The NHS’ problem is poor management,
and whistleblowing proposals don’t fix that

By Emily Barley @ThinkEmily

You may recall that last year I spoke to an NHS business manager about what might be causing the NHS to lose out on contracts to private providers. The message then was clear: poor management and the wrong people in post. Following the release of the Freedom to Speak Up report on NHS whistleblowers, we spoke again. Unsurprisingly, the message is the same.

Below are the thoughts and comments of an interim project manager who has worked in a variety of NHS Trusts, managing the transformation of services to improve care, and increase productivity & revenue. This person’s approach prioritises the best possible patient outcomes, whilst applying business sense. Unfortunately, many NHS managers do not do either.

I have verified their identity & experience, but for obvious reasons I am protecting it here.

Sack the bullies

I have some ideas on why bullying is ignored and why whistleblowing about poor practice is not acted upon.

There will always be a minority of people who are bullies. My view is that these people have no place within the caring profession, in whatever work capacity, and they should be sacked under gross misconduct.

The majority of people who resort to bullying tactics are under pressure to achieve targets that are seemingly unreachable.

The majority of people with concerns about practice or who are being bullied are afraid to report them because they are then classed as trouble makers and life is more often than not made extremely difficult for them.

People do raise concerns about care or practice, but are often not listened to.

The Executive Team usually doesn’t have a clue

The problem? Where to begin! Targets are in place for a reason and the main one is that a benchmarking system helps to ensure equality of care, best standards of care and best outcome for patients. This poses problems for all Trusts, mainly because all of these targets have to be achieved within limited resources. Some Trusts have mostly got it right and are able to ‘run’ their Trust as a business ought to be, taking into account why they are there in the first place and what they need to do to achieve.

Sadly, most Trusts don’t get it right. If we delve deep enough I’m almost certain that most that appear to be performing well do this by robbing Peter to pay Paul. Occasionally they’ll have a poorly performing service and then all resources will be thrown at it so it will meet targets so they don’t incur a hefty fine or have their reputation ruined (as this will not attract future business). However, by doing this other services may suffer as some of their resource will be withdrawn.

So, who is responsible? Ultimately the Executive Team and Trust Board. Then, within senior and middle management we have a piggy in the middle situation whereby they are under immense pressure with responsibility for their teams and also to the Executive Team and Trust Board.

Middle managers are often not fully aware of the real situation and when they are made aware of any problems, however small or large, they don’t do anything about it and they don’t report it higher because to do so would be admitting failure on their own part. Therefore the Executive Team and Trust Board are often ignorant to the real situation.

Poor skills & damaging hierarchy

Why is this happening? I believe it’s because the right people are not in place in senior and middle management roles. They aren’t equipped with the right kind of knowledge, experience, or people skills. The hierarchical system of management, in place the majority of Trusts, is outdated and doesn’t work. Managers don’t spend time in their departments, don’t get to know people, don’t know or therefore understand the actual situation and pressures the clinical teams are under, and have no idea on how to put things right. There is an ‘us and them’ situation in most Trusts and this results in a lack of trust and respect between all.

Clinical teams often don’t appreciate the pressures the management and business teams are under, usually because of poor communication by management. Silo working occurs and this is counterproductive on many levels.

As a result three things happen:

1) People can’t cope and become bullies and/or bury their head in the sand. This results in poor performance by individuals and poor management of people and situations

2) People whistleblow and either get heard and something is done or don’t get heard and the situation worsens, often taking individuals and teams to breaking point. It’s at breaking point when Trusts usually decide to do something, and usually only because if they don’t the media will find out and/or they’ll receive hefty fines.

3) Dangerously, and something which happens in the minority of cases but is unfortunately on the increase, bad behaviour, bullying, poor practice and poor standards of care become the norm. There is no excuse for individuals to accept or condone this, but they do so because they don’t know where or who to go to for help. They feel no one cares, is interested or will do anything. They feel it will open a can of worms, and often they’re right. By this stage they are so low, often depressed and not coping, that it is difficult for them to do anything. They are also genuinely afraid for their livelihood and sanity because they already know that they are likely to be persecuted for speaking out.

It needs a completely new approach

The solution? For me it is simple; I would re-write the job description for all middle and senior managers, taking into account the current situation and future likely requirements. I would re-evaluate the best way for managers to manage, including as a high priority their people skills and approach to collaborative working. I’d remove the hierarchical system. Then I’d make each manager re-apply for their own jobs. I reckon most wouldn’t get their job.

The options then would be to decide what qualities, skills, experience and so on you would truly need a person to have and I’d advertise the job. It would also be sensible to look at providing training for those who aren’t wholly without hope.

I would also implement a good training programme to support continual development of staff, one that is flexible and adaptable, so that ever evolving changes can be met. It would need to be pre-emptive wherever possible.

I’d also be on the look out for staff who could be developed; managers often don’t know when they have potential in their workforce.

If I were on the Executive Team, I’d have more of a handle on what my senior and middle managers were doing. I’d have more involvement with people and teams at all levels. I’d also get rid of some meetings. I’d make sure every meeting had a purpose, with actions coming out of every meeting – too often time is wasted on meetings that go ’round in circles with no decisions made or actions resulting.

‘Whistleblowing guardians’ do not address failures

I don’t agree with implementing whistleblowing guardians. HR are supposed to deal with all that. If HR can’t behave or act appropriately according to each individual situation then why would a Trust employed whistleblowing guardian?

If these guardians are needed why isn’t anyone looking into the performance of HR? I think if they did they would likely find it seriously lacking. Making NHS HR services fit-for-purpose would be a much better way of addressing problems with bullying, whistleblowing and other workforce issues.