Book Review: Being an NHS Chief Executive

Dr Hannah Laidley reviews Being an NHS Chief Executive: What they never told me (or if they did I wasn’t listening) 

Lisa Rodrigues is former chief executive of Sussex Partnership NHS Foundation Trust. Her 13 years running this mental health trust and experiences of depression led her to fight against the stigma associated with mental health. This message is clearly voiced in her book. Her journal entries from the time she was asked to accept her CBE for services to the NHS to her return to work after a bout of severe depression remind you that the chief executive is not in an ivory tower but a grounded, real person.

Stigma was her priority when she became chief executive in 2001, and this was enshrined in the trust strategy. The institutional stigma and discrimination in the NHS remains a problem despite huge shifts in the attitudes of the general public. She describes a colleague who was asked to help control a man with learning difficulties who had presented to A&E with a broken arm and was now fighting staff and smashing equipment. When the colleague arrived at the hospital she found the cast on his arm was too tight and his fingers were swelling.

‘All anyone else could see was a man with a learning disability rather than a man in acute pain.’

Rodrigues describes the cuts to funding for mental health in the NHS as ‘a national disgrace’ and further evidence of institutional discrimination. Not only was funding cut, there was also erosion of the standards and measurements recommended by Professor Louis Appleby in the National Service Framework for mental health. Initially these standards were monitored by Strategic Health Authorities.

‘Commissioners and/or trusts who thought they knew better than the best evidence… were found out and given no option but to improve’.

However, these monitoring responsibilities were lost during repeated reorganisations of the NHS . Reinstating standards and mandating compliance could be the answer to achieving quality care but the recent explosion in the number of measurements healthcare organisations have to produce threatens to shift spending away from improving quality and onto investment in producing these performance metrics.

A Note on Standards and Regulations

 

A study examining the effect of internally and externally generated performance standards  in technological businesses found that the uncertainty a business was facing modified how much these standards hampered innovation. Although the study didn’t look at healthcare it could mean that different organisations benefit from different levels of regulation/standard. For example, in a large acute hospital that has just implemented a change in technology like electronic drug charts internal standards and regulation will allow the organisation to adapt to the new system. Having to face an external inspection from the CQC at the same time will stifle their ability to achieve good quality care in this time of uncertainty. In contrast a long-running general practice that managers think is running well may benefit from an external inspection to give them ideas and challenges on how they could be even better. Most organisations have lots of internal and external standards which  creates a ‘pluralistic regulatory landscape’ where it confusing to know which rules are important.

Looking after our people and ourselves

The author starts chapter 7 with a quote from Intelligent Kindness:

‘turn the focus from chasing poor practice and controlling people to supporting and enabling staff to do what they would in most cases want to do well’.

Leaders can do this by actively confronting blame culture. It is not enough to say you won’t blame people – despite clearly stating in the organisation’s values that executives are there to help and to listen, there are several examples in the book where staff have covered up their mistakes in fear of punishment. Rodrigues admits that she could have done more to acknowledge their trauma when things go wrong. Mary Copeland suggests that ethics and values in an organisation are only maximised when leaders are also transformational – it is not enough to just walk the walk and behave in a way you think it is right, you have to talk the talk and get others to believe you.

‘Bad things happen … Good leaders look after their people at such times.’

It’s extremely hard to devote time and energy into looking after other people if you have not first looked after yourself – it’s a truth that anyone who has ever tried to care for someone when they are stressed or tired or unwell knows. In the year before she retired Rodrigues began to speak publicly about her history of mental illness which had begun when she was a teenager, . When she first became chief executive a patient who saw her speaking about mental health commented that she was so passionate that it was almost as if she had experienced mental ill health herself. On that occasion Rodrigues declined to discuss her personal story, and I think this shows self-awareness and self-restraint.

But she wonders ‘who knows how I, or indeed the staff and services I led, would have fared if I had decided to talk about my own experiences honestly from that time.’

The high demands on leaders and their feeling of isolation can put them at increased risk for mental health problems, so it is important that they lead by example in their practice of self-care.

To conclude, ensuring compliance with standards is imperative since the Francis Inquiries but as Rodrigues writes: ‘we will never be able to stop every person who is determined to abuse their power.’ When things go wrong leaders and regulators should show the same compassion and kindness to staff that they expect their staff to show to patients. Although self-regulation is one of the traits of authentic leaders, too much can lead to a lack of openness and honesty which are exactly the values NHS leaders are trying to uphold.