In the face of the long NHS waiting lists, lack of hospital beds, failure to address social care, lack of NHS medics, incompetent management and falling standards of care, on June 8th the Government NHS website proclaimed the publication of its report as the “Biggest shake-up in health and social care leadership in a generation to improve patient care”. This so-called ‘landmark’ review into health and social care leadership led by General Sir Gordon Messenger and Dame Linda Pollard was announced in a press release on the website.
The website statements are full of rhetoric but without clear meaning: “The review team met over a thousand passionate front-line staff, managers and leaders across health and social care.” And I thought: What is a passionate staff member? How did they define or measure “passion”? Were some more “passionate” than others? And isn’t “passion” a bit of a danger? Do I really want a passionate doctor or nurse looking after me? No, I want a competent and kind professional, not someone who is “passionate”.
Then I read in the press release that the review found what they called “an ‘institutional inadequacy’ in the way that leadership and management is trained, developed and valued”. What does this mean? What is training for management that is not adequate? And what does the report mean about leadership and management that is “valued”? Here again is wishy-washy rhetoric. What are the ‘values’ that should be valued? And how should one show a leader or manager he or she is valued? A pay rise? Biscuits with a cup of tea? Champagne nights out? Holidays in the sun?
And again, the press report states that the review team “found evidence of poor behaviours and attitudes such as discrimination, bullying and blame culture”. This sounds rather threatening to me. How do they define “poor behaviours”, or “poor attitudes” or “discrimination’” or “bullying” or “blame”? Especially when everyone they met, “over a thousand people”, were “passionate”?
Does the full report give more data and detail for these vague statements given to the press? What is the detailed evidence behind the press release?
The full report does not give data or evidence for its statements. There is no appendix of evidence. There are no supporting data attached. There are no records of meetings. Instead it expands the rhetoric – interviewees were not just “passionate” they were also “devoted” and “hardworking”. How did the review team know this, I wondered.
The full report seems to me to include at least five contradictions.
It begins with a message from Sir Gordon: “I have encountered nothing but friendliness, candour, self-reflection, pragmatism and support from the impressive array of experts, front-line staff, academics, service users and leaders who willingly gave us their time to share their views.” The report seems to indicate that he and his review colleagues have based this review on the opinions of the people they met. But is this this an adequate basis for a formal review?
Here is contradiction number one: Subjective opinions (however friendly and reflective) are not evidence. Sir Gordon and Dame Linda may have met some truly impressive and “passionate” people, but that is not an objective assessment or measure of the care given to actual patients in the U.K. health care system. After all, words are cheap.
The second contradiction follows from this: Sir Gordon states that he and Dame Linda (now his “good friend”) bought together an “excellent”, “inclusive and diverse team” which “included representatives from the Department of Health and Social Care (DHSC), NHS England, Health Education England, NHSX and social care leaders, as well as clinicians, managers and academics – all bringing their own lived experience and personal knowledge of the health and care system”. If this was such an excellent, inclusive and diverse team, why are there any problems that need changing? Surely it’s not possible to better excellence? And what is meant by their “lived experience”. How can this be measured or assessed? Is this just how interviewees felt about their “lived experience” on this particular day?
The third contradiction is this: The review team had a “listen and learn” phase. They engaged with “more than 1,000 stakeholders on over 400 different occasions, plus welcoming contribution from all via an open email address”. They did not appear to have gone out into hospitals or community health and social care to look for themselves and to gain their own objective “lived experience”. The methods do not seem to have included visits out of the office (or maybe even away from zoom at home). They do not seem to have gone into wards where patients are being looked after.
The fourth contradiction follows: The review comments on the “excellent” progress made since the Francis Report (2013). But as with the rest of the report, no data or evidence are given to support this wildly generalising and very vague statement. Staff are passionate, devoted and committed but, as the review concludes, there is a culture of discrimination and bullying and blame. This is contradiction number four. Some of these interviewees must have been blaming colleagues to the review team. Otherwise how would they reach this conclusion? The ‘no-blame’ culture desired for the NHS was obviously not being practised by the interviewees giving their critical opinions to the review team.
The fifth contradiction is the apparent lack of understanding of everyday patient care by the review team. This is no better illustrated than in the deeply cynical statement in the review: “Senior nurses talked about ‘going to the dark side’ as a comment often made when they moved into senior management roles.” Senior nurses in management, by moving away from the coal face, don’t seem to understand the everyday realities of practice. They are disconnected from frontline patient care. No amount of postgraduate seminar training (that the review calls for) will remedy this.
So what is the Government intention and objective behind this very vague ‘landmark’ report? Is it to improve health and social care for the population? No, as the press release concludes, the intention is to “ensure the Government and the NHS can continue to tackle disparities across the country”. Ah, the levelling up agenda!
Sir Gordon Messenger is clear that in his view:
The best way that people learn leadership is not in the classroom. It’s through watching others they respect and admire and how they do it. And so there’s definitely something contagious about good leadership. I think that can have a top down approach so if you’ve got a good leader at the top it’s incredible how quickly one can set the tone for the entire organisation.
Thus spoke the soldier, General Messenger.
So leadership cannot be taught, he says, it must be caught. And this is very similar to how health care leadership and management developed in this country and in particular how the nursing profession developed. It was Florence Nightingale’s view. It was the basis for hospital leadership through the working together of doctors and nurses, matrons, medical superintendents, consultants, ward sisters, staff nurses and student nurses, together with the hospital administrator. The Francis report (2013) also held this view.
Oddly, Sir Gordon’s view on leadership does not seem to be given room in either the press release or the full report, despite Sir Gordon’s position as a leader of the review. This makes me wonder how much influence he really had in writing this report. Leadership being caught in practice rather than taught in the classroom is wholly missing from the report and its recommendations. Instead, the recommendation of the review is yet more vague wording. According to the press release, recommendations include “an induction for new joiners to instil core values across health and social care, a mid-career programme for managers, stronger action on equality and diversity to ensure inclusive leadership at all levels, clear leadership and management standards for NHS managers with a standardised appraisal system, and greater incentives for top talent to move into leadership roles in areas facing the greatest challenges, to help combat disparities across the country”.
And in particular the third of the seven recommendations in the press release completely contradicts Sir Gordon’s view that leadership is caught not taught: “Consistent management standards delivered through accredited training, including a single set of unified, core leadership and management standards for NHS managers, and a curriculum of training and development to meet these standards, with completion of this training made a prerequisite to advance to more senior roles.”
This review is yet another costly (by how much we are not told) white elephant that, to mix metaphors, does not address several elephants in the room. It is yet more grandiloquent bombast full of words signifying nothing. It reiterates concepts such “inclusion and diversity” without explaining what they mean, and more importantly, how this will benefit patient care.
The King’s Fund has responded about one of said pachyderms. Suzie Bailey comments: “However, the elephant in the room is really the deep workforce crisis that predates the pandemic and that the Government has been quite reluctant to face up to. There is a huge number of vacancies, staff are exhausted, they were exhausted before the pandemic.” She added: “This review is welcome but my concerns is will it actually address the size of the workforce crisis?”
In fact, the NHS depends now on taking health care workers from other countries. One of these countries is Nigeria, which maintains the nurse training model of apprenticeship in a school of nursing, rejected several decades ago by the U.K. nursing elite, which is arguably a major contributing factor to the current U.K. nursing shortage.
This report fails to tackle another very big elephant in the room: the scathing reports on the NHS such as Francis (2013), Kirkup (2015), CQC (2018) and Ockenden (2022). “These are major markers in our lack of sustained patient safety system culture,” according to John Tingle, a lecturer in law.
These elephants – staff shortages and poor standards of care – could also be addressed by reforming nurse training to bring back student nurses into the paid workforce, away from the university seminar rooms, so that they can learn nursing leadership, management and values from their colleagues in practice. The Francis report (2013) was also concerned about current methods of nurse training. Perhaps Sir Gordon, with his stress on leadership being caught not taught, might agree?
This report of a whitewash review is deeply depressing. It does not focus on the practicalities of improving the care of patients and simply reinforces the public impression that nothing can change and that the NHS is still a captive of the elite managerial cadre which successfully resists all and any calls for a genuine ‘shake up’ of an institution chronically sick from top to bottom. Care for patients is not the NHS priority. Don’t get ill in the UK!
Dr. Ann Bradshaw is a retired lecturer in Adult Health Care.