This report can be downloaded in pdf format here.
The Acting Chair of the Royal Cornwall Hospitals NHS Trust says it needs ‘culture change’ but there are very different views of what that means and how to bring it about. The National Guardian’s Office has found deeply entrenched problems which the Trust is in danger of perpetuating.
Towards the end of 2018 the Royal Cornwall Hospitals NHS Trust began recruiting for a number of senior posts: a Chief Executive, along with Clinical Directors, Heads of Nursing etc, and General Managers, who are to head – as triumvirates – seven new ‘care groups’.[1,2,3,4]
The job descriptions and person requirements for the three categories of care group heads all refer to the importance of ‘culture’ and encouraging teamworking and good working relationships. This looks like an imaginative and positive response to a report recently published by the National Guardian’s Office (NGO) following a review of the Trust: this found that ‘workers described a culture that was highly unsupportive’ and that ‘relations between staff in several parts of the Trust were poor and were characterized by a grievance culture’.
One worker told us that staff where they worked ‘got into trouble’ for raising concerns. Another, working in a different service, said: ‘If you do speak up middle management will block you.’ Two workers from one service commented: ‘Nobody has acknowledged our difficulty or concerns, and we won’t speak up again.
Several staff from different services also commented that there was a culture of managers telling workers not to raise and record issues using the Trust’s electronic incident reporting system. These staff members said they believed this culture created risks to patient safety.
A highly unsupportive culture like this is clearly detrimental to patients. An emphasis on teamworking, which was exposed as sadly lacking in a recent case that led to the death of a six-year-old child, would be a way of developing a supportive culture and – importantly – foster good communication among staff.
The job description for the new Chief Executive is a strikingly different document. The Acting Chair of the Trust has provided an introduction in which she writes ‘We have a significant culture change to make’, but does not spell out what she means by that, and says her colleagues (i.e. the staff) ‘deserve a strong and charismatic Chief Executive to lead them on their journey’. We also read in the document that the appointee is expected to show ‘outstanding and inspirational leadership’, and that the role requires ‘a brilliant and capable leader’.
One would not want to deny that capability and flair are valuable assets in a leader, but the dazzle of brilliance and charisma should not distract us from the fact that there is work to be done. What is the Chief Executive expected to do?
When we look at the job description for the Chief Executive we find no fewer than 54 bullet-pointed tasks. Several of them begin with ‘ensure’ or ‘ensuring’.
So an applicant for the post needs to ask, for example: How, exactly, will I be able to ensure ‘that the quality of patient care is central to the functioning of the Trust’?
We also see from the job description that he or she is to ‘champion a culture of innovation, continuous improvement and trust’ and ‘champion an open and inclusive culture and management style that is receptive to staff involvement, being effective in working relationships and communications with colleagues so they feel motivated, developed, supported and respective (sic)’. All well and good, but the applicant needs to ask: How, exactly, will I be able to do this ‘championing’?
Which raises the question: What resources will be available to the successful applicant for the purposes of ensuring and championing?
On this the Chief Executive’s job description is silent, unfortunately.
However, it does provide a rudimentary organization chart. This shows a hierarchy, with the Chief Executive perched on top of a row of six directors, one of whom is the Chief Operating Officer, who will be similarly perched atop the seven care groups. Anyone applying for the Chief Executive position should ask whether they would be dependent on the Chief Operating Officer for information from within a care group. That person may well have an incentive not to pass upwards information about a problematic situation in a care group if, for example, that would reveal negligence on his or her part. Hierarchies can be hugely dysfunctional for this reason.
The NGO review mentioned above found several instances of the Trust failing to act to address issues raised when staff spoke up. Their report said these were in breach of the Trust’s speaking up policy that states that the trust is committed to ‘listening to our staff, learning lessons and improving patient care’. (Italics in original)
Workers are the eyes and ears of an organisation and are often first to identify actual or latent issues that could impact on an organisation’s ability to deliver its objectives.
The instances described in the NGO report highlight the need for the Trust to ensure that it responds appropriately to its workers who speak up.
The Trust’s policy on speaking up states: ‘In accordance with our duty of candour, our senior leaders and entire board are committed to an open and honest culture. We will look into what you say and you will always have access to the support you need.’
How can this obligation be fulfilled? How can the Chief Executive connect himself or herself with the eyes and ears of the Trust’s workers? Will they, for example, be able to set up their own unit of open-minded ‘roving inspectors’ who are not bound by the restrictions of hierarchy but free to talk to any Trust employee who is involved in patient care?
What the Chief Executive does receive at present is formal reports. At the foot of Page 4 of the Chief Executive Recruitment Information Pack, you will find a link to ‘the Trust Improvement Programme’, a page on the Trust’s website. At the foot of that page is a further link to ‘Trust Improvement Plan – October 2018 update’. That update (the latest) consists of a four-page report to the Trust Board entitled Quality Improvement Programme update. On Page 3 of that report is an Executive Summary, where we can see half a dozen points under the heading ‘Culture and Leadership’.
While these points may go some way towards building a more cohesive workforce – e.g. ‘Increasing local activity seen throughout social media on informal events for staff to come together to build better working relationships which will improve patient care’ – they fall a long way short of exploring and learning from case-studies of actual patient care and of staff speaking up. They also leave unanswered the question of whether workers who carry out ‘hotel’ functions that have been outsourced to Mitie are treated as ‘staff’. So here are more matters which you may wish to explore if you are called for interview.
Importantly, the NGO report noted that there may be cultural issues specific to Cornwall:
Staff comments often referred to a historic poor speaking-up culture across the trust. One senior leader told us: ‘There’s a long and dark history to this Trust, and to Cornwall generally. Getting through to people is labour intensive. Getting through to them to believe that they will really be listened to and taken seriously has been the most difficult of anywhere I have seen.’
Workers highlighted the geographical location of the Trust as a factor in poor staff relations, stating that because of the Trust’s relative isolation staff often stayed in their roles for many years, and where they remained so did the poor relations between them. One senior leader commented: ‘Many [staff] have a long length of service … Their views become entrenched.’
If you are applying for the Chief Executive position you may wish to think about these comments in advance of being interviewed, and also ask the interviewing board for their views on them.
My own conclusions from this brief survey are two-fold and they are stark. First, the culture of the Trust badly needs a shake-up. It is ossified and it needs a revolution. Second, the notion that what the Trust needs is a brilliant, charismatic leader sitting at the top of a hierarchy is utterly misconceived: there is no way in which this can produce beneficial cultural change.
What is needed is a combination of old hands and young minds: old hands to keep the ship steady, and fresh young minds to ask questions, talk to everyone irrespective of their official position, and bring the energy of startup enterprises to the 70-year-old NHS.
And who knows: perhaps we can look forward to the appearance of the Royal Cornwall Hospitals Teamwork Manual. That really would be something!
Notes and references [All websites last accessed 31.12.2018]
- Royal Cornwall Hospitals NHS Trust, Chief Executive Recruitment Information Pack, December 2018
- Royal Cornwall Hospitals NHS Trust, Clinical Director, November 2018
- Royal Cornwall Hospitals NHS Trust, Head of Nursing/Allied Health Professionals, December 2018
- Royal Cornwall Hospitals NHS Trust, Care Group General Manager, December 2018
- National Guardian’s Office (NGO), A Review by the National Guardian of speaking up in an NHS Trust, December 2018, p.12
- NGO (as Note 5), p.4
- NGO (as Note 5), p.12
- NGO (as Note 5), p.12
- Peter Levin, How a lack of teamwork at the Royal Cornwall Hospital contributed to the death of a child with autism, 19 December 2018
- Royal Cornwall Hospitals NHS Trust (as 1)
- NGO (as Note 5), p.19
- NGO (as Note 5), p.19
- NGO (as Note 5), p.12
- Royal Cornwall Hospitals NHS Trust, Trust Improvement Programme,
- Royal Cornwall Hospitals NHS Trust, Quality Improvement Programme update,
- NGO (as Note 5), p.12
- NGO (as Note 5), p.11