Who do you work for?

In the NHS, do we work for an organisation or do we work for our patients? Maybe how we answer that question depends on our professional background, and maybe it influences how we behave.

An artists impression of me in a suit

Trigger warning

There are some trigger warnings that I feel might be useful for me. One of them is stories about whistleblowers and protecting the brand.

This is about one such story, how it made me feel, and why it made me feel that way. It’s not about the story itself - in fact I’m very uncomfortable when such stories get played out in the media, as it often becomes a PR battle rather than revealing any specific truths. That said – post office scandal.

But such stories often do highlight broader points that deserve an airing.

Whistleblowers and organisations protecting the brand

Link to article

Reported in iNews yesterday, in the hyperlink above, was a story with a familiar theme. A clinician in an NHS organisation is highlighting his experiences of raising concerns. He calls out a culture of cover-up and protection of organisational reputation as first priority. I have not read the book referred to, but sadly I don’t even think I need to (although I will), as I recognise the highlights described in the article. It resonated with me and with others, even as I also understand there will be other perspectives on the same specific circumstances here. There is an understanding in the article of the reasons for brand importance – public confidence, staff confidence etc. But there’s also a criticism of personal motivations, or at least the appearance of personal motivations.

I’ve witnessed first-hand whistleblowing of a similar nature. Some of the factors described in the article were at play. It was resolved to mine and the complainant’s satisfaction, but was uncomfortable, and left a bad taste in my mouth. I had to educate myself about Boards – Executives and Independent Members, their responsibilities, roles and terms of engagement. I eventually became a Board Member, and found myself engaging with Board Members, (both Executives and IMs) of other organisations. Realising that Independent Members were there to apply scrutiny to the organisation’s executive members gave me some reassurance, and in the instance, I allude to here, that dynamic was key. Senior managers and clinicians worked together dealt with the underlying issue rather than avoiding appropriate scrutiny.

The Corporate Response

The issue I experienced was resolved and handled well by those to whom the task fell. But I have also seen how readily organisations who have experienced an adverse incident, report or audit, or feel criticised (by an external actor or from within) will rush to ‘protect the brand’ with greater energy than they might address the underlying issues. Those at a senior level may well move rapidly to protect the reputation of the organisation: they’ll recite successes and deflect blame (lack of money, other NHS organisations for failing to spend enough/ do what they’re told/ modernise). I have seen this first-hand on many occasions. There will be truths in there: as I say the issues are complex, but it’s overall not a great look for the ‘NHS’ brand. This type of reaction is often labelled a corporate response.

Cases like the one linked to above make me wonder why people develop a ‘corporate’ mindset. Mostly, these are not inherently bad or uncaring people, so what’s going on? For clinicians, much of the work we do is perceived as being part of a broader system, spanning more than one organisation. Maybe it’s slightly alien to some of us?

What makes people corporate?

I’ve seen the word corporate is used both positively and negatively. For some it indicates a team player, someone signed up to the goals of their workplace. For others, especially many clinicians it’s a derogatory term. Am I corporate? Some colleagues are laughing at the back.

Early years

In my first decade as a doctor, I was generally unaware of the organisation I worked for. I considered that I worked for hospitals, units, practices and didn’t notice the name of the organisation on my payslip. Or maybe it was ‘NHS’ I worked for? But actually, I genuinely felt as though I worked for patients and the population at large, perhaps under that umbrella NHS badge. I know how that might sound a bit worthy or even pompous, but it was true and is how many clinicians were brought up as undergraduates and early graduates.

The organisation I was employed by and who paid me was largely irrelevant to my day-to-day job. Strategy may have existed, but for me it was definitely in the ‘whatevs’ basket. Sometimes there would be a poster somewhere that would be text heavy and have some management-sounding words on it. The posters evolved into ones with pictures and shorter, terndier buzzwords and completed their evolution to their current endpoint of infographics with cartoons, icons and cool snappy phrases in different font sizes. I have vague memories of straplines and mission statements appearing sometime in the mid to late 90s – or at least that’s when I first became sentient in an organisational sense.

Most clinicians and staff are in this space in their early years. Some remain in it for the duration of their careers. They’re often the ones who are smiley and seem happy in their work.

Moving to the dark side

This cliché about a move into ‘management’ is often delivered in apparent jest – but the recipient usually knows it’s not a jest. A colleague has told me how they were the recipient of three Darth Vader keyrings on making a move into a managerial role. When I moved into this space, initially as a Clinical Director, I made myself even more of a target by starting to wear a suit when not on duty clinically. Partly this was about sending a subliminal message to colleagues that I wasn’t available for clinical queries, but mainly because I thought I looked good in a suit. Uncannily like the bloke in the picture above. I almost literally became a ‘suit’.

Like most clinicians in my ken, I moved into ‘management’ roles partly because I thought I could do the job as well as the incumbent but was worried about who might take over instead when they were moving on to something else. There were colleagues very happy to push me forward – ‘we’re right behind you (at a safe distance)’. This is changing now, in that these roles are called ‘leadership roles’ rather than management, and that perhaps makes them more attractive. It certainly does describe their nature much more appropriately, although I do subscribe to the Mintzberg school of thought that you need to both lead and manage. I may write about his excellent book ‘Managing the Myths of Healthcare’ on another occasion. There is also the danger that too many people might be attracted to the label: leader sounds better than manager, and I’m not sure that’s a better motivator than believing you’re the least worst option.

The suit may have been an outward signifier of ‘corporate’, but I did internally embrace the whole environment of organisational strategy, working for a ‘bigger picture’ vision, recognising the complexities and interdependencies that made my agenda seem less important. That last point became quite challenging for those colleagues who were ‘right behind me’. As I began to replay them some of those organisational considerations, the accusations of ‘going native’ or ‘turning corporate’ arrived by the Inbox load. I hadn’t even been a prefect at school, so I wasn’t prepared for this level of anti-establishment opprobrium.

In those early days, by contrast, the welcome from those in the middle and upper corporate levels was good. I brought clinical stories, clinical analogies and a mid-range M&S suit to the table. Like many arrivistes in this world, I was seen as a breath of fresh air. Inevitably, I eventually became a nagging draught, and some might even say a beast from the east, although because I had a couple of supportive and breeze-tolerant chief executives during this period, I survived.

Sinking to the top

As I moved up the organisational hierarchy, the tension between what I thought needed to be said and what my colleagues at that level wanted to hear grew. Even so, I eventually became a Board Member, so at the ‘top’ of the organisation. That earlier self-directed learning on Boards and IMs became important. I was able to reach out to some excellent non-execs who gave me help and advice and who wanted the best for patient care. And at an individual level, those Execs with whom I established 1:1 relationship were supportive, and likewise caring in relation to patient services. But there was a but.

There was always something I couldn’t quite put my finger on in those conversations, as though I was still missing part of the picture. It was during collective conversations that it was most striking. I’d read that a background in psychology was useful for going into leadership roles, but I’d started to see that much of what happens in organisations is about behaviour in groups rather than individuals, and I’d advise anthropology as an equally good background.

When bad news arose, there was often a genuine expression of concern and a desire to rectify or ensure no repeat, but it was always tempered by conversations which could be characterised as ‘how the story should be managed’. I was definitely uncomfortable at times that the latter was generating more focus than the former. There was no question that protecting the reputation of the organisation was an important consideration, and though it may have been a misperception on my part, it did sometimes seem to be the most important consideration. There were no cover-ups, no dishonesty, but there was definitely a feeling that my anthropological background was different to the others present - there was a group response I wasn't quite in step with.

It is understandable that managing a message would be important. Public confidence and staff confidence in health services are important to maintain, even in the face of adverse events. The majority of services were routinely delivering very good care, and it is important for those who continue to be, or oculd soon be the recipients of care to understand this and not feel unduly alarmed. Likewise, it is demoralising for staff delivering safe and effective care to feel that all of their great work counts for nothing in the face of an adverse incident. That doesn’t mean, or at least shouldn’t mean covering things up, rather ensuring that there’s a proportionality in how such events are communicated.

Most clinicians would argue the best way to maintain confidence is to display transparency, but not all the clinical professions have a spotless reputation in that regard either – there has been a culture of clinicians ‘circling the wagons’. The protection of reputations and brands is not unique to senior managers and executives.

Importantly, those in leadership positions should expect to be held to account, and like anyone else, will expect that to be fair and hopefully positive. If they are being held to account over ‘how things appear’ rather than ‘how thing really are’, that will drive behaviours. So those at the very top who hold that accountability role need to ensure they are doing so on the right basis. That was one of the considerations in developing a National Clinical Framework with a very clear emphasis on meaningful outcomes, and a much broader clinical network informed accountability process. Creation of a legislative Duty of Candour might help, but it’s not going to be enough without supporting the change in mindset it requires. To be fair to its authors they wouldn’t claim that to be the case either.

Before moving on, a final word on accountability goes back to that relationship between Independent Members and Executive Members. My roles had meant I spent some time interacting with the Boards of other health organisations in Wales. There were some in which it felt like there was less challenge and perhaps too cosy a relationship between the two. By design I’d have expected a degree of challenge and maybe even some friction to work through. It may have been performative of course, for external consumption, but it jarred with my experience of IMs who asked appropriate but challenging questions.

Clinicians and Managers; Synergy not Discord

I feel the need to clarify before going on to my closing points.

This is not an attempt to argue that clinicians are better than managers, nor is it that managers are better than clinicians. Those two tribes are similar but different. It’s their experiences and upbringing in a professional sense, that shapes their perspectives. I believe that when working in equal partnership, they are synergistic. That belief comes from experience. I have also had experience where one group seeks to dominate the other. That only ever brings discord, disharmony and builds resentments that persist.

It's also a generalisation. I work, and have worked with many managerial colleagues who have a sense of duty as deep as mine, or any other clinician, towards the NHS or to broader public service. Maybe what I'm trying to describe is something about the professional oaths some clinical professions adhere to in terms of caring for the patient above all else, and having the experience and privelage of actually delivering that in a face to face sense. But I also have colleagues who have a clinical background, but who have become part of that corporate mindset I'm trying to understand - as though organisational values have trumped their professional ones. So I don't think it's a question of managers not caring as much - it would be crass to argue that clinicans are a seperate species who care more than others - I don't think that is true, and it certainly hasn't been my experience. It's something more subtle.

I’ve tried here to postulate one way in which the two broad groups’ thinking might differ slightly, suggest why that might be and then provide a call to arms that harnesses the differences: hybrid vigour and all that.

Stewardship as the solution?

When I was doing more of the ‘managing’ than the ‘leading’ part of the job as CD, many of my medical colleagues were genuinely perplexed by organisational considerations. If I was communicating or trying to implement something perceived as a 'management initiative', they would often say their duty was act only in the patient’s best interest day to day, and that was there only concern. (The best would say they worked in the patients’ best interests of course). Some were even more explicit in making clear the low degree of relevance they attached to an organisational directive. I would sometimes find this frustrating, and it could feel as if a trump card was being played to win an argument, but I learned that it was deeper than that. Most clinicians had a deep-seated vocational sense of duty, and even if sometimes expressed arrogantly or piously, it was genuine. There were a few who probably were playing cards, but very much a minority.

Is it the case then, that on some level, maybe even subconsciously, that clinicians consider they are working for patients rather than organisations? Do non-clinicians in leadership roles, and clinicians who have ‘become corporate’ feel that they work for an organisation whose brand must be protected? It might partially explain why many clinicians are prepared to criticise the organisations in which they work if they feel it’s merited. They are, of course, part of the very thing they criticise, but maybe they don’t feel they are? I’ve certainly been told by clinical colleagues that they do their jobs as a duty towards their patients, and in spite of rather than because of their organisation.

This may be relevant at national level, maybe even more so. I’ve had several years’ experience sitting at those tables, and I think some of the illustrations above also hold water here. I sense a desire to protect the brand, whether that’s a government one, or that of the NHS, perhaps informed by the reality that those are the employing organisations. I’m not saying that reputation is the only consideration, but it does often seem to drive the conversation more than is healthy.

At those national tables there is much talk of ‘levers for change’. Leaving aside any conversations about whether such levers are even connected to the system, the language may be inherently unhelpful. It continues to foster the idea that somehow, it’s possible and desirable to control an operate the system from the top. Because that’s what organisations generally seek to do. If instead, we characterise the language around stewardship, then at national level the conversations move on to one that’s more about setting the conditions for the component organisations who actually plan and deliver services to do their work, providing the central guiding hand function and holding them to account on the basis of clinical outcomes rather than on a successful public relations exercise.

The strategic ambition laid out in A Healthier Wales did seem to be leading in the direction I’ve attempted to describe here, particularly in relation to an NHS Executive. The Welsh Parliamentary review, from which AHW had its genesis, imagined it would be that guiding hand function, perhaps freed from illusions (or delusions?) around levers for change, but focussed on setting the environment and fostering a clinically led system both in direction setting and accountability. I’m not sure it has been established in a way that allows delivery of that vision, although doubtless there will be a review process to examine whether or not it has.

I hope that this great opportunity to set an environment of transformational change is not lost. The Welsh Parliamentary Review called for a revolution from within, but my sense is that even an attempted velvet revolution is in danger of being suppressed.

Next time

There was another story for which I should have had a trigger warning which appeared in my news feed this morning. That was about the ongoing failure of the NHS to embrace digital technology at pace, and deficiencies in an ability to deliver best practice arising as a consequence. It is not unrelated to this blog, as themes of governance, accountability and reputational protection will be covered.

That’s for the next one though.