Abstract
‘There is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things. For, the reformers have enemies in all those who benefit by the old order and only lukewarm support from those who profit by the new order, because of the incredulity of mankind, who do not truly believe in anything new, until they have the actual experience of it’
Those who cannot remember the past are condemned to repeat it – at the heart of every major NHS inquiry over sixty years, there have been two critical issues: the first is people and relationships, which for those looking in from the outside, appears to be a nebulous, somewhat hard to understand issue, when the presumption is that all healthcare professionals work together to act in the patient's best interests. The second issue is the brutal lack of kindness – something us professions struggle to come to terms with, but the issue that most angers the general public and leads to demands for public inquiries. Anyone who has been seriously ill knows that it is the individual acts of kindness on the part of nurses, doctors, receptionists and portering staff that make it possible to cope. 3
History suggests that we don't learn the lessons – in fact, experience reflects that we make the same mistakes with increasing confidence. It is almost as if we invest vast amounts in public inquiries but never seem to pause long enough to understand, learn from and respond to the lessons emerging. How many more public inquiries do we need to fully grasp the cost of poor, indifferent or absent leadership among our professionals? How much more regulation is possible? Once you lose trust in a person, a political party, the brakes in your car, the safety of an airline or the competence of your hospital or GP, then everything about your fallen object of trust is seen with new eyes. Consider the growing elderly population for instance. There is a real, evidence-based (regulatory body report after regulatory body report) concern on their and their relatives' part that an NHS elderly medicine ward is a place of no return. 4 In the drip, drip of insights seeping daily from the Francis Mid Staffordshire Foundation Trust Inquiry, the steady erosion of trust in the NHS continues. The emergent consensus is that there was a lack of clinical engagement – that the doctors and nurses didn't seem to care enough. The culture described wasn't confined to just one hospital but is known to exist in part and in whole throughout the NHS. That culture has at its heart poor leadership – individuals in responsible positions who failed to take responsibility, who permitted poor behaviour, who themselves displayed unacceptable behaviour – through their attitude, emails, conversations, clinical care and relationships with their colleagues – good individuals who did not do the right thing, particularly on a difficult day and were not accountable. Individuals who had completed many leadership development programmes. Individuals who did not act, less because of a lack of regulatory guidance and more because of a deeply felt reluctance to go against ‘how things are done around here’. How many local GPs knew what was happening in Mid Staffordshire and couldn't find their voices to protest? Similarly, how will clinical commissioning groups challenge secondary care consultant led services that are deemed not to be of an acceptable standard? Don't we spend a fortune on leadership development and if so, what is it we teach? How do you influence a poorly behaving colleague in an organization with weak governance and workforce practices? All of this has been known for many years and certainly before the Mid Staffordshire inquiry began. 5–7
Without fit for purpose leaders and proper leadership development of the over 250 clinical commissioning groups who will assume £60 bn of funding from 2013, there is real potential for the undermining of public trust in the NHS and for clinical catastrophe at scale.
Governance and regulation from outside are important but they are less important and can do less for patients than professionals at the bedside and in the surgery. Self-regulation needs revisiting: doctors influence doctors and nurses influence nurses. Leadership and vision are everything in this context.
This piece is an introduction to lessons in leadership which will offer real life learnt lessons on how to influence capable professionals to do the right thing on a difficult day. There will be no mind-numbing case studies about ‘enablement’ ‘empowerment’ or ‘process re-design’. There will be stories on the understanding that narrative is data and that there is no such thing as an isolated incident.
DECLARATIONS
Competing interests
None declared
Funding
None
Ethical approval
Not applicable
Guarantor
AH
Contributorship
AH is the sole contributor
Acknowledgments
None