Guest post: What will help prevent tragedies like Mid Staffs happening again? Time for a shift in attention.

Steve Onyett

Care and appreciation. Simple but more
powerful than we realise
Pictue: Deviant Art

It seems to have become fashionable to criticise the NHS – or in newspaper-speak to ‘attack’ it. Of course scrutiny of public services is important, but the relentless focus on blame for failures worries me. In the words of Dr Cliff Mann, president of the College of Emergency Medicine, ‘we want to make sure that we don't end up demoralising the very people that we need to keep our health service going’. This sentiment was echoed in a recent open letter in the Guardian from leaders of ten NHS organisations. I’m encouraged by campaigns like ‘Big Up the NHS’ on Twitter which recognise that, as all parents know, praise and encouragement generally get you much further than relentless criticism.

It’s worth being absolutely clear, though, about the scale of the culture shift needed to restore a sense of meaning and vocation among NHS staff. Can this be achieved? How should we go about it? I’d suggest the solutions are radical but also surprisingly simple.

Let’s be clear first about what won’t work. Culture change is not achieved by leaders standing in front of the workers extolling a new set of values, or extorting behaviour change with threats. Nor are rewards and incentives the answer (though people should have access to decent pay and conditions). People are waking up to the dangers of naïve and insulting approaches to incentivising moral behaviour. As John Seddon observed ‘All the research evidence shows that incentives get you less work and, more importantly, they result in people attaching less value to their work’.

Instead, initiatives such as the Good Work Commission highlight the motivational importance of meaning and the inherent social value of work. For example, Barry Schwartz tells the story of a hospital janitor who had the job of cleaning the room of a young man who was in a coma following a fight. This young boy’s father was keeping a vigil all day every day, except for the times when he would pop out for a cigarette. On one occasion the dad was out smoking and didn’t see the janitor clean the room and wash the floor. In fact he accused him of not cleaning it. Although angry at this injustice, the janitor cleaned the room again. He did this so that the boy’s father could see him clean it. He had some understanding of what the father was enduring and wanted to do something that the father could think of as a direct contribution to the welfare of his son.

Schwartz observed that this janitor and all the other invisible people who show daily compassion, could do this because they weren’t being over supervised, and ‘still [had] time to do what they thought was their real job, which was to provide comfort and care to patients and their families’. This is skilled and satisfying work. As Schwartz noted, ‘Over time, you learn when to intervene, how to intervene and [what] small things you can do that make a big difference’.[1]

The Government Response to the Mid Staffs Inquiry suggests addressing morale through adequate staffing. This will help. Imagine that same janitor closely monitored, and over-supervised in pursuit of an unrealistic target (such as the number of contacts our community care staff have to achieve, particularly overstretched local authority contracts).

However, I worry about some of the other recommendations of the report: in particular the emphasis on increased scrutiny through performance management and swift punishment when things go wrong. Of course, we need to be alert to failures in care, and punishment may play well for politicians. They might even think this is ‘leadership’. But psychology teaches us that if we want to change the culture, we need to make our main focus something else: celebrating the good wherever we find it. The things we focus on tend to get bigger[2].

Effective and sustainable cultural change is both personal and simple. It involves us all shifting our attention further towards the positive in each other and in the actions we take. As Tony Suchman observed, ‘We are creating the organisation anew in each moment by what we are saying about it, and how we are relating to each other as we carry out its work’[3].

There is an opportunity here. It is no surprise that our immediate line managers are the biggest source of influence on our wellbeing and performance at work[4]. This opens up a huge opportunity to do something powerful and extremely scalable. Research on NHS leadership has found that simply showing authentic personal concern for someone you are managing probably has more impact than anything else you might do[5]. In a similar vein, the ratio of positive to negative comments within teams has been found to be four times more powerful than any other factor in creating effective team performance[6]. Clearly, offering care and appreciation to staff is not simply a nice thing to do. It is the most powerful organisational intervention that any leader or manager can make.

So how can we relate that to recent NHS failures? Much of the criticism of the NHS in 2013 was sparked by the lamentable lack of compassion encountered by patients in Mid Staffordshire. It’s worth thinking a little about what compassion actually means. Andy Bradley describes compassion as ‘where kindness meets suffering and we are encouraged to flourish’. We flourish when our own suffering is met by kindness. In other words we are able to offer compassion when we experience compassion ourselves. This has been recognised by spiritual traditions for a very long time and is as true for NHS staff as anyone else. In the oldest Theravāda Buddhist tradition the cultivation of loving-kindness (or Mettā) begins with the self.

If we imprison someone’s natural inclination to express their vocation through doing good as a commodity to be represented as an activity target or an annual performance measure, we risk smothering the love they bring to their work. When this happens we should not be surprised if people expressing loving-kindness for themselves by taking their love elsewhere – literally, by leaving the NHS, or more subtly and perniciously, through closing down and becoming exhausted and inert.

Peter Gilbert was an influential writer on public sector leadership who sadly died in December 2013. His obituary cited his belief that we all have a spiritual side that needs recognition and expression. In Peter’s words this is ‘something about the transcendent; something beyond ourselves that keeps us going’. For some of us it is a sense of radical connection with everything around us that we might call ‘love’. Others might call it ‘God’. Whatever we call it we need a compassionate approach to leadership that includes hosting spaces[7] in our hard pressed public services for staff to maintain their connection to this aspect of themselves – and give it expression. This requires that they are free to do the right thing with the resources to be effective. Secondly, they should gain praise and recognition for the good hearts that drew them to this supremely important and meaningful work in the first place.

Steve Onyett is Associate Professor in Clinical Psychology at the University of Exeter and Director of Onyett Entero Ltd. You can follow him on Twitter @SteveOnyett

[1] See Schwartz, B. & Sharpe, K. (2010) Practical Wisdom. Riverhead. Similar points about the value of focusing on intrinsic motivation are made by WWF-UK Change Strategist Tom Crompton in this talk and in the report ‘Common Cause’ and in this Daniel Pink TED talk.

[2] This for example is a central tenet of innovative and effective approaches to organisational change such as Appreciative Inquiry and work with a Solution Focus.

[3] Suchman, A. L., Sluyter, D. J., & Williamson, P. R. (2011). Leading Change in Healthcare: Transforming Organisations Using Complexity, Positive Psychology & Relationship-Centered Care. Radcliffe, p.23.

[4] For example the Corporate Leadership Council’s (2004) report ‘Driving Performance and Retention through Employee Engagement’ cited in Pendleton, D. and Furnham, A. (2012). Leadership- All you need to know. Basingstoke. Palgrave.

[5] Alimo-Metcalfe, B., Alban-Metcalfe, J., Bradley, M., Mariathasan, J., & Samele, C. (2008). The impact of engaging leadership on performance, attitudes to work and well-being at work: a longitudinal study. Journal of Health Organization & Management, 22, 6, 586-598

[6] Losada, M. and Heaphy, E. (2004). The role of positivity and connectivity in the performance of business teams. American Behavioral Scientist, Vol. 47 No. 6, pp. 740-65.

[7] See McKergow, M., W. (2009). Leader as Host, Host as Leader: Towards a new yet ancient metaphor. International Journal for Leadership in Public Services, 5(1), 19-24.