On being “inside the tent”

Being “inside the tent” is not much use without values, courage and strategy.

A recent conversation with a very senior NHS person went like this (I have paraphrased but only slightly)

· Me: But why have you put you name to a policy that you know won’t work?

· High profile person: Sometimes you have to make compromises to stay inside the tent because outside the tent one’s influence is vanishingly small

· Me: But we both know this policy won’t work

· High profile person. That’s not the point. Not going along with this risks being excluded from future discussions.

Don’t get me wrong. We all make compromises, We all duck and dive. I’ve done it many times over the last 55 years. The question is at what point might supporting a policy or a decision that we know won’t work (or remaining silent in the face of injustice and serious risk to staff or patients)  be justified?

Raising concerns, asking awkward questions, challenging those more powerful than we are is not easy.  All of us have, from time to time, made a careful calculation about the risks and benefits of doing so. And we may have decided now is not the moment to raise a concern or ask an awkward question. If the risk is to your job, to your career, to your family’s welfare then those who say they never hesitate are being economical with the truth. And it is worse if you are a new recruit, on a temporary job, or in one of the many groups of staff who have to pay particular attention to being singled out  - such as black and minority ethnic staff

Most organisations are hierarchical and do not welcome “difficult” news or “difficult” people

As Robert Francis put it in his landmark 2013 NHS report on the scandal at Mid Staffordshire NHS Foundation Trust:

“There lurks within the system an institutional instinct which, under pressure, will prefer concealment, formulaic responses and avoidance of public criticism’; and an institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern.”

I myself have three Compromise Agreements from trade unions I worked for after raising difficult issues with three different unions I worked for and then had to leave.

Almost every week since the Francis Report I have been told of NHS staff silenced (or sacked) after they raised awkward questions, expressed unease about policy developments  objected to their own unfair treatment or that of others, or simply not been seen as “one of the club.”

A significant number of these colleagues have been senior staff including a surprising number of Board members.

The issues may be prosecuted by HR staff or meet a reluctance from HR staff. They may involve the mistreatment of HR staff, I do not want to suggest that those whose job it is to lead on employment relations in an organisation or whose job includes trying to make progress on issues such as discrimination, whistleblowing, discipline, bullying and harassment should never compromise, duck and dive, or make that calculation as to when and how to raise a concern.

The best colleagues in OD, workforce culture or HR do question, challenge and are determinedly curious when Ministers, CEOs and Chairs - and senior managers - seek to set policy and direct its implementation or behave in ways that are unacceptable. So do many other professionals who are asked or required to work in ways that are a risk to themselves, to colleagues or to patients.

But silence is not an option. When all else fails, such staff need to find a way to at least place their concerns on the record.

To not do so means neglecting your duty of care to colleagues and patients. It means not treating others as you would want to be treated yourself. It may well mean leaving the challenge to poor behaviour to those subjected to it or actually colluding in it

It may not always be possible to say or do what you know is necessary in the moment. 

But you should always ensure that in some way your concerns are placed “on the record” if only as an audit trail for future better practice and your own protection. And rather than just raise a concern you should do your very best to try to articulate an alternative to what is proposed or is happening  and evidence your concern. Silence is collusion.

Many of the most important improvements in the NHS have come from staff who spoke truth to power for themselves, for colleagues or on behalf of patients.

Consider what happens if you don’t.  Is there are a single one of the maternity scandals where staff did not raise the very concerns subsequent inquiries upheld? One might go further and ask what do local leaders of any profession do when it was apparent or should have been that something serious was amiss?

Until very recently improvements, evidence-based initiatives on workforce culture, have very rarely come from the national leadership of the NHS. One exception was the crucial support from Simon Stevens for the Workforce Race Equality Standard. But even this was achieved in the face of resistance from the national employers body, the largest NHS trade union, and from those who argued that the EDS2 scheme was a worthy alternative to the WRES even though it relied on self-reported Trust judgements – marking their own homework.  I recall one conversation from 13 years ago (I have the notes) which went as follows:

Employers’ leader: We are happy to accept ethnicity data collection on senior leaderships but not the list of metrics you are proposing  on other issues within the WRES.

Me: But only monitoring who gets to the most senior positions is like counting who gets to the top story of a building without putting in place metrics and mechanisms to enable and ensure access to the stairs, lifts or escalators needed to get there.

Most other initiatives of workforce culture have been driven by events outside the NHS or by those within the NHS who were prepared to be curious, question, challenge or simply get on with developing local improvements. To give some examples:

• The disciplinary triage initially devised to challenge racism in disciplinary processes but which has benefitted all staff and organisations

• The work to minimise harm in employment processes (especially discipline)

• The evidence for work to highlight and address incivility in NHS workplaces

• The evidence, for and work to create, a more compassionate NHS culture

• The evidence for, and work to tackle, the silencing of those who raise concerns about racism

• The work done by numerous patient safety advocates to move away from a “blame culture”

• The work on a “just and restorative culture”

• The development of an evidence-based approach to recruitment and career progression despite the best efforts of senior leaders to undermine them

• The campaigning work led by the #MeToo campaigners outside and inside the NHS which led to legislation and national policy

An interesting example of how work done “outside the tent” can influence and be done in a collaborative work with those inside the tent was been the recent development of the draft NHS Guidance on Investigation Processes and related training programmes.

A good example of where the NHS nationally has taken little or no notice so far of the evidence base is on how to create a more open culture where staff can raise concerns safely and effectively is on Speaking Up. We have bookshelves of policies and procedures despite the evidence showing something quite different is needed. Leaders need to stop wring their hand and stepping in to lissten and act.

But there is a wealth of evidence on what does work (and why the current obsession with policies and procedures doesn’t work) but it is largely ignored.

There are many “inside the tent” doing their very best to make progress, challenge injustice and support evidence-based initiatives. But real progress will depend on mobilising both those within the tent determined to do the right thing and those outside the tent who can be the “grit in the oyster” making sure it actually happens.

Those who rely on impressing Ministers or national leaders in order to stay “within the tent” do those issues they purport to care about no favours.  They set an example that deference, silence, a nodding head and a closed mind is “how things are doing round here” When that happens why would other staff further down the food chain risk their career to speak truth to power?  Too many leaders still contribute to a culture of deference and collusion that obstructs transparency and compassion. The current versions of leadership and management Codes will make little difference.

Those who are entirely “within the tent” but without an ethical compassion, courage and strategic intelligence risk not seeing the daylight outside. They also risk abandoning those who do have an ethnical compass and courage but pay the price when their immediate managers betray them and the wider system looks the other way,  Those who are tentatively within the tent but keep having to prove their loyalty are no better.

As one former, excellent, NHS chief executive who won her employment tribunal but was betrayed by NHS “leaders” in this way replied when I mentioned  this challenge that said  “I am now not even on the same campsite, never mind inside the tent”

If the new Secretary of State for Health and Social Care Yvette Cooper is serious about improving the NHS, she should beware those who simply nod their heads. Instead she should listen to those who are curious and constructively challenging, guided by a moral compass and uplifted by their courage. And then make clear she expects all NHS leaders to do the same.

If she doesn’t, no daylight will enter her tent.