Leadership in a rewarding, complex and demanding world by Paul Gray (@PAG1962)

The people we serve – the people who live in Scotland, and visitors too – have high expectations of us. And so they should. We operate in a complex and demanding environment, but NHS Scotland is a successful organisation, delivering to high standards of timeliness and quality, and always seeking to improve. The people I meet work day and night, every day of the year, to deliver compassionate care, and whole range of ancillary and supporting services from health science to finance to laundry. And the rewards of speaking to someone whom we have been able to help, who expresses their thanks and wants to emphasise how much they appreciate the care they have received, can’t really be quantified.

Some facts and figures might help. What are we actually delivering each year, with a workforce of over 150,000, and a budget of £12bn, serving a population of 5,295,000?

• Over 24 million GP and practice nurse consultations
• Over 450,000 acute day case procedures
• Over 1 million acute inpatient procedures
• Over 1.6 million A&E attendances
• Over 4.6 million outpatient attendances

And we have over 4.7 million patients registered with an NHS dentist, and real progress on improving oral health in children through the Childsmile programme. Pharmacy is developing too, with services being introduced including Minor Ailment Service (MAS), Public Health Service (PHS), Acute Medication Service (AMS) and Chronic Medication Service (CMS).

We’ve also made considerable and measurable progress on patient safety through the internationally recognised Scottish Patient Safety Programme. Our most recent data show a 16.1% reduction in Hospital Standardised Mortality Ratios since the implementation of the Scottish Patient Safety Programme in 2008; and cases of C.Diff in patients aged 65 and over are at their lowest level since monitoring began.

We are integrating health and social care, so that more people can be supported to stay at home, or in a homely setting – some of whom might be quite unwell, with complex conditions. That means different ways of working, with a range of partner organisations, while maintaining our focus on safe, person centred, effective care. And Sir Lewis Ritchie is leading a review of Primary Care out of hours services, which I am sure will offer some important recommendations on the way we structure and provide unscheduled care. The demographic trends we face are well known to us – we do have an aging population, with increasingly complex health conditions; and there is clear evidence that people generally have better outcomes, and are happier, when they can be cared for at home. Indeed, it’s worth remembering that although there is clearly pressure on General Practice, 87% of patients say that the overall care provided by their GP surgery is good or excellent.

When people do need to come to hospital, we work hard to treat them within the standards we have set, whether that’s to see and treat 95% of people within 4 hours of attending an Emergency Department, or to deliver treatment within our 12 week Treatment Time Guarantee. We’ve made considerable progress on getting to the 95% A&E target across Scotland and I’m grateful for that – but I do know that there are peaks in demand, and that patients are tending to present with more serious and complex conditions. And I know that some specialties are finding recruitment tough, which adds to pressure, but we should also remember that 89% of Scottish inpatients say overall care and treatment was good or excellent – which is highest figure since surveying inpatients began in 2010.

We continue to look critically at ourselves, through a combination of internal assessment and governance, and external assessment through Healthcare Improvement Scotland, and Health Environment Inspections. We don’t pretend that we always get it right, and when we don’t, we act systematically to understand the issues and to implement the changes we need to make with purpose and commitment. And we learn too from reports from elsewhere, like the recent report on maternity and neonatal services in Morecambe Bay, to which our Chief Medical Officer, Catherine Calderwood, contributed, and earlier reports such as those on Mid Staffordshire, including the report “A promise to learn – a commitment to act” to which our National Clinical Director for Healthcare Quality, Jason Leitch, also contributed.

So what does this mean for leadership in the face of complexity and increasing demand? What does it mean for leadership when often the external narrative – whether in print, broadcast or social media – focuses on problems, and gives less recognition to the things that are going well or improving? I offer the following suggestions. It’s drawn from my own experience of the things that have worked for me, so in that sense it’s personal. But I hope that it prompts you to think and reflect, or to have a conversation with someone. If it did, that would be great.

• Ask yourself if you can describe what you do, and the outcomes you need to achieve, simply and clearly in a few sentences. If you can do that, it helps you and those around you to understand how they fit in to this complex world.
• Remind yourselves and those around you of what we do well. Take time to recognise success and to praise a job well done.
•  Build on what we have – almost all of the people I meet are proud of what they do, and want to do it better.
•  Remember that leadership is about proactive actions, not job titles. Some of the best examples of leadership I have seen include:
•  the porter who realised that a patient was upset, spoke to her about how she was feeling, made the staff on the ward aware, and got her a cup of tea. In her words, “He turned my day right round”;
• the receptionist who realised from the questions asked by visitors that the signage somewhere in the hospital was misleading, went and found the misleading sign, wrote out some better wording and gave it to her colleagues in Estates.
•  Be open to feedback. Seek it out – and don’t be afraid to reflect on what you hear. Don’t be afraid of external scrutiny either. It can be tough, even painful at times, but better to learn, improve and grow than to stagnate and provide a service that is less good than it could be, or to put patients at risk.
•  Learn all the time. Encourage and support others to learn. Learn from the best, as well as learning from what went wrong.
•  Have honest conversations. Don’t let issues fester until they create a real problem. Prepare for these conversations. Good conversations don’t often happen by accident.
•  If there is an issue or a problem, describe it specifically, and think carefully about the best way to tackle it. Ask yourself if there’s a contribution you could make to the solution.
•  Uphold the core values of the NHS. If you see or experience inappropriate behaviour, such as bullying or discrimination, speak up, or seek help to address the issue. Don’t let it slide, or suffer in silence.
•  Think about what the complexity and demands mean for the people in your teams. Acknowledge the situation when things are difficult, or the going is tough. People appreciate honesty, and see through hyperbole.
•  Ask people for their ideas about how best to tackle problems. They will have some amazing ideas – I promise you!
•  Leaders take advice and ask for help. They know that they don’t know everything. They recognise and value that expertise that others have. So don’t become isolated, especially when times are tough.
•  Involve others in decisions – especially in decisions that are about them, or affect them in some way.
•  If you’re wrong, say so, and apologise. Be transparent. It’s not weakness to admit a fault or a mistake.
•  Understand the people who work with you, for you and around you – including people who work in different organisations, who might have a different governance context, face a different set of pressures or demands, and use different language from that used in the NHS. They will appreciate that, and if you understand people and their motivations, it’s far easier to be influential. People are far more likely to listen to you if they know that you understand their perspective.
•  Be someone who offers more often than they ask.
•  Be someone who gives credit to others, and doesn’t seek it for themselves.
•  Be persistent and methodical – if something is right, don’t be deflected by setbacks and criticism. If you have considered a course of action carefully, listened to advice, and considered the evidence, follow it through. In a complex world, people value leaders who keep a steady course, and don’t chop and change every day. However, if the context or the evidence changes, review your course of action. Persistence in the face of adversity is good leadership. Dogged pursuit of an outmoded idea isn’t.
•  Look after yourself. Build and develop networks of people you can consult and talk to when the going gets tough. Take time off, and take a bit of exercise. Make time for family, friends, and things you enjoy outside work. Easy to say, I know – but we do need to restore our energy and keep our perspective. We give our best when we are at our best.

And finally – a big thank you from me. I am both proud and humbled to be associated with NHS Scotland. I am proud of the work we do, and of the people who do it. We have a great privilege to serve patients, their families and their carers, and a strong and shared commitment to do it well.

 

Paul Gray is Chief Executive Officer for NHS Scotland and Director General Health and Social Care, Scottish Government.