Why is it so hard to make soft changes?

carrotAs Robert Francis is a lawyer, he understands British legal culture, in which rules are deliberately kept as explicit as possible. Nuance cannot be the basis on which legal judgments are made, and so all the factors needed to reach a verdict have to be transparent and ‘hard’. But his final report on the mid-Staffordshire hospital crisis was wise enough to acknowledge the need for complex cultural change, and the challenge of making such ‘soft’ changes happen.

However, the actions that have emerged following the publication of his report in February seem to reflect his views less than the need of politicians to be seen to be doing something. The report may refer to the ‘softer’ less quantifiable aspects of healthcare such as ‘caring’ and ‘culture’, but the remedial steps announced so far seem to be based mainly on regulatory systems predicated on punishment and duty, not on motivation or positive intent.

Thus, the Secretary of State for Health announced ‘a new regulatory model under a strong, independent Chief Inspector of Hospitals’ and introduced ‘a new statutory duty of candour for providers, to ensure that honesty and transparency are the norm in every organisation’. Even the stipulation that nurses should spend a year as health care assistants before they take on ‘proper’ nursing seems a fairly mechanical way of changing values (as well as saying a lot about how we distinguish caring from curing, and the ‘proper’ role for nurses).

I may overuse the aphorism that ‘the floggings will continue until morale improves’, but if ever there was an illustration of its paradoxical ridiculousness, then this must be it. Concepts such as honesty, candour and openness patently cannot be forced onto staff, and so even at face value, such statements will only increase the cynicism that besets so much of the NHS.

The announcements are in themselves an important indicator of the deeper malaise in NHS leadership, where there seems to be no insight either into the manner in which the workforce functions, or into the importance of coherence between rhetoric and behaviour.

Let’s start with the workforce. Vocational occupations, such as medicine, nursing, teaching, policing, and even parenting, all depend for success on their practitioners’ professionalism. My personal definition of what professionals do, is to fill the gaps left by reductive methodologies. Once the rules have been applied, the spreadsheets completed, and the safety checks carried out, it is professional judgment that assesses the nuances and shades of uncertainty that highlight the impending disaster, the malingering patient, the struggling pupil.

The detective’s hunch and the doctor’s gut feeling are key skills, and without such professional behaviours, all the activities described above (even parenting – or NHS management for that matter) tend to lead to worse, and more expensive, outcomes.

Professionalism is the mortar between the bricks of the formal tools, holding them together, yet by definition it cannot be pinned down (or it would have been formalised into mechanical tools long ago). The systems depend on their professionals applying their nebulous skills effectively, but enforcement is nigh on impossible as the ephemeral nature of these skills means that we can’t easily identify deficiency as if wewere checking the accuracy of a temperature or the frequency of a bowel movement.

The motivated detective, keen for approval and promotion, will use his inspired hunches to brilliant effect, whereas his demotivated, burnt-out partner will stick to the rules and hide from disapproval and discipline behind an impenetrable ‘jobsworth’ shell, without actually doing anything wrong. The more we reinforce these respective behaviours, the more each detective will stick to them.

The key to successful change is to understand the factors that actually drive professional behaviour. Approval and promotion work better than disapproval and discipline. For professionals of any kind, the way to motivate them is to tempt them with increases in status, peer approval, patient benefit, pet projects, better income, and more fun in their work.

Of course, carrots need their obverse sticks, and the implicit threat of reduction in status, peer disapproval, patient disbenefit, lower income, and boring, difficult work probably all have a place in the successful management of professionals.

However, carrots work better than sticks – once a culture is perceived as punitive rather than encouraging, then motivation becomes logarithmically harder to achieve.

Jeremy Hunt’s edicts about firmer regulation and harder floggings are likely to be counterproductive, in the same way that thirty years of bullying clinicians to behave more corporately has had so little impact. Until they can understand and feel the benefit of a new behaviour personally, doctors, nurses, teachers and policemen will at best ignore or at worst sabotage each new exhortation, and feel less and less inclined to change.

The NHS is supposed to be a single state-controlled system, so there probably are important elements of corporacy that need to be developed, such as more consistent treatments, communications, and outcomes. But if corporate behaviour is important, then the way to implement these targets is by relating the desired behaviours to professionals’ own agendas. Include the clinicians in problems, involve them in their solution, ensure that the personal benefits and dis-benefits are clear, and so on – there’s a lot more to be said about this on another occasion.

However, the final point to be made is the most important. The incongruity of trying to bully professionals into less bullying behaviour will not be lost on any of the professionals working in the NHS, and the mixed message it gives them about the system in which they work means that their behaviours are unlikely to change.

This blog is based on an article published in Pulse in the UK on 22 April 2013.

Will aptitude tests do more than paper over the cracks in the NHS? (first published 19 Feb 2013)


One of the recommendations made by the recent Francis Report is the introduction of aptitude tests for nurses at entry into the profession, though interestingly, not for doctors. These tests would ‘explore, in particular, candidates’ attitudes towards caring, compassion and other necessary professional values.’

Like so many other ‘shutting the stable door after the horse has bolted’ reports, Francis seems to assume that cause and effect can usually be linked; in this case, a nurse with aptitude for caring can care, whereas one without it can’t.

It is clearly a truism that people who do not have an aptitude for caring really shouldn’t go into any of the caring professions, be they potential nurses, therapists, or doctors.

However, life isn’t that simple, and the report really misses the point by assuming a) that aptitude is the only determinant of caring, and b) that it will remain rock steady, despite all the prevailing pressures. The reality, as almost everyone who has worked in the service will tell you, sacked chief executives included, is somewhat different.

In practice, nearly everyone who joins the NHS is highly motivated, and with a strong vocation both for caring and working in the public sector. Let’s take myself as an example: as a bright graduate, I could have chosen to go into banking or commerce, or industry, where the working conditions and the pay would have been considerably better. However, I wanted to become a doctor in the NHS because it was there that my need to put something back into society, to care in its broadest terms, would be satisfied.

However, when you have a dedicated, motivated workforce, the inevitable temptation is to exert a kind of moral blackmail, exploiting the ‘aptitude’ for caring, and increasing work place pressures.

Rare is the health visitor who refuses to take on a new patient because (s)he has reached their recommended caseload; curmudgeonly is the doctor who refuses to see an extra patient at the end of surgery; and slippery is the slope down which we slide if indeed we do get into that ‘jobsworth’ mentality.

Staff usually accept such pressures, but their acceptance assumes a certain ‘reasonableness’ in return. Such informal understandings, based as they must be on handshakes and unwritten agreements, can work between individuals, but do not sit easily when formal organisations with their need for transparency are involved, and it is here where much of the NHS cultural difficulty begins.

The National Health Service is a massive, politically driven system, where the welfare of the individual – staff or patient – ultimately takes second place to the welfare of the whole. The utilitarianism of ‘the greatest good for the greatest number’, was explicit when the NHS was founded, but even in these days of patient choice and consumerism, the system is bound to use a ‘currency’ that looks for egalitarianism and equity over the needs or job satisfaction of the individual.

So staff expect and are prepared to be somewhat exploited when they recognize the problems and agree with the issues. However, once the gargantuan monolith of The System begins to place importance on priorities that have little or no meaning to individual staff members, they then see themselves as unwitting slaves to a master whose cause they don’t recognize at best, or willfully resent at worst. When that stage is reached, then their willingness to be exploited lessens, their resentment begins to grow, and their ‘aptitude’ may be a little weaker.

In Mid Staffs, the financial priorities imposed by Monitor probably had little resonance with clinical staff; and when staffing levels were reduced, putting extra work onto the remaining staff who were not ‘on message’ with the task, it was perhaps inevitable that standards of care dropped. Not much about aptitudes, more about abusing the basic tenets of human decency.

Valued staff usually exceed their job descriptions, often by considerable margins. Staff who feel themselves to be ignored and undervalued will eventually underperform, however strong their initial commitment and aptitude.

There are two lessons to be learned here: the first is that the creation of  ‘aptitude tests’ to see whether candidates are worthy of joining an industry that will then almost certainly chew them up and spit them out is unlikely to solve many problems. The second, and more important, is that people respond to their environment; initial aptitudes are bound to wither if staff are always blamed and castigated for problems over which they have no control, whereas staff who feel as if their input is genuinely valued will maintain and even increase their ‘aptitude’.

Symptom control is never as effective as diagnosis and treatment; the medical metaphor is entirely apposite, and one that looks as if it is once again being ignored.