NHS bodies were created as trusts with their own boards so they had some autonomy and could set their own cultural norms – except this was largely illusory as they were not independent, and many senior staff carried baggage and had wider loyalties. The executives often looked to the Strategic Health Authority for their steer not to their board; not all Non Executive Directors were sensible appointments. The Strategic Health Authority, the top down performance managers, had tentacles everywhere, drove things forward. This was not just about meeting national targets supporting national intentions – it was far more pervasive as the Strategic Health Authority often had their own agendas and plans they wanted to drive through, or the Department of Health launched some new cunning plan.
It was worse for fledgling Primary Care Trusts which came into being from scratch with an incoherent business model (both provider and commissioner) with largely inexperienced NEDs and with many senior executives promoted into their new roles. By and large PCTs were outposts of SHAs which by and large were outposts of the DH.
The emergence of Foundation Trusts which had something approaching autonomy and some freedom from SHAs helped, but the SHA could still bully the commissioners and they could then use contract leverage to manipulate the FT. And being an FT did not prevent the executive team and indeed the Chair from being shouted at by DH or SHA and warned about future prospects.
There are a few bits of the NHS out of reach. It will be interesting to see if behemoths like Leeds and Leicester, struggling for years yet still years away from being FT ready, are judged too big to fail. A few big teaching hospitals have a very large degree of autonomy. And Mental Health trusts (with usually much stronger association with user groups and partners like local authorities) are less open to top down management by shouting.
But the rump is suffused with a culture that is top down, defensive, insular, reactive – and incidentally largely impervious to criticism from staff or patents and public groups but highly sensitive to top down attention. Bullying is rife in the sense of strong performance management.
Many directors have been shouted at for saying the wrong thing or doing the wrong thing; just about everyone I know has had some experience of threats and intimidation. I know of several people who went into the NHS after many years of distinguished public service and with an established reputation yet were treated in ways they never experienced before in long and successful careers. That is the NHS way.
Not everyone is bullied or victimised thanks to another poisonous facet of the NHS, cronyism. Many at senior level owe their position to friendships and connections and an in-crowd who toe the line and keep quiet are protected. Protection sadly also extends to large payoffs for failure – anything to keep issues out of the public glare – as the spotlight might then be focused on those above. People have effectively been removed for failing to execute plans that were signed off by the level above but which turned out to be flawed. Someone very senior must have signed off each of the numerous failed plans, daft PFI contracts and other major programmes costing £100ms – nobody has ever been taken to task.
The culture of bullying runs deep and did not start in 2006. It has roots in the style of consultant (stereotypical but essentially true) who bully their juniors and the nursing staff as they waft through the hospital; just as they in turn had been bullied.
The clinicians’ culture ensured the NHS was isolated and not part of the wider public service; it supported the siphoning of funds into the acute sector and denigrated mental health and primary care; it had no sense of value for money and happily operated rationing through waiting; it protected unacceptable variation; it saw no role for the public other than as patients to be dealt with.
Many still look back nostalgically to the golden age that never was before Griffiths and before any form of management. Leave the clinicians to do their job. That arrogance from the most powerful group led to the style of management which had to try and challenge it when finally someone started to try and impose long needed reform.
Putting more clinicians into management might help but only if they genuinely shifted away from their tribe and their colleagues and were willing to make unpopular and difficult decisions.
Maybe targets and terror was the only way to get things done. It fitted with the way things were. Now I believe the game has changed and voice is powerful enough. We can now change the culture but it will take a generation. We can only start once those who for years have operated the old culture are gone.
And I said all this in 2006.