It's Not Systems That Stop Abuse

Author: Su Maddock

This article was previously published on the Whitehall Watch blog.

Mid-Staffs Hospital is the tip of an iceberg that has been hiding neglect for many years. It is true poor practice was made worse by the target culture, but let's be honest - abuse, neglect and poor care have a long history. 

It is not just the abuse that is horrific but equally worrying is the level of complacency among senior staff and their vilification of whistle-blowers. Challenging complacency is not easy and those that do are often subject to ridicule themselves, many leave because their promotion prospects decline each time they voice concerns. The more insular an organisation the more resistant staff are to change.

A lack of empathy underpins poor care and abuse. The challenge for managers is that abusive staff are protected by complacency and colleagues. Changing behaviour is difficult and depends on leaders being able to shift the norms within work-cultures. In the NHS this means valuing and respecting those who care. As society changes so do social norms. 

For instance, the barriers to women in the NHS 1980s were almost solely due to men thinking women unsuitable for executive posts. We tolerate less sexism now but we are still poor are promoting transformative leaders preferring the more compliant leaders ‘safe pair of hands’, failing to notice their impact on staff morale and patient care.

This is not new. However, over the past ten years we have seen some exceptionally good transformative leaders in the public sector. For instance, Alexis Cleveland, a former Director General of the Pension’s Service, changed staff attitudes by suggesting they interview claimants. Irene Lucas, a local authority executive gave front-line staff a purpose and ‘Bin-men’ smart phones, Karen Maclusky changed attitudes to knife crime by involving gangs. Carole Hassan galvanised interagency collaboration in Yorkshire and Humber. Mike Farrar welcomed innovators into the NHS resulting in discernable change. There are of course many more.

In my experience, those who lead successful change care about people first, and systems and protocols, second; unfortunately, the reverse is true for too many practitioners and managers in the NHS. The preference for system management is an important obstacle to improving practice and care and the focus on paper-work and corporate, management systems does nothing to reward those good with people. This is not getting better. Too many good social workers receive bad appraisals because they find writing reports difficult – these are usually people who are excellent with people and need help with the paperwork. However, it is not just front-line staff who need to hone their people skills, it is also senior managers who need an ability to persuade others to engage and explain why ‘caring for people’ (read talking and listening) matters to all personal services.

As finance becomes tighter, senior leaders focus on reorganisation and budgets, staff become anxious, a management vacuum allows bullies to dominate. You cannot have culture of care if those who provide it are neglected themselves. Staff are not cogs; anymore than patients are objects. The problem for policy makers is that they want change tomorrow and care little about those who are supposed to bring it about. It is then the smaller, more isolated and lagging services that fall prey to a pathological cycle driven by the political desire for savings and quick wins; civil servants are promoted for short term political gains; senior managers assessed for their technical skills of managing reduced budgets; that staff suffering increased workloads become more resistant to change and deliver poor care which is then picked up by the media terrifying the public. This is a system failure.

Towards the end of their final term Labour recognized the negative impact of targets on front-line staff and on service innovation. The Coalition rejected the ‘target’ culture but failed to recognise that restructuring and out-sourcing rely on the same forms of performance management geared to corporate systems, efficiencies and savings. The last 30 years has given rise to a form of public sector management that is transactional and competitive, when what is needed are transformative, collaborative leaders able to develop a forms of governance that create the conditions for patient care and service innovation.

At the heart of public service innovation is an appreciation of people’s experience; but sustaining more positive practices requires incentives and performance management which values staff-patient interaction as well as compliance. Because cultural change and improving professional practice depends on greater empathy and an ability to talk and listen it does not easily translate into one neat model for change. This is why chief executives are so important to the process, they can model more responsive practice and change incentives and performance management, including recruitment, appraisal and promotion, if they fail to do this then corporate practice stifles innovation.

Transformative leaders recognise that staff at all levels need to be empathetic to people’s experience. Their starting point is tackling intransigent problems and finding solutions with people, they talk about what they are trying to do. Cultural change comes from people collaboratively tackling problems together and staff understanding what is expected of them. This is very difficult from implementing a cultural change programme cold with no explanation and when such leadership is weak, staff are fearful of change. Transformative leaders are system innovators who listen to whistle-blowers instead of silencing them. But they also transform corporate values, corporate management and the allocation of resources.

We may not have an adequate business or management model for collaborative and caring cultures, but there is learning to be gleaned from those many public sector leaders in the UK who have led cultural change.

The publisher is the Centre for Welfare Reform.

It's Not Systems That Stop Abuse © Su Maddock 2013.

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