Bullying Culture in the NHS

Roy Lilley recently wrote about bullying in the NHS. Ruth Hadikin, a midwife who later became a coach, wrote a book a good few years ago about the “bullying culture” in the NHS.

Sadly, in a service as badly organised as the NHS, bullying seems almost inevitable.

I remember a District Administrator (I think that was what we used to call them) saying very clearly when the purchaser-provider split was first mooted that he wanted to be a purchaser because it would be much harder to hold him accountable. In our increasingly fragmented “system” it becomes increasingly difficult to trace accountability at all. Just like the recent debacle on the railways, the provider companies blame network rail who are damned if they cut corners on maintenance and damned if they take too long to do the impossible, so NHS providers are held responsible for failing to achieve the impossible.

It seems at the moment that a publicly funded and privately provided service (like the banks, and in part the railways???) is on the cards for the NHS. Taxpayers put the money in and take the risks, private companies and associated politicians take the profit and management is so screwed up that those who are really responsible (the politicians largely) cannot be held accountable except every five years or so at an election. Even then we never seem to be able to choose politicians who will be realistic about the NHS and the dangers of continuous re-disorganisation and privatisation.

Good management and clear purpose (health not profit) are the keys to unlock this unholy mess. The myth that good management is only found in the private sector and bad management only in the public sector must be dispelled. I have seen excellent management in not-for-profit organisations and we have all seen awful management in private corporations ( ENRON, the Banks etc.)

Happy New Year!

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23. Being proactive rather than reactive: the importance of developing personal values, vision and goals and alignment with the organisation.

The text below is reproduced with permission from Radcliffe e-bulletins “Leadership for Doctors” number 23 and is co-authored by Stephen Curran and myself. Earlier bulletins can be found under the Leadership for Doctors tab above.

January is typically the month for New Year Resolutions. To be proactive rather than reactive is perhaps one of the best! Stephen Covey, a very influential management writer of the 20th century, placed it first on his list of the 7 Habits of Highly Effective People (1). Many years ago, when one of the authors was elected as Chair of the Old Age Faculty at the Royal College of Psychiatrists, he resolved not to be always reacting to Government and other initiatives but instead to ask the Faculty what they wanted to achieve during his chairmanship. We called it “seizing the initiative”. So, in any new management role (and perhaps at the start of a New Year, too), it is worth thinking about what you want to achieve. The annual appraisal and job-planning cycle also provides an opportunity for deciding on what you want to achieve and reviewing how well you have achieved it. However, sometimes Personal Development Plans and Job Plans will be heavy on organisational rather than truly personal work ambitions. These will need to be reconciled.

Underlying assumptions and values

Virtually all senior doctors are (or should be) involved in leadership. The degree of involvement in leadership will vary from leading a clinical team, through leading a particular specialty locally (or nationally) to providing Medical Leadership to a multi-million pound NHS Foundation Trust. Individuals and organisations have (often unwritten) assumptions about the “way the world is” and the values that they think should underpin behaviour. There are also broader cultural assumptions and values. It is good to be explicit about these assumptions and values. Where there is agreement between the assumptions and values of the broad culture, the organisational culture and the individual, life will be relatively easy and there may be relatively few challenges for the leader to overcome. Where, as often seems to be the case, there are differences between the broad culture’s and the organisation’s or individual’s assumptions and values, things may be more challenging. Where there are major differences in values between individuals and their organisations it is time for change (of one sort or another).

Cultural assumptions and values

We do not live in an homogenous culture. Nevertheless, a particular view of the world often holds sway at least at the political level. Writing in the last century, E.F. Schumaker characterised the then dominant culture in the following words: “The modern economy is propelled by a frenzy of greed and indulges in an orgy of envy, and these are not accidental features but the very causes of its expansionist success.” (2) Has much changed? Schumaker alleged that underlying the dominant culture was a series of “metaphysical” assumptions, which are presented in abbreviated form below:

  • Darwinian principles of evolution and “natural selection” apply not only to phylogeny but also to economics, organisations and possibly countries.
  • “Higher manifestations of human life” (as Schumaker calls them) such as religion, philosophy and appreciation of beauty are fantasies (Marx) or the results of frustrated basic biological drives (Freud).
  • There is no absolute truth (relativism) and the only genuine knowledge is that which can be derived from direct observation (positivism).

Schumaker, following Gandhi and Ruskin, proposed an alternative economics in which work was valued not only in monetary terms but also for the satisfaction which it gives the worker. In his vision cheap, small scale, intermediate technology would be used to provide a better quality of life for all and to avoid destroying the “natural capital” of world resources, making the earth uninhabitable through pollution and warming of the atmosphere. These principles can be applied to healthcare. In 1967 Maurice King published a symposium on Medical Care in Developing Countries (3) which included (amongst many others “axioms”) the principle that healthcare should be delivered in the smallest, most humble, most local setting that can meet the health need; but that is another story!

Personal values

We have discussed in earlier bulletins how doctors, other clinicians and some health service managers will share many values as expressed in the ethical codes of the caring professions. It is worth reflecting on what values have been recognised as positive in different cultures, over the ages. When Martin Seligman (known to psychiatrists for developing the “learned helplessness” model of depression and subsequent work on “learned optimism”) was President of the American Psychological Society, he and his colleagues started  a project to establish a positive psychology (4) to balance the pathological focus of the diagnostic scheme used by psychiatrists and clinical psychologists. In their project they looked at a variety of cultures, philosophies and religions in an attempt to discover character strengths or values that were universally (or at least very widely) held in high esteem. Twenty four specific strengths consistently emerged across history and cultures and were grouped under six broad headings: wisdom, courage, humanity, justice, temperance, and transcendence. These are expanded in Box 1.

1.Wisdom and Knowledge Cognitive strengths:Creativity, Curiosity, Judgment & Open-Mindedness (including thinking critically), Love of Learning, Perspective.2.Courage – Emotional or motivational  strengths involving exercise of will:

Bravery, Perseverance, Honesty, Zest.

3.Humanity – Interpersonal strengths:

Capacity to Love and Be Loved, Kindness, Social Intelligence including emotional intelligence.

  1. Justice – Civic strengths that underlying healthy community life:

Teamwork, Fairness, Leadership.

  1. Temperance – Strengths that protect against excess:

Forgiveness & Mercy, Modesty & Humility, Prudence, Self-Regulation.

  1. Transcendence – Strengths that forge connections and provide meaning

Appreciation of Beauty and Excellence, Gratitude, Hope, Humour (including playfulness), Religiousness & Spirituality (linked to meaning and purpose).

Box 1 Modified from the Values in Action Institute classification of human strengths. For more detail see http://www.viacharacter.org/www/ or http://www.ppc.sas.upenn.edu/

There is a pervasive cynicism in modern culture that tends to attribute everything to pseudo-Darwinian motives, such as status through riches and celebrity to enable men to attract the fittest partners. In fact, as Robert Wright has ably shown in his works The Moral Animal (5) and Nonzero (6), this is a very simplistic interpretation of both biological and cultural evolution. The near universal human strengths recognised by positive psychology are an important reminder of a more enduring understanding of human strengths and values.

Interestingly, a leading Thatcherite economic theorist, Brian Griffiths (7) argued that “the Market” was incapable of generating its own ethical values and needed a set of values which were derived from a wider understanding of the human condition. He cited, as common values needed to underpin a market economy, principles of justice or fairness, mutual respect or reciprocal regard, stewardship or trusteeship of “God’s creation” and honesty or integrity (which includes truthfulness and reliability).

These correspond roughly to Justice, Humanity, Courage and Transcendence in the Positive psychology movement’s list above. Perhaps significantly, the values of Temperance and Wisdom do not appear in Griffiths’ list. If they did, we might have avoided the market collapse of 2008.


Exercise 1.

Do you agree with Schumaker about the dominant assumptions and values in modern (perhaps now, post-modern) society? Consider your personal values. If you want you can use the Values in Action Inventory of Strengths which can be accessed at  http://www.viacharacter.org/www/. Alternatively you may want to simply reflect on box 1 above or on values derived from your own religious or cultural background.

How does the team or organisation you work with rate these values? How does the main service commissioner in your area make purchasing decisions? What values (apart from “value for money”, whatever that means) are important to them (you, if you lead a commissioning organisation).

How can we prevent the less attractive “values” of the “hard-nosed” marketplace from displacing those more traditionally associated with the “caring” professions?


Relationships and values (alongside organisational and external factors) are the foundation on which to build and achieve your vision as a leader.

Once the foundation of good relationships and shared values is established, it is time to decide. What is your vision as a leader? What contribution do you, as an individual, want to make to the group which you lead or help to lead? It is a uniquely human facility to be able to imagine the future or several different futures, and to choose one future that you as an individual or group want to work towards. Of course, it will rarely be possible to realise your vision in full; there are too many outside influences on our healthcare system. However if we know where we want to arrive we are likely to get closer to it even if we have to endure the “slings and arrows of outrageous fortune”. The following case study is a personal example of developing and implementing a vision taken from Practical Management and Leadership for Doctors (8)

Case study. One of the authors was asked to support medical management (one day per week) in a Primary Care Trust that provided Mental Health Services. The Medical Director (the only substantive psychiatric consultant in post in the whole Trust) had died unexpectedly, following an accident, not long after recruiting several new consultants on short- term contracts from the European Union.  The vision was to get the medical aspects of the mental health services working effectively again. There was concordance between the values of the author and that of the organisation which focused on providing first class services for people with mental health problems and enabling them to contribute fully to their own recovery. This vision broke down into a number of very practical goals some of which are listed below:

  • Support the induction of the new consultants into the Trust including an understanding of the organisation of the NHS and the Trust, Psychiatric Practice and Mental Health Legislation in England, etc.
  • Establish and implement policies and procedures for medical employment, leave, continuing professional development, appraisal, job planning and performance management etc. (There were “legacy” policies from a previous organisational set up but they did not “fit” the new organisation).
  • Re-establish the Trust as a respected provider of medical education and training.
  • Support one locum consultant in gaining access to the specialist register via article 14, a route for non-European qualified specialists and others.
  • Develop the consultant workforce to a point where long-term appointments could be made to consultant posts and a substantive Medical Director for Mental Health could be appointed from amongst the consultant body.
  • Support the establishment of an enduring culture of co-operation between the medical workforce and the management of the organisation in which the needs of service users were the first priority.

The initial timescale for achieving this was 1-2 years. This was too ambitious! With an incredible amount of support from the Director of Mental Health Services, the Chief Executive, the medical personnel specialist, administrative and secretarial staff, the consultants themselves and the Medical School and Deanery, these goals (and a number of other important goals that developed over the period) were all achieved within 4 years. In addition, the culture of co-operation meant that special interests of consultants were harnessed to improve the service by developing specialist services for people with borderline personality disorder, eating disorders and family therapy.

Not all leadership roles will be so time limited or so circumscribed in their intention. Nevertheless, if you have not already done so, it is worth considering your personal vision for what you want to achieve over a realistic time period (maybe this year, since it’s January). It may be something as limited (but not necessarily easy) as developing a co-operative culture, or establishing a good reputation for training or it may be a “higher order” vision like “getting the medical aspects of the mental health services working effectively again”.

The foundation for any project involving people is relationships and (shared) values. Next comes a realistic appreciation of where we are and where we want to be (the “vision”). After this it is necessary to consider the possible obstacles and the resources needed to achieve the vision (after which the end point may need to be revised to a more realistic position!). Finally the tasks needed to achieve the goal/vision need to be prioritised and steps need to be designed, ideally with timings sketched in (see Practical Management and Leadership for Doctors (8)) for an illustration of this model

For Reflection (and action):

Choose an area of leadership where you want to bring about change. This corresponds to the first of Stephen Covey’s 7 Habits of Highly Effective People(1) being PROACTIVE and prevents the disappointment inherent in always REACTING to other people’s initiatives). State this vision as succinctly as possible and decide on a realistic date for achieving it. (This corresponds to the second habit “begin with the end in mind”). Look at the gap between where you are now and where you want to be. Consider what resources are needed to achieve the change (this may be good quality relationships, alliances and communications as much as, or more than, financial resources). Think about likely obstacles and how they can be negotiated. Prioritise and break the vision down into goals that are manageable and time-limited. (Third habit “First things first”.)

Working creatively with others, start progressing towards you goals, keeping a note of what you have achieved in your diary.


  1. Covey, S.7 Habits of Highly Effective People. London : Simon and Schuster, 2004.
  2. Schumaker, E. F.Small is Beautiful. London : Vintage, 1973, 1993.
  3. King, Maurice. Medical Care in Developing Countries. Oxford : Oxford University Press (Tanzania), 1967.
  4. Seligman, M. Authentic Happiness. London : Nicholas Brealey, 2003.
  5. Wright, R. The Moral Animal. London : Abacus, 1994.
  6. Wright, R. NonZero. London : Abacus, 2001.
  7. Griffiths, B. Morality and the Marketplace (2nd edition). London : Hodder and Stoughton, 1989.
  8. Wattis, J and Curran, S.Practical Management and Leadership for Doctors. Milton keynes : Radcliffe, 2011.



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22. Understanding organisations: metaphors as tools for understanding.

The text below is reproduced with permission from Radcliffe e-bulletins “Leadership for Doctors” number 22 and is co-authored by Stephen Curran and myself. Earlier bulletins can be found under the Leadership for Doctors tab above.

The medical profession, rightly, have an education that is biased towards “the sciences” and evidence-based practice. We are less “at home” in what used to be called “the humanities”, yet we all recognise that a good knowledge of  science is not enough. If we are going to elicit signs and symptoms from patients, help them understand their problems and engage them in treatment we need a variety of interpersonal skills. We also need a whole set of different tools for understanding what is going on in complicated managerial situations. We have already discussed the use of the “Parent-Adult–Child” metaphor derived from Transactional Analysis (see issue 18). In the last Bulletin, we re-introduced metaphors as a powerful way of understanding organisations.  Often these metaphors may be more implicit than explicit, leading to implicit expectations about how people in the organisation will behave and consequent disappointment. Metaphors are tools of enormous but limited value. We need to be able to apply them with discernment and with understanding of their limitations. We need to recognise when other people are understanding organisations from a different implicit viewpoint, with different assumptions. Gareth Morgan (1) discusses eight powerful metaphors that help us to understand organisations:                                                                                      

  • Organisations as machines
  • Organisations as organisms
  • Organisations as brains: learning and self- organisation
  • Organisations as cultures: creating social reality
  • Organisations as political systems: interests, conflicts and power
  • Organisations as psychic prisons
  • Organisation as flux and transformation
  • Organisations as instruments of domination

All these metaphors can help us to understand an organisation (and they all have limitations). Good doctor-managers will seek to take a number of different points of view as they grapple with an organisational problem. Other metaphors will occur, too, such as organisational diagnosis and treatment! In our book Practical Management and Leadership for Doctors (2) we discuss two of Morgan’s metaphors in more detail: organisations as cultures and organisations as flux and change.

Here we will focus on understanding organisations as cultures. This choice is not arbitrary. One of the authors found the concept of organisations as cultures particularly useful when he first moved into medical management. It helped enormously to understand that different parts of the NHS have different cultures, implying different modes of operation, motivators, success criteria and time frames.


Organisational Culture

The idea of management cultures first came to prominence following the phenomenal success of Japanese industry after the Second World War. Academics who studied management realised that there were cultural factors at work. Another, more topical, example is the “bonus culture” in banks that preceded the financial crash of 2008. In this case it is possible to make a case that traces the diffusion of American child rearing practice first into American commercial culture and then into the global marketplace. The idea is very simple. Wanted behaviour should be rewarded, preferably with tangible rewards.  So, the theorist might argue, the practice of giving children sweets for being good led to the practice of giving fund managers bonuses for doing their job “well” (i.e. securing short term profits). Fuelled by greed, this led to ever more complex schemes for “making money” and then to disaster!  Culture, in this case “the bonus culture”, can be very powerful.

Charles Handy is sometime described as the only “home grown” British “management guru”. Indeed the term “management guru” was allegedly coined by a journalist to describe him. Writing at the end of the 20th century (3), he described four dominant cultures in modern organisations. He identified each with a god from Greek mythology (reflecting his own classical education). His scheme undoubtedly over-simplifies but is still incredibly helpful in understanding why different bits of the organisation behave in different ways.  Handy also proposed an important theory of “cultural propriety” that suggests that all the cultures are equally valid but that each has its place. To this we would add the importance of cultural sensitivity in the manager. People in different management cultures are motivated in different ways and influenced by different rewards. To extend Handy’s metaphor, the “god” of the “bonus culture” might be called “profit” or “money”.

Table 1 (taken from Practical Management and Leadership for Doctors) lists some of the attributes of the four cultures described by Handy.

“God” and Culture Attributes Best suited to: Control  & Influence
Zeus: the “club” culture Based on knowing (the top) people, makes speedy, intuitive decisions Small entrepreneurial (often family) businesses. Also found at senior levels in politics! Personal praise or punishment from the “boss”. Who you know is more important than what you know
Apollo: the “role” culture Related to the “machine” metaphor essentially sees people according to their roles, as replaceable parts in the organisation Routine tasks where change is minimal and unexpected variation unusual; surprisingly common in the NHS given the amount and pace of change Impersonal exercise of economic and political power to enforce standards and procedures. Room size, desk size, car size = “status”
Athena: the “task “ culture Focus on the continual and successful definition and solution of problems Team working to solve problems where complexity and variety are common. A common culture for the clinician. May waste time/resources in routine settings Personal commitment to the task, rewarded by success. Team members valued for their competencies rather than who they know or their role “labels”
Dionysus: the “existential” or “craft” culture. The organisation is there to enable Dionysians to achieve their purpose. Situations where individual talents or skills are most important. Also found in clinical practice. Enjoyment intrinsic to the exercise of skills (which may include meeting the needs of others)

Table 1 NHS perspective on Charles Handy’s dominant cultures of organisations (from Practical Management and Leadership for Doctors (2)

Handy’s book includes a questionnaire for individuals to look at their own cultural preferences and those of their organisations.

Exercise 1: Consider your own organisation. How does it work at various levels? If you work in a clinical team, does the team subdivide to tackle the tasks around the individual needs of patients or are you more a collection of individualists, each exercising their own skills in the service of patients but without much co-ordination? Do different disciplines in the team work according to different models? What about the immediate organisation you work for? How important is the enforcement of standards and procedures? Do conflicts arise between different cultures? How much scope is there for team working? Are people expected to enjoy their work? How does your organisation compare with the wider health service in terms of its dominant “gods”? How do your own cultural expectations mesh with those of the organisation?

Consider how appropriate different cultures are for different tasks. How do Athenans or Dionysians feel in an Apollonian organisation? What are the vices and virtues of each culture? If you really want to get a grip on this have a look at the book “The Gods of Management” (3) and try the questionnaire in the chapter on “the gods at work”.

Doctors working in the health service often see themselves as “Athenans” or “Dionysians” working in organisations that are still predominantly “Apollonian”. This causes tension.  The difference is summed up in different ways that we picture organisations. The typical management diagram is hierarchical with a controlling box at the top and various numbers of layers between the top and the people who actually do the work at the bottom. This kind of diagram is “Apollonian” in Handy’s terms. The picture that more accurately describes the situation from the clinician’s perspective would be a series of concentric circles with the patient in the centre surrounded by their family and carers. The next circle might be the “primary care” services of general practice and personal social services. Around that is a circle of secondary care services and around them again are the commissioners. Finally comes the circle that represents the “top layer” (but the most remote from the patient) the NHS Commissioning Board, and the various inspectorates and standard setting organisations. A picture of this illustration appears in Chapter 3 of Practical Psychiatry of Old Age (2)  

However, doctors in management need to have a wider appreciation of the culture(s) of the health service. Handy does not suggest that one culture is “better” than another. He speaks of “cultural appropriateness”. Thus a role culture may be good at regular, repetitive tasks such as paying all our salaries but hopeless at dealing with the complexities of a real-life clinical emergency where the team culture is generally most appropriate. Problems arise when the different cultures do not know their place in the wider scheme of things. One of the tasks for a medical manager is to ensure that cultural appropriateness is not violated. Another task is to understand the different cultures and their different languages (“jargon”) so as to be able adequately to represent one to the other without misunderstanding.

Another way at looking at cultures in Healthcare is to examine the development of Health Services in the UK in the last century. Before the NHS there was a “market” culture, supplemented by various forms of insurance and the individual charitable donation of time to “the poor” by some doctors and organisations.  The early NHS was predominantly a top-down organisation with strong elements of role culture but with clinicians relatively free to function independently, a structure we have previously pictured as “bureaucratic dangle” with the various layers of management hardly connecting with clinical teams (or interfering with “clinical freedom”). We have called this a “service culture”. Then, under the influence of economic and political theorists, the “internal market” was introduced, here described as the “commissioner-provider” culture. This was designed to remedy the so called “producer capture” where the “workers” of public service industries were (somewhat insultingly) seen as running the business for their own benefit. Gains in efficiency were also predicted (though the long term efficiency of markets in healthcare must now be in some doubt). It has been taken a step further in recent years with the deliberate (and de-stabilising) opening up of health care provision to “for profit” organisations. Finally, running alongside this evolution, we have the wider phenomenon of the consumer culture. Table 2 gives a much simplified account of the characteristics of these different cultures. As the English NHS evolves, the consumer model, as presented here, is essentially a market model with service commissioners (and individual General Practitioners) acting as moderators and purchasers of service on behalf of consumers.


Culture Market Service Commissioner-Provider Consumer
Who “knows“ best? Buyer Provider Commissioner Service user
Who disposes of resources? Buyer Provider Commissioner Service user  limited by commissioner
Who is in charge? Buyer Provider Commissioner Service user (in theory!)
Some advantages: Good for those with lots of money Providers do know more. Needs altruism  in workers to work well. Interests of different stakeholders considered Service user is “empowered”
Some disadvantages: Bad for those who are poor “Producer capture”- run in interest of workers not users Costly extra layers of management Duplication of supporting functions Costly extra layers of management. Service user empowerment may be illusory

Table 2 Evolution and Development of dominant cultures in English Health Services

For Reflection

The overall structure of the Health Service is (some would say unfortunately) a matter for politicians. However, as NHS leaders and managers we can do our best to ensure that, in our area of influence, the organisational culture is understood and developed in the most appropriate direction possible. Consider also how control and influence are exercised in different parts of your organisation and how explicit understanding can help make you more effective. Consider also how an inappropriate understanding can cause unnecessary conflict and offence. Finally think about the implicit values behind different cultures and how they can also cause hidden conflict. Remember that as a manager your job is to work with the world as it is, as a leader you may also be privileged to change it a little!


1. Morgan, G. Images of Organizations. London : Sage , 2006.

2. Wattis, J and S, Curran. Practical Management and Leadership for Doctors. London : Radcliffe, 2011.

3. Handy, C. The Gods of Management . London : Arrow Business Books, 1995.

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21. Understanding organisations: the historical and political context of the NHS.

The text below is reproduced with permission from Radcliffe e-bulletins “Leadership for Doctors” number 21 and is co-authored by Stephen Curran and myself. Earlier bulletins can be found under the Leadership for Doctors tab above.

To lead in an organisation it is necessary to understand it. This is not an easy task for health care systems which are often complex and, increasingly in the English setting, fragmented organisations. The English part of the British NHS is the setting that the authors are most familiar with. Since political devolution of control of health services to Wales and Scotland, different parts of the UK health service have developed in different ways, so that one can no longer refer to the British NHS as a whole.

There are many different tools for understanding organisations and we intend to address this in two ways. In this bulletin we will give a brief historical account of the origins of the NHS and its development, concentrating on the English setting for the more recent history. In the next bulletin we will examine more general ways of understanding organisations that can be applied in many different settings. In particular we will focus on the work of Gareth Morgan who, in a highly influential work, Images of Organisations, used metaphors as a way of developing understanding. He listed 8 metaphors (Box 1):

1. Machines,2. Organisms,3. Brains,4. Cultures,

5. Political systems,

6. Psychic prisons,

7. Flux and transformation, and

8. Instruments of domination.

Box 1 “Metaphors” or Images of Organisations (after Morgan)

These metaphors (and others) can help us think about organisations; but it is also important to remember that they represent aspects of reality and all are incomplete in themselves. Using only one metaphor can severely restrict our thinking and our capacity to find creative solutions as leaders. The person who views organisations as machines and people as “cogs” in the machinery may find the people don’t agree! People who see English NHS organisations only as agents within the NHS “market place” (another metaphor) will also find their understanding is limited. In the next bulletin we will explore some of these metaphors in more detail but, for now, as we recap the history of the health system in the UK (and more recently in England) after the end of the Second World War, it may be useful to consider how these different images apply to the different stages of development.

A brief history of the NHS

“The collective principle asserts that… no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means.”

—Aneurin Bevan, In Place of Fear, p100 (1)

The British NHS came into being in 1948, after the Second World War. The underlying cultural assumption was that this was an expression of kinship and mutual responsibility (see Intelligent Kindness (2)). Bevan, as Minister of Health, oversaw its inception in a time of great financial difficulty. It was essentially shaped on mechanistic or bureaucratic lines with a top-down ‘command and control’ structure. Control was partly by central government through Regional Boards, partly by local executive committees (general practitioners, opticians, dentists and pharmacies) and partly by local government (public health and ambulance services). Teaching hospitals retained a degree of independence with their own Boards of Governors. The centralised structure modelled on the Emergency Medical Service which had performed well in the face of the disruption and casualties caused by the bombing of cities during the Second World War. There were incremental changes over many years.

Then, in the 1990s, under the influence of economic theorists from Europe and the USA, there was a fundamental change with the introduction of a market-oriented system with a purchaser-provider split, at least at the secondary care level. Now the underlying philosophy was increasingly individualistic and materialistic. For a thorough consideration of the changes this has gradually wrought in the way patients and clinical staff are regarded and supported in the Healthcare system, see, again, Intelligent Kindness (2). A service ethos was partly replaced by a market ethos, where organisations competed for customers (patients) via their GPs and where financial efficiency was the bottom line.

In England, commissioning has been through several iterations, starting with Fundholding General Practices and moving through Primary Care Trusts to (supposedly) GP led Clinical Commissioning Groups. Commissioners were helped in their tasks by various organisations like National Institute for Health and Clinical Excellence (NICE), which set standards and approved treatments for NHS use at the (English) national level, with different arrangements in different parts of the UK. The tension between the old ‘service model’ and the new ‘commissioner-provider’ model was high in the area of service design. The old system tended to rely on the expertise of local clinicians, especially consultants. The new system relied on evidence abstracted at a higher level through organisations like NICE. There was a potential for more superficial uniformity but perhaps at the expense of innovation, expertise, local application and inspired clinical leadership.

In an attempt to ensure that standards were maintained there were inspectorates (the Care Quality Commission, CQC, in its latest incarnation). These created a high anxiety environment which contributed to the disruption of the very caring culture that the CQC might have been expected to promote. Another organisation ‘Monitor’, was concerned mainly with the financial viability of Foundation Trusts. The inadequacy of these arrangements was nicely demonstrated in 2009 when the Mid-Staffordshire NHS Trust, in its anxiety to achieve Foundation status, concentrated on financial savings, cutting clinical staff and disregarding a marked excess mortality. A subsequent investigation by the Healthcare Commission (the predecessor to the Care Quality Commission) found, among other failings, that the Trust had shed too many clinical staff in an effort to balance the books. From the narrow point of view of Monitor, they succeeded, being granted Foundation Status just before the Healthcare Commission commenced its inquiry. Nor did the Healthcare Commission come out of the episode covered in glory. The excess mortality was first picked up by a semi-independent public health monitoring body called ‘Dr Foster’, www.drfosterintelligence.co.uk,  not by the Commission. A further Public Inquiry led by Robert Francis Q.C. resulted in the eponymous Francis Report (http://www.midstaffspublicinquiry.com/report).

Strategic Health Authorities at Regional level tried to hold it all together and provided support to the PCTs but these have now been abolished and replaced by CCGs and various other bodies. The detailed situation varies from year to year but the basic division was and still is into commissioning bodies and provider organisations with separate standard setting and inspecting bodies. There is also an increasing involvement of multi-national “for profit” healthcare providers and commissioners.

At the time of writing it is too early to predict all the effects of the current reorganisation but some of the possible implications are briefly outlined in Box 2. We are now in the middle of these changes and managing the transition to the new system will demand a great deal of skill and flexibility from doctors in both primary and secondary care organisations.

Competition and commercialisation: Choice of provider organisations will be extended to ‘any willing provider’. There is a risk of commercial organisations ‘cherry picking’ the easy-to-provide and profitable services leaving Foundation Trusts to deal with the difficult and costly. However Foundation Trusts themselves will become much more commercially oriented so that conditions that are persistent and difficult to manage may be relatively neglected. There is also a risk that large commercial organisations will provide services as “loss leaders” until they have driven out competition from Foundation Trusts and Social Enterprises (see below)

Secondary care provision: Secondary care NHS organisations will become or become part of Foundation Trusts or Social Enterprises. The latter have been described as membership organisations which create surplus to reinvest in their core purpose, thus giving incentive to act, be decisive and save to do more community good. One example the authors are familiar with Is NAViGO (http://navigocare.co.uk/) which provides mental health services and has a membership of staff, service users and carers with equal voting rights. This model has the merit of service users and employees being serious stakeholders in the organisation and having more influence on its direction. Unless there is close collaboration the expertise of secondary care clinicians in both types of organisation in planning and designing services will be wasted.

Commissioning consortia: Consortia have to be of sufficient size to fulfil many of the functions currently filled by Primary Care Trusts. With the ever-continuing development of medicine, services will continue to be delivered in the community and through the Primary Care Team whenever possible. This may lead to conflict of interest and loss of quality in services for vulnerable groups who need a high level of expertise but who are best managed in the community (for example people with long-standing mental health problems). There is also the risk that private organisations will move in to support GP Commissioning in a way that perverts the aim of the NHS from healthcare to profit.

Box 2: Some possible “pressure points” in the latest re-organisation.



Examine what is happening in your area in terms of commissioning and provision:

  • How far are the concerns described above being realised?
  • Are other issues emerging? How are they being resolved?
  • How far have consultants and general practitioners (other than those in senior management positions) been able to avoid/address any issues that have arisen?
  • How far have consultants and general practitioners who are involved in senior management positions been able to influence matters?

Make a list of the benefits to patients that have genuinely arisen from the new arrangements and of the problems for patients that have arisen:

  • Which is greater?

Make a list of the benefits and costs (including emotional costs like anxiety and insecurity) to staff.

  • Which is greater?

We have to work with the changes and systems that politicians (in their wisdom) impose – so how can we increase the benefits and mitigate the costs?

Cultural changes

We will be examining some of the metaphors used to help understand organisations in the next bulletin. We would like to close this bulletin by referring back to the change of culture in the (English) NHS from a co-operative enterprise for the common good to a market-place culture where there is at least a danger of excessive profit for the few becoming more important than the common good.

Ballatt and Campling (2) point out that working with ill people, particularly those who have long-standing illness or are dying is in itself anxiety-provoking and needs the cultivation of an attitude of “intelligent kindness”. They identify some of the pressures that they believe are undermining this culture in two chapters entitled “Unsettling times” and “The pull towards perversion”. One of their arguments is that the constant re-organisation (or “re-disorganisation”) of the NHS in recent times is counterproductive and engenders anxieties in staff that can disable them from meeting the needs of patients. They also identify what they call “corrupting forces” that encourage inappropriate anxiety and defensive attitudes in staff. They list these as:

  • The active promotion of a competitive market economy on the basis of a commodified view of needs, skills and service.
  • The process of “industrialising” healthcare, turning work undertaken by skilled individuals in relationships with patients into the mechanical delivery of processes and systems.
  • The framework and currency of specification, regulation and performance management.

They argue that these forces engender high levels of anxiety in clinical staff which mitigate against the kindly delivery of care.

For reflection

In your personal, local situation how are you handling the tensions generated by:

  • Instability in the healthcare system?
  • The promotion of a competitive “market economy”?
  • Processes of industrialising and fragmenting care?
  • Increasing specification, regulation and performance management?

How can we as professionals and leaders develop resilience in ourselves and those we lead to deal with these pressures in a positive way and not to allow our human vocation to care for those who are ill to be subverted?


1. Bevan, Aneurin. In Place of Fear. Whitefish : Kessinger Publishing LLC, (facsimile reprint) 2010. 978-1163810118.

2. Ballatt, John and Campling, Penelope. Intelligent Kindness: reforming the culture of healthcare. London : Royal College of Psychiatrists, 2011.


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This book could change the NHS – and possibly the world (if only people read it and act on it!)

Intelligent Kindness: reforming the culture of healthcare

John Ballatt and Penelope Campling, RCPsych Publications, London 2011.

If its voice is heeded, this prophetic book could change the future direction of the NHS. It could redirect it from its current rush into industrialised, market-dominated selfishness back into a collective enterprise, wise, efficient, effective and kind. However, the political and economic powers that have been driving the fragmentation of the NHS are very powerful. The original co-operative culture of the NHS has been systematically dismantled by an ideologically driven belief that privatisation and private profit will deliver “better” healthcare.

Don’t let my rant put you off. This book is painstaking and convincing in its analysis with what has gone wrong with the NHS. It argues that kindness, based on kinship and common humanity is the missing ingredient in modern healthcare. It has been driven out by a variety of forces. These  include   industrialisation, marketization and burdensome but ineffective regulatory regimes.

What is perhaps unique about this book is the way in which it explores the effects of these changes on those who deliver clinical care using the lenses of psychodynamic theory and social psychology.

It proposes in effect a counter-revolution in which individual patients and the clinical staff who serve them become the focus of managerial effort.

Please read the book and make up your own mind.

Then go out and do something about it…

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Leadership for Doctors


This Radcliffe e-bulletin is published monthly and the current series are co-authored by myself and my colleague, Stephen Curran. You can sign up to the e-bulletins at http://www.radcliffehealth.com/e-bulletins  (leadership for doctors)

I will be posting the contents of the e-bulletins on this site approximately a month in arrears. There is also some shared content with our book for Radcliffe Practical Management and Leadership for Doctors  (Wattis and Curran, 2011).



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Revalidation-ready appraisal: will organisations learn the lessons?

I have just been on the “train the trainers” session for this, run on behalf of the Revalidation Support Team (RST) by Drs Gleek and Bibby. It was good. An amazing amount of work has gone into this and many thousands (hundreds of thousands?) of doctor-hours will go into the process in future. Is it all worth it?

Since doctors who want a licence to practice have no choice, that is, perhaps, the wrong question. A better one would be: how can we make it all worthwhile?

I think that two things that will make appraisal worthwhile are to focus on a developmental emphasis for the doctor and to ensure that every doctor is adequately supported in their day to day clinical work and in their appraisal and the personal development plan that flows from it.

Appraisal with a developmental focus produces the best results. Appraisal with an external performance-management emphasis removes the locus of control to outside the doctor and results in (at best) reluctant compliance.

MOST DOCTORS START OFF THEIR PROFESSIONAL LIVES WITH AN AMBITION TO MAKE THE CARE OF THE PATIENT THEIR FIRST CONCERN. What these doctors need is developmental appraisal that meets all the GMC requirements for revalidation and encourages and enables them to continue to put patients first. Sometimes public and private health care systems go askew and push doctors into putting other things first. This must be resisted. Sometimes individual doctors will have wrong motivations or will fail to maintain their competency and this, too must be rooted out.

It is doubtful whether annual appraisal is the best way to identify doctors with problems, these problems will  come to light occasionally during appraisal and then it is very important that appraisers know how to deal constructively but rigorously with such issues.

What is more doubtful is whether organisations are ready to learn from the appraisal process about how best to support their medical staff in delivering quality services and putting patients first. Unless this issue is tackled, appraisal may fail to achieve its full potential benefits

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Seeing ourselves as others see us?

“O would some power the giftie gie us to see ourselves as others see us.” Robert Burns (1759-96)

Appraisal for revalidation has arrived. The job of the appraiser is to enable the appraised to see themselves as others see them. Stripped of all the (necessary?) bureaucratic wrapping surely good annual appraisal is all about a realistic self-assessment of what we have achieved over the last year and how we can improve over the next year. One of the joys (!) of preparing our annual portfolio for appraisal is that it does often remind us of what we have managed to achieve in the last year, often in spite of the rapid changes in our NHS.

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Maintaining Balance

Keeping your balance is important, literally and metaphorically. Physically, lack of balance can lead to falls and painful injuries. The old phrase “whilst the balance of his mind was disturbed” reminds us of the importance of mental balance. But what about balancing family and work, thinking and doing, resting and acting, etc. etc.

Two common themes emerge from this metaphor for me. The first is expressed well by the phrases “keeping everything in proportion” and “everything in its (proper) place”. The second, which comes from my cycling experience is that it is much easier to keep my balance when I am moving forwards. This in turn leads to the idea that I need a sense of direction. Otherwise, how do I know which way is “forward”?

Coaching is concerned with balance and many coaches use a metaphor of the balance wheel which consists of a circle with important issues like family, work, recreation, finances, etc. arranged on the radii. Clients are then asked to rate each area from “0” at the centre where that area is completely unsatisfactory to “10” at the edge of the circle where that area is completely satisfactory (see chapter 1 of “Practical Management and Leadership for Doctors” for an example). The resulting “wobbly wheel” helps coach and client think about areas where coaching work may be needed.

Coaching is also concerned with setting direction and moving towards our goals. Having sorted out what is important in our lives, how do we build up the good things and leave those that are not helpful behind?

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Happy New Year

This is the beginning of a New Year. Let’s hope it’s less full of violence and greed than the last! If you are reading this, I hope you have a great new year! I don’t usually make New Year’s resolutions but this year I decided to start a new website to share some of my thoughts  in the context of my Quaker faith. If you are interested, you can find it at www.thinkingquaker.co.uk

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