (including issues like road safety – still the biggest cause of death for our children, the environment and pollution, the real effects of austerity on our communities, the power of advertising and the high cost of healthy food). And as we talk with our citizens, we are not coming in with ideas of how to fix things, as though we are some kind of experts. People are the experts in themselves the their communities, and we have some expertise in a variety of fields. So, we have a meeting of equals. We are waiting to see what rises within the communities themselves and looking to support initiatives where that is wanted. Communities are having some really exciting conversations and some people are standing up to become ‘health and well-being champions’ (the photo is taken from a recent event, supported by our Mayor in Carnforth, looking to do exactly that), who want to help steward the well-being of the community and the environment. It is incredible to see how many people want to get more involved with making this area more “healthy”. Volunteers are springing up with ideas like gorilla gardening, shopping for elderly neighbours, cooking meals for those coming out of hospital, setting up choirs, starting youth clubs, community transport services to help housebound people get to appointments, cleaning up our streets, creating safe parks and being hands on with support for those receiving palliative care. People are learning to ‘self-care’ and care for each other more effectively.

Atul Gawande, another hero, has written powerfully in his book ‘Being Mortal’ (a manifesto for change in how the medical profession deals with the whole topic of death). It challenges the ways in which we don’t face up to our mortality very well. We end up spending an inordinate amount of money in the last year of someone’s life on drugs which have a lottery-ticket chance of working, when all the time, we could help people live longer and more comfortably if we introduced hospice care earlier and treated people with compassion. We are looking to launch compassionate communities here, where we are not afraid to talk about the difficult issues of life. We want people to have the kind of care that allows them to make supported choices to live well, right to the end. Our BCT Matron, Alison Scott, is a true champion of this cause, along with Dr Pete Nightingale, the recent RCGP national lead of palliative care, Dr Nick Sayer, Palliative Care Consultant and Sue McGraw, CEO of St John’s Hospice.

From the moment of conception to the moment of death, we want people to have optimal health in Morecambe Bay. We want people to be able to live well in the context of sometimes very disabling and difficult circumstances and illness. We want to see care wrapped around a person, recognising that this cannot always be provided for by the current ‘system’.

Better Care Together

Before the government launched its five year forward view for the NHS, we were already in the process of learning to work very differently here, around the Bay. We have been blurring the boundaries between various care organisations (including the acute trust, the mental health trust, the GP practices – now forming into a more cohesive federation, community nursing in its various forms, the police, the fire-service, local schools, the voluntary sector, the county council and social services), building relationships between clinical leaders, sharing the burdens of financial choices and care conundrums, strengthening the pillars of the various players, redesigning care pathways across the clinical spectrum to ensure better care for patients and infusing everything we do with integrated IT.

The creation of integrated care communities (ICC) is at the heart of the vision to transfer more care out of the hospital setting and back into the community, whilst ensuring that the funding follows the patient. Our care co-ordinators become the new first port of call for our most vulnerable or ‘at-risk-of-admisison’ citizens. The idea is to wrap care around a person in the community, with the appropriate services being called in. Many times a care coordinator can bring in help from allied professions/volunteers and avoid unnecessary admissions or overlap of services. This means less pressure on the Emergency department and less pressure on General practice. We are also working to ensure our Urgent Care provision is fit for purpose with GPs, NWAS (our ambulance/paramedic service) and Out of Hours care offering much more of a buffer for our Emergency Departments.

Radical Leadership and the Challenges Ahead

There are many challenges ahead and both local and national threats remain. We are steering a huge ship through an iceberg field, and the so the waters are dangerous. We risk a lack of transfer of funding towards General Practice making it difficult for appropriate ‘buy-in’ for the changes we need to see. GPs ourselves have some brave leaps of faith to make. We will not be able to guarantee more money in our own pockets, but we must decide between protecting what we know or federating more fully for a more sustainable and excellent provision of care in the future (providing better education and career development in the process). We risk disengagement from senior clinicians in our hospital trust if the vision is not fully owned and shared by all. We have huge risks associated with the truly shocking cuts being forced upon our county council and a destabilisation of social care. We risk our nursing care home provision causing a halt to the entire program due to the vast complexities involved. Political whims, rules and pressures often seems to knock the wind out of our sails and could still utterly destabilise and destroy what is tenderly being built here.

However, one of the things which I have found most encouraging here is the quality and attitude of the leadership. Andrew Bennett as the SRO for BCT and Jackie Daniels, the CEO of UHMBT (the acute trust), have built stunning teams of people! I have the privilege of sitting on the executive board for the CCG and we have exec to exec meetings with the acute trust, in particular. The truth about Better Care Together is that for some it may mean doing themselves out of a job, letting go of power, and choosing facilitation and servanthood over domination and self-preservation. Leadership that is determined by the future and is able to lay itself down for the sake of what is really needed in our communities is exactly the kind of leadership we need. The leadership here across the spectrum is brave, it is altruistic, it is kenarchic, it is relational and it is rooted in the community.

And so we press on, knowing that we cannot remain as we are, knowing that in building together with our communities, we are finding that the future is not as bleak as it might otherwise be. Together we are wiser, braver and kinder. Morecambe Bay is no longer the butt of the jokes. It is becoming a place of hope, a place of potential, a light that is beginning to burn, dare I say it – a place shaped by love. It will be a place where health abounds in the beauty that surrounds.

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Reimagining Health

Conversations about Health and Wellbeing

Tag: leadership

3 Keys for the Future of Healthcare

What Lies Beneath?

A Co-operative Future for General Practice?

Time to Face the Music

A Different Kind of Leadership for the NHS

Changing the Culture of the NHS

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