There is a toxic culture at the top of the NHS

I know because I have worked in several senior NHS positions and have seen it first-hand. It works like this…..

• All major NHS institutions from NHS England down are managed by a board consisting of Executive Directors (EDs) who do the actual work and Non-Executive Directors (NEDs) who are there to hold them to account.
• The EDs are appointed by the NEDs, who also have the power to remove them if they are not up to the job.
• EDs are required at intervals to provide the board with assurance that things are going well and that if this is not the case that there are plans in place to correct the situation.
• It is essential that the board accepts this assurance. If they are not assured they must report up to their regulator – usually NHS Improvement.
• If they are not assured the easiest action they can take is to get a new ED who will assure them better.

The problem is that the EDs know full well that that rising demand, inadequate funding, a catastrophic manpower plan and health inflation will make it impossible to provide honest assurance to the board, but to say they cannot deliver a safe solution is professional suicide.

On the other hand NEDs cannot afford to hear that there is no safe solution. It means that they have failed and in all likelihood NHS Improvement will replace them.

This is where the rot sets in

All board members know that the real state of affairs but they are not allowed to admit it. Yet they cannot lie, or at least be caught lying, or they will certainly be for the chop. In board meeting EDs choose their words carefully, glossing over the negatives and emphasising the positives. They are overoptimistic about the likely success of recovery plans.

The NEDs don’t believe a word but it is not in their best interest to challenge too hard, especially when is no solution that will be acceptable to the government. Indeed they will often exert considerable pressure on EDs to get them to say what they need to hear. This is where NHS bullying culture originates. NEDs accept the assurance in the knowledge that when it all goes pear shaped they can say they were misled and will have an obvious scapegoat to blame.

So boards are made up of intelligent people who know the score but can’t see a solution, who dance round their handbags misleading each other, desperately hoping they will make it to retirement or the next job before it all falls apart.

This climate of deceit and bullying filters down to middle management and ultimately poisons the whole NHS.

They tend not to lie on paper because that can be more easily challenged. They have to put the facts in the board papers but hide them in a sea of “boardspeak” platitudes.

If you don’t believe me take a look at this image.

It is the risk register taken from the NHS performance report presented to the last NHS England board meeting in December 2016. It is a sea of red and amber risks which cover almost all areas of NHS service. Things do not seem to be improving and there is no sense that the mitigation plans will make much difference.

Then read the board paper from which this table is taken. It glosses over this appalling situation. (I know you won’t read it but believe me it is a bit limp to put it mildly).

Now have a look at this recording of the part of the board meeting where the paper was discussed. Most of you will not have seen this. Indeed at the time of publishing this blog only 53 people have bothered to watch it. It is twenty four minutes long but you will get the gist after 2 minutes.  It is really worth doing the first 10 minutes if you want to get your blood boiling as they start to talk about the emergency department crisis.

I was reminded of this culture by Professor Jane Cummings latest missive about closing beds to free up cash for social care. She cannot really believe this will work when we have fewer beds and doctors per head of population than almost anywhere else in Europe. She is spinning the current lie that NHS England board members are deluding themselves with in order to keep her job.

So we seem to have the appalling situation where everyone at the top of the NHS knows that it is falling apart but in order to keep their jobs they have to reassure each other and their political masters that everything is fine. In the meantime the NHS is going to the dogs, clinicians are burning out and patients are suffering.

We desperately need senior people in the NHS to admit what is happening. I hope this will start with clinical board members – Medical and Nursing Directors in particular. They have duty to protect patients under their respective professional codes of practice.

It is about time for them to grow a backbone, and to speak out – before it is too late.