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Friday, 14 February 2014

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.


  1. Couldn't agree more. Having had a couple of really punitive managers in my time it really resonates. The public want what they think of as incompetent staff brought to book though. While I'm with you about care and appreciation how do you sell it?

    1. Hi Ben. Thank you for your words here. This issue of "selling" care and appreciation it is a really interesting and powerful one I think. There is a huge amount of evidence that expressing care and appreciation at work has a material effect on outcomes. For example Bev Alimo Metcalfe's findings that the most powerful thing a manager can do is show authentic personal concern for a direct report. This "engagement" factor has been shown to predict outcomes like improved crisis team performance for example. See also the wealth of evidence in Sarah Lewis's great book- Positive Psychology at Work and all the experience of applying affirming approaches such as Solution Focus (see Jackson and McKergow book), Appreciative Inquiry and Asset Based Community Development.

      I guess the risk of "selling" anything is that the intention becomes confused. I am with Tony Suchman cited above (a great book BTW) that cultures are created in the microinteractions between people and the stories we weave together to create a shared reality. So it is more of a case of embodying, living, modelling it. That old golden cliche of walking the talk.

  2. Steve Onyett is right to point out the dangers of a lack of compassion in NHS management. What changes, though, are needed at an organisational and public policy level to support such changes? Although a culture of setting targets seems common sense (after all we need to aim for clear goals) the problem is that often the targets are set without the involvement of those who have to meet them. When the unrealistic nature of targets are raised with managers they don't want to know because they are faced with the same message from their managers. This leads to an awful lot of euphemistic obfuscation -- services, for example, are now regularly (annually in some places) being 'reviewed' or 'redesigned' i.e. cut. One presumes that those going for these senior management posts either don't understand that many targets are unrealistic or they don't care (they'll no doubt be moving on to another highly paid position in a few years, perhaps with a nice private healthcare company). Although target culture seems an obvious way of reacting to public concern perhaps it's part of the problem. Target culture is an effect of an over-reliance on hierarchical management systems where accountability is vertical (i.e. people at the bottom accountable to those further up the hierarchy). An alternative is to move towards systems where we're accountable to those we work alongside (professionals and those who use services) -- i.e. horizontal accountability. Rather than people at the top setting targets for those below (people who they probably haven't even met) how different would it be if teams were accountable to meetings of service users, carers, ex-clients and other members of the local community? This might provide both more direct feedback and more direct encouragement and gratitude. There are obviously lots of details that would need to be considered (funding, equity of service etc) but the time has come to move away from seeing change as lying in sending orders down from the top. NHS staff have now lost trust in the class of politicians and senior NHS managers who continue to trot out the same euphemistic lines about doing more with less. The Staffordshire Hospital problems had much to do with targets and cost-cutting but some of the changes recommended in the reports seem to repeat the mistake with more targets when what is needed, as Steve Onyett argues, is a more genuinely compassionate culture. Perhaps a move towards more horizontal accountability might help.

    1. Completely agree. We need to move from oligarchic systems to polyarchic ones. The people who are closest to the experience of the end user of a service have the answers (inc of course the end users and their supports themselves!). This means we need to move from models of leadership that expect leaders to have answers to ones where they host spaces in whcih the right questions get asked.

      Having said that I do also find my heart sinking when I encounter a team that says it does not have a hierarchy and is wholly democratic. In my experience this just means there is a denial of difference and the real power relationships are covert and all the more powerful for that. I think hierarchy can be too easily equated with oppressive power relationships and they need not be synonymous.

      John Seddon is particularly strong on the folly of the target culture and offers a powerful argument for how, for example, the response to the tragic death of Victoria Climbie created the context for subsequent tragedies (e.g. Baby Peter). He has a great talk here which makes strong points about targets.

      I don't think targets are inherently bad. For example the National Service Framework for Mental Health at the end of the 90s was a great filip to mental health service development. It is those targets that are not based on any current assessment of the capacity of the system to deliver, and/or that are inherently meaningless because they do not actually relate directly to anything that the end user actually wants.

    2. Absolutely, Steve, I completely agree with these points.

      Child protection is a good example too of how policymakers swing from one extreme to another in the wake of the most recent crisis. So pre-Cleveland, social workers were to focus on what was in the best interests of the child but, following the Cleveland Inquiry then began a campaign against taking children into care and asking social workers to consider both the child's and parents' interests. Then the next set of inquiries blamed social workers for not taking children out of risky situations.

  3. The janitor story is a nice example. One wonders how that act of patience and kindness was received and interpreted by colleagues? Or valued even? More importantly one wonders how it was constructed by the person known who is the janitor? How did he find a way to stand accused of doing wrong, holding that and doing something kind. Because it seems to me when we talk (and in nursing i we can be particularly crass in this regard) about human qualities like compassion we talk about them as though they are constantly available but just not being chosen. A bit like imagining that England could take a young Pele with them to the World Cup but are choosing instead to go with Andy Carroll because we are bloody minded in that regard.

    If we want a culture that enables, values and celebrates compassion, generosity of spirit, care and a gentle attention surely we have to do more than assume they are endlessly available to everybody and simply require selection. We need to recognise them, support them, restore them when they become jaded, invest in them when they become lost and reconstruct them when they begin to unravel.

    It astonishes me that our primary response to Mid Staffs and a variety of surrounding CQC reports have been to police and punish the loss of care rather than to restore and support the loss of 'heart'.

    I suppose the former is easier and the latter complex and unfashionable. We tend toward blame, it is easier and culturally comforting. Yet taking up the spirit of the post there is an opportunity available isn't there? To educators and managers and supervisors and colleagues. Perhaps an opportunity that begins by suggesting that compassion or kindness are not bottomless pits or constantly available. If we value them and I really, really hope we do, we need to work at them. I think we could do that if we chose to.

    1. This is an excellent essay. The culture of blame and punishment appears to have been accerbated due to several factors, all of which are challenging to unpack but are also being increasingly experienced in NHS healthcare and aslo in higher education. As new standards are set 'from above' with little or no discussion with those below who are tasked with carrying out the directives, it seems to me an increasing feeling of distance and separation sets in between the value and purpose of the work. How do we best care for people, is a question that gets lost. Asking the janitor, for example, how he or she thinks is the best way to clean a room and how to let people know it has been cleaned, might be a simple way to connect up valuing the work with its purpose. A target of 6 rooms cleaned every hour, for example, sets up a very different relationship between value and purpose as opposed to the target of 'how do you know a room is cleaned'; the latter invites a cooperative way of investigating a problem and values both the worker and the patient.

    2. Thanks for this. There are so many factors at play aren't there, including the "Social systems (esp institutionalisation) as a defense against anxiety" that goes right back to Isabel Menzies Lyth's work in the late 50s, the structural devaluing of care work, the examined human reaction to intimate personal care (cf findings that people are often abused shortly after they have soiled), our natural desire to put human decay and our own mortality out there residing in some "other", so much so much. And for that reason I think that simply creating safe spaces where people can come together without fear or judgement to share their experiences in the workplace and reclaim their shared meaning and love for the work is so important. It is this practice of creating space for people to speak and listen from the heart that has drawn me to the Way of Council (as practiced by the Ojai Foundation) in the states, and the work that Andy Bradley is taking forward with his Compassion Circles. I truly believe that people are intrinsically loving and benign when given their freedom and that really we just need to create the spaces for this to emerge.

      And if that makes me sound as if I am sitting here in a kaftan about to head out to hug a tree - well. No apologies

      Man ; )

  4. One additional point I would make is that an institutional identity--and pride in this identity--is important. This is why I'm a little sceptical of outsourcing roles such as cleaning etc, despite the very valid economic arguments. An appreciation of an institution's history is vital to this process, and alas, mental health care has a tendency to erase its past. (I've written more about this here:

    1. Niall- you are spot on. Have you seen Alex Haslam's "New Psychology of Leadership" book. It is all about identity. Crucial also to the question of resilience where a sense of radical connection to others and serving a higher good is so important.

      And I am not even sure the economic arguments on out-sourcing are that strong. Again see John Seddon on this - he cites many example of waste generated from fragmented process due to such practices- esp call centres providing an unintelligent (tho no reflection on the people doing the work) front end on services. Like the elderly woman who contacted the local authority because her bath lift wasn't working and her concern being sent to the maintenance department who replaced it as some outrageous cost something like 17 times I think! She just needed someone to explain how it worked!

      Loved your Lancet article. Did you happen to hear the moving Radio 4 book of the week - The Last Asylum on Friern Barnet by Barbara Taylor. Very moving and powerful- and frankly sobering in terms of where we have come.

  5. Susan Fairlie, Professor of Quality Improvement22 February 2014 at 15:12

    Steve, as ever you are so insightful. I love this essay - completely resonates with much of my work and thinking. For those who haven't come across Dan Pink's work, see the following RSA animated video - simple yet full of wisdom regarding motivation
    It is also worth looking at Prof Rhona Flynn's work about staff engagement, performance and patient outcomes - when we are rude (or even witness rudeness) to each other, our performance dips - no real surprises but worth bearing in mind when about to undertake a technical skill such as surgery!.
    Another great paper is the work of Prof Michael West - Kings fund:Leadership and engagement for improvement in the NHS, 2012 - a direct correlation between staff engagement and patient mortality.
    Finally, it was great to see the Berwick report which focuses much more on valuing our staff and adopts a more Appreciative Inquiry stance. Don is one of those rare leaders who, in my opinion really does walk the talk - Joy at Work was one of the organisational values he strove to uphold whilst at the IHI. I am speaking about much of this next week at the Florence Nightingale Conference - a great opportunity to spread the word re compassion for both staff and patients and the conditions for flourishing.

    1. Thank you so much for this Susan. Loved the Dan Pink animation and the emphasis on the importance of transcendent purpose. I think once people have their basic needs met (e.g. re enough pay- so that the issue is "off the table" as he says) then this is completely central and the focus on so much for the coaching that I am asked to do. It is also a central feature of this thing we call 'resilience'. Finding that extra resource to keep going because we see that we are contributing to some higher goal. Thanks again Susan- keep spreading the love!

  6. Great article, Steve, and nice to see you writing here. One of the things which I often think is missed is that the majority of people who choose a health and social care career probably start off with some desire to treat people with compassion and empathy and would like to develop that into compassionate practice. Compassionate practice is not always as obvious as it sounds as people can mistake sympathy for empathy, for example, or not know what is the appropriate time to intervene or not, or say something or stay silent. This is what our students (hopefully) are learning while they are being educated for a health and social care profession. The question we should be asking is how to encourage and nurture that compassion and how to create the conditions where it can flourish - and this is clearly what you are advocating.

    The more uncomfortable question we as educators might avoid asking is what we are doing that might be contributing to extinguishing that empathy and compassion and replacing it with cynicism and disconnection from our fellow humans when they mysteriously become 'patients', 'clients' or 'service users'. The 'us' and 'them' culture of health and social care practices often seems to allow an 'othering' which condones negative actions like deciding we know what is best for others without listening to what their wishes might be, right through to shocking examples such as disregarding the needs of people with learning disabilities to the extent that they die from malnutrition on a hospital ward.

    I personally think that we need to be taking a long hard look at the way we treat each other in all contexts particularly where there is some kind of power (im)balance at play. Punitive rather than encouraging practices seem endemic in health and social care from training/education through to practice education and then practice itself.

    Having said that, I don't think one can disregard the political and economic context in which health and social care has been taking place over the past 15 years. A consistent and deliberate attack has been going on by the Murdoch press to portray public services as inefficient and ineffective in order to pave the way for mass privatisation as the 'saviour' of our services. It was propaganda, nothing less. These were extremely difficult discourses to resist and most people knew someone who knew someone who had suffered some negligent or bad practice. The fact that our system was actually one of the most efficient and effective in the world (second best according to some sources) was never presented. We had much to celebrate and good practice to share - New Labour did attempt to promote this through many of their initiatives in the early days before targets took over. There are huge social forces at work dividing and individualising us and this has only accelerated since the Con-Dems have come into power.

    I sincerely hope that the work you and colleagues are doing on reconnecting with others through compassion and loving-kindness brings about change from within and is like a small flame melting the icy heart till it beats again with warmth and life.


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