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Leadership Listens: inspirational podcasts

Compassionate Leadership

Episode 0Introduction to the Compassionate Leadership miniseries

Leadership Listens is a series of curated podcasts for leaders in health and care. This mini-series of podcasts, as part of the Leadership Listens series, is all about compassionate leadership and is a collection of conversations between Professor Michael West and leaders from across the health and care sector.

It’s based around Michael’s latest book – Compassionate Leadership: Sustaining Wisdom, Humanity and Presence in Health and Social Care published in 2021 by Swirling Leaf Press.

Transcript

Hello, and welcome to Leadership Listens, curated podcasts for leaders in health and care.

My name is Paul O’Neill, Head of Strategy, Research and Development at the NHS Leadership Academy, part of the people directorate of NHS England and Improvement.

This mini series of podcasts as part of Leadership Listens is a series all about compassionate leadership and is a collection of conversations between professor Michael West and leaders from across the health and care sector.

Michael is Senior Visiting Fellow at the King’s Fund, London, Professor of Organisational Psychology at Lancaster University, Visiting Professor at University College, Dublin, and the Emeritus Professor at Aston university.

His work has a strong focus on healthcare; looking at teamworking, innovation, culture and more recently, compassionate leadership. He has some 20 books and 200 scientific articles to his name and as a fellow, many international learned societies. He has a long history of advising on policy and practice in health and care services.

Michael led at the independent inquiry on behalf of the UK General Medical Council, into the mental health and wellbeing of doctors in 2019, (‘Caring for doctors, caring for patients’) and the 2020 review commissioned by the Royal College of Nursing Foundation into the mental health and wellbeing of nurses and midwives.

He was appointed a CBE in the Queen’s birthday honors list in 2020, for services to compassion and innovation in healthcare. His latest book on, which these podcasts are based, is ‘Compassionate leadership, sustaining wisdom, humanity and presence in health and social care’ published in 2021 by Swirling Leaf Press.

These conversations were recorded at the beginning of 2022, as the country and the NHS, were beginning to emerge from the worst aspect of the COVID-19 pandemic and setting a path for recovery. There are conversations between Michael and a variety of clinicians, leaders and citizens who reflect on different aspects of the role of compassion in care and treatment, of self-compassion, of compassion in teams, organisations and systems and its criticality and providing high quality, continually improving, health and care services.

Other episodes cover compassion and inclusion, leadership development and education about compassion and some of the myths surrounding compassionate leadership being a ‘soft option’ and it’s true place in not only creating a culture of kindness and consideration but as the very best way of delivering high quality clinical treatments with good outcomes, strong financial performance and person centered care.

I hope you enjoy the miniseries. Listen to all seven episodes, if you can and look out for other podcasts in the Leadership Listens series for more content like this.

Episode 1The importance of compassion in medicine and the importance of self-compassion

This recording is a conversation between Michael and Dr. Alison Sykes, consultant in Emergency Medicine at Lancashire Teaching Hospitals and the conversation focuses on the importance of compassion in medicine and the importance of self-compassion.

Transcript

Paul O’Neil [00:00:02] Hello and welcome to leadership listens, curated podcasts for leaders in health care. My name is Paul O’Neill, Head of Strategy, Research and Development at the NHS Leadership Academy, part of the People Directorate of NHS England and Improvement. This mini series of podcasts as part of Leadership Listens, is a series all about compassionate leadership. It’s a collection of conversations between Professor Michael West and a leader from the health and care sector. This recording is a conversation between Michael and Dr. Allison Sykes, consultant in emergency medicine at Lancashire Teaching Hospitals, and the conversation focuses on the importance of compassion in medicine and the importance of self-compassion. 

Michael West [00:00:54] Welcome everybody, my name is Michael West, and I’m delighted today to be joined by Dr. Allison Sykes. Allison is consultant in emergency medicine at Lancashire Teaching Hospitals, and the foundation programme director at Lancashire Teaching Hospitals for the North West of England School of Foundation Training and Physician Associates. Welcome, Alison. 

Allison Sykes [00:01:17] Thank you, Michael. 

Michael West [00:01:18] We’re going to be talking today about compassion and kindness in health care and the centrality of self-compassion and self-compassion in leadership. And so to begin. Allison, let me just say a little bit more about you. You started working I know as a consultant in emergency medicine in 2010, and your role as a foundation programme director at Lancashire Teaching Hospitals, is very much focussed on how to bring about change and improvement in placements for doctors in training; and also helping other doctors find a way to make it all work in these really challenging circumstances we face. And I think what’s particularly relevant to people is also, that you’ve pioneered the development and implementation of a compassionate leadership programme for trainees, and I know that you’re extending that to others. So I want to ask you obviously some questions about that pioneering work. But really, the first question is it’s a kind of an obvious question, but I think it’s important to explore it. Why is compassion important in healthcare and in medicine? 

Allison Sykes [00:02:27] It’s tremendously important for us as doctors because I think it is the essence of what we set out to be. It is why we went to medical school all those years ago for some of us, was to look after people, to care for people, and to help others. And that is what we are. We are compassionate beings and we know if you just look at the research, we know that children show compassionate behaviours at the age of 14 months. It’s what makes us human that desire to want to care for one another. And so when people set out on their journey in medicine, that is fundamentally why they went to medical school. It’s very important right now because I think at this stage that we’re at, we’ve lost sight of that. We have in some way become connected with what is a core value to be human. And there’s many reasons for that, in terms of the pressures of work, the current situation we find ourselves in. The lack of staff, but it’s about reconnecting with that core value of being compassionate, and we know it has hugely beneficial effects for patients, for staff and for us as individuals when we do reconnect with our core, which is compassion, which is to help and to serve others. 

Michael West [00:03:51] So you were saying that when people go through medical training, the evidence suggests that compassion in many cases declines. Is that because in a way we’re so concerned with developing technical skills, and memorising all of the information we need, and going through processes, that we we become focussed on doing rather than being in the relationship? Is it something around those sorts of difficulties that overlay our way of being? 

Allison Sykes [00:04:21] I think that’s part of it, Michael. I think we go through your medical training and you come out the other side as a doctor and the next thing that you’re looking to is. Which speciality am I going to go in? Which set of exams am I going to do? What of those skills and knowledge I need to achieve those things? And so you have this sense of forever being on the hamster wheel, there’s always another hurdle, after the first round of exams is inevitably more. And then there’s jobs to think of. Where do I need to locate myself to get the best CV for what will hopefully lead me to the right post for me as an individual? And in amongst that you do lose part of that connection of why we are truly there. But I also think there’s more to it than that. I don’t just think it’s about pursuing knowledge and skills. I think it’s also the sense of time, of what time we have available when we’re working. And as you’ve mentioned, I work in emergency medicine, so for me, if I see one patient, there are still probably another 10 waiting to be seen, at least. And not just for me. That’s the same for all of us. There is a huge time pressure to see a large number of patients in the shortest time possible. And you can end up just rolling from one to the other without pausing, without stopping to draw breath and even just reflect on what you’ve just seen and done. So you become hardened to it, I think. I think that’s definitely what happens. I was I was aware I was losing touch with my humanity. I felt like I was, I was just leaking my humanity out because I was always running from one thing to another. And obviously, people watch television programmes about doctors and casualty and things like that. But the reality is that you do have shifts where there’s one patient after another that’s coming through the resuscitation rooms are our sickest patients. They deserve and need our attention immediately. And you just have to go, you have to do it. And that’s right and proper that we do, so when we don’t have enough staff there is no opportunity to pause, to breathe and go phew, that was tough. And so I think you become a little bit hard and I don’t just think it’s about the the focus on skills and knowledge, although that is definitely some of it. We don’t draw attention to this as an area in the same way that we would talk about managing heart disease. And yet we know this is just as important. 

Michael West [00:07:00] So I think these are hugely important observations. I’ve been really impressed. Amazed actually by a review of the research on compassion in health care published by Trzeciak and Mazzarelli  in their book Compassionomics a few years ago, which basically showed us, I think, from the hundreds of randomised controlled trials and metanalysis that compassion across the board is the most important intervention in health care, probably. And you know, some of the studies showing visits by anaesthetists to patients prior to surgery, where anaesthetists are extra compassionate, much lower requirement for painkillers, post surgically and much shorter length of hospital stay. The randomised controlled trials of patients with an early diagnosis of lung cancer, who are given early palliative care, if you like extra compassionate care, living significantly longer, 30 percent longer and studies of the treatment of long term conditions like diabetes and HIV, where clinicians are compassionate, much better outcomes, much better adherence to treatment protocols. And in the treatment, of course, of mental health problems, therapies, compassion being associated with much better outcomes. And also, I suppose that well, a couple of things, one is the research showing that being compassionate has an impact on clinicians own well-being, lower levels of anxiety, stress and depression, but also that compassion doesn’t need to take any longer. That in some of these interventions, the protocols used scripts that involve compassionate statements that only took about 20 seconds. But the other point that you make, it seems to me hugely important, is the issue of staffing and workload. And I mean, that’s just a huge point in the current work context. And actually, it has been four years from before the pandemic, with hundreds of thousands of vacancies across both health and social care and very large numbers of staff intending to quit and the problems of chronic work overload, leading people to be absent, to be sick at work. And as you say, that that is having an enormous impact on clinician wellbeing, and that’s partly why we’re losing so many clinicians. So, you’ve also seen the impact of the pandemic, and can you say a little bit about what that’s been like in terms of the experience of you and your colleagues working in emergency medicine? 

Allison Sykes [00:09:29] I think it varied between the waves. I think it’s quite important to make that distinction, because the first wave there was a lot of fear. There was a lot of uncertainty and unknown for all of us. And there was also a very different message being sent to us about what we were going to do. There was a lot of reference to almost military terms about going into battle to a to an enemy you can’t see or hear or touch. And the first wave we, in our emergency department at Lancashire Teaching Hospitals, we actually retained our staff, so none of our staff moved on. So we kept everybody that we started with at the beginning of December, stayed with us for about eight months. And that was hugely beneficial and protective because we all knew one another and there was that herd sense. We, you know, we looked after one another and we looked out for one another. And certainly for us in the Northwest, the first wave was not as severe as it was in London, and we had time to sit with one another to debrief at the end of shift. So at the end of every shift, we would make sure that the outgoing team were able to talk about their experiences and to share that load. So the first wave was quite different to the next wave that we then got. So we got our second wave in June in the Northwest, and that was different. And then the third wave, which was the national second wave. Again, there was then the pressure that we had to catch up, we had to hurry up. There was work that hadn’t been done. There were long waiting lists. We were asked to commit to high levels of workload as an organisation, 120 percent. And that felt really different because suddenly you weren’t just coping with the devastation that COVID was causing to individuals, to families, to communities. You were also trying to cope with additional workload on top of that and catch up. And I think that was a far more damaging situation to be in for individuals, for people’s health and their wellbeing. And also, we were back on track. We were trying to do all the things that were normal. So our trainees were moving on. They were rotating back, which was right and proper for them. It’s right and proper. That training was developed and I want to make sure that I stress that point. But that meant that they were back to moving between different departments so that lengthy attachment was lost. We still instituted the same things, but when you lose team members and get new team members and then obviously it changes the dynamics and when you with somebody for a longer term, you have a deeper connection with each other. So, I think we’ve seen more damaging effects from those second and third waves than we did from the first wave. I think the first wave was hard for us in terms of adjusting to the environment that everybody found themselves in. You know, it wasn’t just health care workers that were struggling, it was everybody was struggling. As a friend of mine says the quiet pandemic, the mental health pandemic that’s going on as a result of the COVID pandemic. So that was hard for everybody. The second and third wave were hugely damaging, I think, for individuals, for staff because they’d got through the first wave. And if you’d had troops in some country or other fighting, then you would have rested them and there was no rest for NHS staff. There was no pause, there was no break. And in fact, it was worse than that. It was right. Come on, get on. We’ve got work to catch up on. We’ve got to deliver 120 percent. And you could almost see it in people. There was a – really you want more? And so that was more damaging and. And it’s sad, really, because it’s sad for those individuals that suffered, and it’s sad for the NHS, but it’s sad for communities because the result of that is that we lost the highest number of staff in December 2021 than at any other time. So more staff have chosen to leave the NHS now. And I do feel that if we done things differently, that wouldn’t have happened. But it has. We’ve lost people and that speaks volumes about where staff are at in terms of their health and wellbeing, levels of burnout and what they actually think they can now do what they feel they’ve got to give left inside. 

Michael West [00:13:53] And so what could have been done differently, Allison? 

Allison Sykes [00:13:56] For me, it would be about recognising where individuals were and acknowledging that, and I don’t think that there was never going to be a cavalry coming over the hill for the NHS. We all knew that. But we did need something else. We did need hope. We needed some way to, to find a way through. To not be asked to give more, but to be honest, to give what we could perhaps, and then to support staff and look after staff and that support and looking after staff needed to be timely. People shouldn’t have waited the length of time people have waited to get help when they’ve needed help for PTSD, depression, anxiety. It needed to be faster than that. It almost needed to be there at the same time as people were going through this so that they didn’t leave a shift having experienced moral injury and then take that home with them to then come back in eight o’clock the next day and go through it all again. But that didn’t happen. People came into work day in, day out. They delivered, they cared. They did what they could, and then they were burnt out. And it’s no surprise we are where we are. 

Michael West [00:15:03] I’m impressed, and I think it’s really important that in your department you have these end of shift huddles, if you like, where people could talk about what they had experienced and what they were feeling on a daily basis, that feels important. And I think the deeper point, an important point is that I think there is a real danger. There has been a danger traditionally, but I think there is a real danger still, even with the pandemic, that people are often reluctant to talk about workforce shortages and chronic excessive workload, partly because they’re anxious that they don’t have solutions for these things. In the middle of all of this Allison, you made the decision to introduce a Compassionate Leadership course for foundation doctors and physician associates. How did that come about? What was the motivation for that? I mean it’s a pioneering course in the country. 

Allison Sykes [00:15:54] Thank you for that, too. That’s that’s lovely. So it came about because I worked very closely with Professor Paul Baker at the Northwest of England School of Foundation and, and his view, what he said to me was, we are two steps away from compassionate leadership at foundation level. I want you to talk to Professor West about it. And that was how it started. And then we had our conversation, and I think it became apparent that if we accept that foundation doctors are more compassionate than at any other time in their future careers, they are the fertile ground to which we should apply this knowledge, these skills, this information to help them go on and lead the rest of us in being compassionate, almost a bottom up approach. So that to me, struck a chord that we should really be doing this for our foundation doctors. And then I looked more into where they’re at in terms of their health and wellbeing. I was quite surprised to hear that they also suffer higher levels of burnout than any of the training grade. So it seemed to me a perfect match. We’ve got high levels of burnout and we know they are probably the most receptive to this type of information. And so then with yourself, with Professor Baker and with the University of Lancaster, we started to develop the compassionate leadership course for foundation trainees, and we were able to start delivering that in May 21, which was great. And we developed an eight week course looking at several aspects of compassionate leadership, but also providing a reflective space where the trainees could talk to one another. They could exchange their experiences, their views, their solutions as well, because, as you know, I love my bees, I’m all for a hive mind of sharing information, and they were able to sort of explore the material to look at compassion as a state of being as a way of living their lives. And I think when we’ve looked back at the information that we’ve received in terms of feedback in the interviews, I’ve been absolutely amazed by what has come out from that, for them as individuals. And for me, I think it was the right thing to do, obviously. I still think it’s the right thing to be doing because I think they are our future. They’re the doctors that’s going to be looking after all of us. So, you know. 

Michael West [00:18:28] What’s the structure of the course then that you’ve developed, Allison? So thank you. 

Allison Sykes [00:18:34] We start with about an afternoon just looking at what compassionate leadership is. And in doing so, we’re looking at the principles of compassionate leadership, attending, understanding, empathising and helping. And we use a very reflective space so that they can try those things out, see how they work for them and experiment with them. We then move into self-compassion and we’ve found that that’s particularly difficult and challenging. So we’ve spent longer on self-compassion than actually we planned to do, but we’ve seen the benefits from doing so. So it was the right course of action. We then move into compassionate leadership in teams and across teams looking at our relationships with one another, not thinking of the I and the you, but actually about the we, and how we can move forward together to serve the common purpose, which is to care for those in our community that need our help. And then we look at compassionate leadership in difficult or challenging situations, and try to find ways to make that easier to cope with because those situations are not just damaging for patients, but they’re damaging for us as individuals. So actually, it’s hugely important that we find ways people can manage that situation and cope with it better. Ideally not end up there. But if it happens, then we look at that as well. And then we close by looking to the future, by how we can implement these principles in the way we go about our work. But as we’ve mentioned, it’s not just about our work, it’s about the way we interact with everybody, with our colleagues, with our friends, with our family. 

Michael West [00:20:14] So, so there’s a couple of questions, I guess, that arise from what you’ve said. I mean, it’s pioneering. You have done something really at the moment, quite unique in terms of the training of doctors. And yet it seems utterly obvious that we should be developing compassionate leadership for doctors. What were their reactions in the middle of this intense training that they’re going through in the middle of a pandemic? What were their reactions? What maybe was difficult for them and what was most important to them in the content of the training? 

Allison Sykes [00:20:44] It landed on many different levels for them all in different ways. We obviously held a very reflective space for them, which was. Very different to how a lot of medical education is delivered at this stage to trainees. So there was a little period of adjustment, didn’t take long, just a tiny period of adjustment for them to actually engage with that space. And then they flourished in it. And in terms of individual things landing for them, it was humbling to read one of our doctors attributing her staying in medicine as a result of the course. I had no idea that that was going on for her, that she was considering leaving. Yet the course gave her confidence and it gave her courage, and it gave her a different approach to how she would progress further in medicine. And she’s still working in medicine. And so we have that extreme. And then I have wonderful stories of trainees talking about working and seeing a patient unable to butter their toast, and him stopping and pausing and seeing this and going over and buttering this lady’s toast for her because she couldn’t do it herself. That’s just a wonderful connection between two people and acknowledging that we can do those things for one another. And that rippled out further. Just that little interaction between the foundation trainee and the patient was observed by a nurse, and the nurse said, I’ve never seen a doctor do that before, you know, and that then made him feel emboldened to try other things. So he went off and did different experiments. So when he was quiet, one of our sister departments is Chorley District Hospital, and they only open at 8:00 in the morning. And when there was no patients in at 8am, he helped the nursing staff do the nursing checks and really was sort of swept along on a tide of teamwork in a compassionate leadership way that was hugely beneficial, not just to him but to the team he was with. And of course, that then had an effect on the way that day went, which then impacted on the way the patients received the care. And we know that don’t we, from all the evidence that we read how just these small things can actually have massive effects and ripple outwards, which is it’s a wonderful idea, isn’t it? 

Michael West [00:22:55] So there’s a really uplifting examples, Allison. And actually what might be useful is if you just very briefly say what the content of the course covered and what do you think the most powerful part of the course was for the doctors? 

Allison Sykes [00:23:08] So it was really about the how and the what have compassionate leadership was what we set out to achieve over an eight week course, and we met with the trainees for an afternoon every week. That was partly to give them that space for reflection as well, so that when we talked about various aspects of compassionate leadership, they had a week to reflect on it, to think about it and to experiment as well. We encourage them to try things out, see how it felt, see what it meant to them and to others in terms of the actual subject matter that we looked at. So we initially spent the first session looking at what is compassionate leadership, what the aspects of it are, why it’s important not just for individuals but for themselves, not just for patients, but for staff as well. 

Michael West [00:23:53] So you covered those four behaviours of attending to the other understanding that challenges empathising and then helping. 

Allison Sykes [00:24:01] Absolutely. That was how we started. So bringing in what we term the principles of compassionate leadership with the attending, understanding, empathising and helping, and then we moved along into self-compassion again using the same principles. And, you asked me which was the most difficult and this was the most difficult for people. It was the most challenging to accept, to think about themselves compassionately, that that was definitely the hardest part for them. And I’m going to be honest and say for me and for all of us, that will leading in on the course, we are all still learning. I’m no expert on this material at all and very much a work in progress. So, um, so the self-compassion was the most challenging for everybody. 

Michael West [00:24:50] Why do you think that was? 

Allison Sykes [00:24:52] I think that as doctors, you come in to serve, you come in to focus on other people. You come in to care for the people. So to turn you direction towards yourself seems unnatural. And, there’s also the hidden curriculum around being heroic and stoic. We see it on television programmes. You hear it if you’re on the wards about how, you know, I’ve just worked the last 48 hours non-stop and I’ve done this and I’ve done that, the underpants on the outside, sometimes term that kind of behaviour. So there’s this whole heroic and stoic the hidden curriculum really about being a doctor, about how you can cope with all these things and survive them and keep going and see the next 400 patients, whatever. So there is that mentality around medicine, too. So a strong sense of altruism, the heroic and stoic behaviours that we have been immersed in. You know, from early days of graduation, if not before graduation, that affects the way people behave. So to turn compassion onto oneself is really going against the tide. That’s difficult stuff. And actually, that was born out by us recognising we needed to spend longer on that, perhaps than any of the other material we wanted to cover. And for me, it was fundamental to have a good bedrock in self-compassion because if you don’t have that, then trying to empathise without being overwhelmed will be incredibly difficult and perhaps damaging. So for me, you have to be moving in the direction of self-compassion to then be able to be compassionate to others, to then be able to be that compassionate being that is what you are at your core. It’s a wonderful thing, isn’t it? Because as a leader and I’m now thinking about when I’m working clinically, as a leader, if I show my self compassion, it’s enabling for everybody else to do the same. It sends a very powerful message and that helps other people see this as important for themselves. See it as something that they should be doing. 

Michael West [00:27:09] And I guess what feels really powerful in what you’re saying is that compassion is a way of being isn’t siloed in the sense. It’s not just about being compassionate to others who are providing care for. It’s also about compassion being my orientation to the others that I work with. And that compassion is also about my relationship with who I am with myself, and that in a way to develop our ability to be compassionate. It means that all relationships with others and with ourselves are characterised by that compassion of paying attention to ourselves, being self-aware and in the moment. And seeking to understand how I’m feeling and why. And accepting the feelings rather than rejecting them and then bringing a nurturing, loving attitude to ourselves. I suppose I think that that notion of having a loving attitude towards myself, a caring, nurturing attitude towards myself is quite a hard one for people because as you say, it goes against the norm that we would be loving towards ourselves. And yet each of us is as deserving of love as every other human being. And so I think when we are loving towards ourselves, then we’re more likely to take the actions that help us to be the best we can be. 

Allison Sykes [00:28:34] Hmm. I think that’s true. And I think when we started working with your material, Michael, we realised very early on that, that this wasn’t just a set of skills and knowledge. This was a way of being, and being not just at work, but in every aspect of our lives that it would ripple through and the self-compassion again. Absolutely, I agree with you. I think turning compassion on to ourselves is, it’s incredibly difficult, but it’s so important to do because if you’re not compassionate with yourself, then what other people see is not authentic. It doesn’t make sense. You become a paradox, don’t you, in that you are wanting to to be compassionate to everybody else, but you cannot give yourself that compassion. And it’s difficult. It’s not an easy thing to do. I’m not saying that this is something that I’ve got right. I definitely haven’t. This challenging time still for me to be compassionate myself. 

Michael West [00:29:32] And so how does self-compassion manifest for you? What do you do to be self compassionate? 

Allison Sykes [00:29:38] I think it’s important to make the distinction between self-care and self-compassion. I think there are things I do to look after myself regularly, which which will involve sort of exercise and diet and things like that. And and hobbies obviously are important. So as you know, I keep bees, so I in the summer will go and spend time out with my bees looking at them and and I find I can draw a lot from the world around me to the nature that I live amongst. But we have quite a wild garden and so we have quite unusual visitors. And I also like to be up mountains quite as often as I can. 

Michael West [00:30:17] What you’ve just said chimes wonderfully with all the research. Professor Sabina Sonnentag University of Mannheim, has done over the last 20 years on recovery from work, showing that people who have stressful work need to be able to recover. And the activities that enable recovery are things like engaging in activities that help you psychologically disengage. So you’re not just thinking about work all the time you’re thinking about other things the bees or a Netflix series that you’re watching, but also that it’s quite helpful to do tasks that give you a sense of effectiveness, some sense of achievement in doing something a little bit challenging, maybe the bees or cooking a nice meal or whatever. And of course, relaxation, meditation, those sorts of activities. And I was struck by her research showing as well that people need to be able to, outside of work, not just have another huge raft of tasks they’ve got to do, but they’ve got some choice about what they do in non-work time. And that work breaks are important not only for recovery, but also for safe patient care and obviously exercise. Her work shows that spending time in nature is astonishingly powerful for recovery, and there’s a kind of hierarchy of natural environments, with blue being at the very top lakes, rivers, sea, closely followed by green environments, mountains, hills and then a little way down urban green environments. But even being outside at all can be beneficial. So what you’re doing in terms of you’re taking care of yourself is very much mirrored in her work. And of course, we know that probably the most important factor in terms of human wellbeing is spending good quality time with the people we love and who love us, and that has a huge effect. And it’s also why compassion is so important. You were going to talk about a second area that you focus on in terms of self-compassion. 

Allison Sykes [00:32:19] So I get a lot of comfort out of those aspects that we’ve just talked about. But for me, the self-compassion starts by recognising that I need to do something. I need to change something or listening to myself to where I’m at. And so for me, there’s that first step of recognition, of knowing that my stressors, my anxieties are perhaps just on the boundary of what I can tolerate. To cope with that, I need to do something just to move away from that boundary or reinforce it a little bit. And quite often, I think for us in many different aspects of our lives. It’s not just applicable to doctors, but obviously that’s all I know about. But for us in healthcare, you do feel quite often that you can’t change some of the things. So you’ve mentioned chronic excessive workload and where we are at the moment, there’s nothing I as an individual can do to change that. So for me, recognising when that is too much, and knowing when I need to step back from it, and not spend the time coming home sorting out the washing and the ironing, but coming home and saying, I’ve got to go off the mountain today or I’ve, you know, there’s something else for me as an individual that I need, that I need filling up in some way. For me, that’s the first step is recognising that and accepting where I’m at with it, that there are things I can’t change, but I can change the way I feel about them so that I can choose how I cope with it, 

Michael West [00:33:55] Rather than just being impelled forward to working harder and harder, not having any respite. Mm-Hmm. 

Allison Sykes [00:34:02] Yeah. So I can choose what I do. So accepting it and stepping away and and taking that time to look after myself in whichever way that is, but not feeling guilty either. I don’t have to feel guilty about a day out up in the hills, so I have agency I think is what I’m saying. If Mike Perset, that was with me, one of my co facilitators, he would say, You’ve got agency. You can choose how you do this. 

Michael West [00:34:29] And that’s so important, isn’t it is the sense that we we have some control over all of this. I find the guidance that Tara Brock gets in her book on self-compassion really powerfully talks about an acronym of reign, and I think the first two steps are so powerful, so recognising what I’m feeling. Having the courage to be self-aware in the minute and to recognise feelings. Feeling overwhelmed, feeling guilty, feeling angry, feeling at the end of my tether. Feeling joyful, feeling happy. And then she talks about accepting the feelings, just just accepting it, rather than denying them or berating ourselves for having them or pushing them away. And those first two steps that involved the courage to be self-aware, recognising and accepting how I’m feeling, and then being able to enquire in the eye of reign into them so that I understand where’s this coming from? Why am I feeling like this this minute? To see it clearly and unpack it. Oh, I just had that difficult interaction with that person, which is left me feeling actually a bit hurt and then bringing a nurturing, loving, caring attitude to ourselves to say, you know, yes, this hurts. It’s hard and almost as it were, you know, metaphorically or physically even to hug ourselves. And then that makes it much more likely, as you say, that we’ll have agency and consciously take a choice to do something that helps us to be happier, the best we can be. Enable ourselves, as you say, by going up into the mountains for a day. So, Allison, what’s the one, maybe two things that you would recommend for leaders in healthcare? Doctors in health care? That they could do to embody, if you like or implement self-compassion, that would be most helpful for them. 

Allison Sykes [00:36:25] I think that was quite difficult because we’re all very different, aren’t we? For me, it was about connecting and, and recognising my connection with the world around me and and I live that through through beekeeping, that’s my hobby. But it’s more than a hobby. It is about connecting with the world. And if I can just explain what I mean by that connection by a lovely piece of science that I read last year about how a flower well hear and I put “hear” in inverted commas for me, and we’ll hear a be approaching and what it does that it releases, it increases its flow of nectar for the bee. What a beautiful picture of a connection of compassion, of help that we find in the world around us. To me, my bees are a hobby, but they’re also a connection with something far deeper, far greater than than just a high. 

Michael West [00:37:27] I was listening also about how daisies turned to the sun as soon as it’s there, they open up and turn to the sun and they get really warm temperatures in the middle of the flower so that when the bees come, they get warmed by the flowers as well makes it makes those daisies particularly attractive. But that lesson of interconnection I think of interbeing is in a way, the message at the heart of compassion that we are connected with each other and we are connected with the entire planet and universe, and that our growth, our happiness our fulfilment are all greater when we recognise and live that interconnection. 

Allison Sykes [00:38:10] I do agree. Absolutely. 

Michael West [00:38:13] Allison, I’ve got a question for you. How many hives have you got now? 

Allison Sykes [00:38:18] (laughs) I’ve got nine. 

Michael West [00:38:20] Okay, so my question is, what have you learnt from the bees that can help us human beings? 

Allison Sykes [00:38:26] Oh, absolutely loads. One day I’ll write a book about it. I’m compassion and bees. So for me, they’re a community. They are a perfect community in everything that they do is for one common good, and that’s to see them all through winter. So that is their primary purpose to care for everyone in the colony. And it is a magical thing to look inside a hive and to see them all working together. And when the bee comes in laden with pollen, just as an example, that the hairs on the bees legs are exactly spaced for dandelion pollen to sit one atom of dandelion pollen directly on. So when they come into the hive, they can’t get that off that off their legs. So think of the bees come in and they clear the pollen off and they put it into what we call bee bread, which then feeds the baby bees and life goes on and they all have a purpose. And that is to look after the whole, the whole colony of the community. So for me, that speaks volumes about, about how we could live our lives, thinking about one another and caring for one another. There are many other aspects, but I was aware I bore people after a while. 

Michael West [00:39:37] Not at all. Allison, it’s been just a joy and a delight to spend this time talking with you about the amazing work that you’re doing in the most difficult circumstances as well. So a huge thank you from me. 

Allison Sykes [00:39:52] Thank you very much for asking me. 

Paul O’Neil [00:39:57] I hope you enjoyed this conversation. Please look out for others in this mini series and subscribe to the Leadership Listeners’ Collection for more content like this. 

Episode 2 – Compassionate leadership and quality improvement and delivery of high-quality services

This recording is a conversation between Michael and Annie Laverty. Chief Experience Officer and Kate Thompson Dep Dir of HR and OD at Northumbria Healthcare NHS Foundation Trust and the conversation focusses on the role compassionate leadership plays in quality improvement and delivery of high-quality services as well as its importance across teams and organisations.

Transcript

Paul O’Niell: Hello and welcome to ‘Leadership Listens’, curated podcasts for leaders in health and care. My name is Paul O’Neill, Head of Strategy, Research and Development at the NHS Leadership Academy, part of the People Directorate of NHS England and Improvement. This mini-series of podcasts as part of ‘Leadership Listens’ is a series all about compassionate leadership. It’s a collection of conversations between professor Michael West and a leader for the health and care sector. This recording is a conversation between Michael and Annie Laverty, Chief Experience Officer and Kate Thompson, Deputy Director of HR and OD at Northumbria Healthcare, NHS Foundation Trust. The conversation focuses on the role compassionate leadership plays in quality improvement and delivery of high-quality services, as well as its importance across teams and organisations.

Michael West: Welcome everybody. My name is Michael West. I’m Senior Visiting Fellow at the King’s Fund and Professor of Organisational Psychology at Lancaster University. I’m really delighted today to be joined by Annie Laverty, Chief Experience Officer at Northumbria Healthcare Foundation Trust and Kate Thompson, who is Deputy Director of HR and OD at the same Trust. Warm, welcome to both of you. 

Annie Laverty: Good morning, everyone. Really lovely to be here. 

Kate Thompson: Morning – same here. Thank you, Michael. 

Michael West: So, just to say a bit about you both; Annie, you’re Chief Experience Officer. There’s a phrase to roll around the mouth and think about. At the Trust, you’ve led on one of the most comprehensive patient experience programmes. So, the Chief Experience Officer’s partly about patient experience. It’s one of the most comprehensive programs in the NHS and it’s based, I guess, on the Trust shaping its strategy by listening to the feedback from thousands of patients and then acting on that. I know a few years ago, you expanded the role to make staff experience equally important so that not just patient experience but people experience, generally, shaping the strategy of the Trust. You’re a Generation Q Fellow (people probably won’t know what that is). You graduated in 2012 from an 18-month health foundation leadership scheme, focused on developing skilled leaders for quality improvement in healthcare. And I know you direct Rubis QI, an NHS consultancy, which supports other NHS organisations, social care, third sector organisations to develop quality improvement. So that’s hugely important for the topic we’re focusing on today: quality improvement and innovation. Kate, Deputy Director of HR and OD at the Trust – I know that you also bring huge experience of innovation. You’ve been 17 years at the Trust, so you’ve seen the development of this amazing organisation over that time and the extraordinary things it’s accomplished and you’re a mother of three children, so you’re also flying the flag for working parents. It’s just a delight to have you both here.

I guess for me, the starting point is, it might seem rather obvious, but really to ask you the question of why are quality improvement and innovation important? Why don’t we just get on and do the job the way we’ve always done it?

Annie Laverty: I think, Michael, it comes from a deep connection to the work that we do. I’ve worked in the NHS for 30 years, (more than 30 years actually) and had the privilege of having worked with extraordinary colleagues in that time. My love of the NHS and what the NHS represents, in terms of access for all to meaningful and high quality safe and compassionate healthcare, is something that is at my core. I think if, like me and other colleagues, you care deeply about that purpose, then that involves recognising that from a position of humility, if you like, and authenticity, that it can be better. If we really listen to people, to our communities, to patients and families, we will hear lots of times when we get that absolutely right. But we will also learn where we fail to meet people’s expectations. So, quality and improvement and innovation, I believe, is a fundamental part of our ability to keep striving to be better, to never be satisfied with the status quo and to recognise that the world around us changes, so the needs of the people around us changes and the workforce needs change. We have to adapt and grow. So, it’s an exciting part of our roles. I would feel very sad if my role didn’t involve a fundamental part of how we think about getting better, changing things for the future and responding to the needs of the people who use us. 

Michael West: I was having a conversation with Don Berwick a couple of years ago now in the King’s Fund. (Don Berwick, as you know, was the, I suppose, founder of the Institute for Healthcare Improvement in the U.S. and he was also Barack Obama’s advisor on healthcare during part of that presidency). I remember him saying, “if quality is not improving, then it’s going backwards”. And I think that’s a really profound comment. It’s that, it’s an illusion to think that things will stay as they are. And in fact, the more I’ve thought about it, the more it chimes with what we understand about the universe, (the concept of entropy), that if we don’t work continually at things, there’s a gradual decline into disorder. So, if we’re not continually seeking to improve the quality of care, then it’s getting worse with real consequences in terms of patient outcomes. I’ll just pick up on a couple of things that Annie said, just firstly to say that it’s a real privilege to be a leader in an organisation that is so innovative – I think that’s reflected in a lot of the staff experience data that we receive. 

Kate Thompson: For me, the point Annie made around moving with our workforce. So, we’re getting there now where there’s a generational shift and now staff are wanting different things. They’re wanting to work in places that are innovative, they want to work in places that have a real, huge corporate social responsibility. We have that responsibility to widen participation for our local community. And the way we do that is looking at innovative ideas and how we can bring those people into our organisation. Innovation, for me, excites people and it keeps people going and it’s a key focus for me for engagement in people’s roles. I think as you mentioned there, Michael, that you can end up going backwards if you’re not excited about what the future holds. And so always keeping that in people’s sights, for me, is really important. 

Michael West: What you say, Kate, reminds me that the arc of human history is an arc of innovation. We are the species that has constantly developed new understandings. We’ve gone from being relatively simple animals to discovering the code of our own genetic makeup, to exploring the outer reaches of the universe – and we’ve done that through innovating. I guess I started looking at innovation in healthcare back in the 1980s. And what I came to understand was that creative ideas are a consequence of human interactions between people but particularly the implementation of change, of applying creative ideas in practice, (innovation,) is dependent on teams working together. That in a way, almost, the measure of a team’s effectiveness is the level of innovation. If a team with diverse knowledge and skills and abilities and experiences is working well together, then innovation will be the consequence, inevitably. And if they’re not working effectively, they’re more like stagnant ponds than sparkling fountains as it were. The question that that begged then was, how do we get such effective teamworking? 

Kate Thompson: Just to pick up on your point with regards to diversity and teamworking: at Northumbria, we have developed comprehensively a number of staff networks and an example of that really good teamwork and innovation is that our autism mental health and enable networks have contributed hugely to our wellness action plans. We’ve listened to them, they’ve had some fantastic, innovative ideas. We’ve implemented them as an organisation. So, it’s really good relationships with those people that have the ideas and us listening to the right people. So, we’re not making decisions in isolation and not making decisions about things that we don’t really have the knowledge about. We’re asking the right people. I think that’s really important. 

Michael West: Yeah. And the research that I’ve seen on innovation across sectors is that the most innovative organisations, companies and the private sector/ the public sector, are those that are hearing the voices of the people who use the services and the products that they develop.

Annie Laverty: I think undoubtedly, one of the reasons that are probably stayed with Northumbria for three decades is that I’ve had the privilege of being part of some quite extraordinary teams. I think some of the things that those teams would have shared are a number of features that really enable teams to thrive, to innovate and continuously improve. So thinking about those things, I think the first for me is, if we aren’t working in an environment where it’s safe to say what needs to be better, then our ability to improve will always be limited. We need to feel psychologically safe. I got my current role by writing to my Chief Executive and my Medical Director to say, what are we really doing about person-centeredness in the organisation? Innovation by itself is going to involve falling over, it’s going to involve making mistakes or having to rethink our original assumptions. But if we’re part of a safe and supportive team, then we’re not scared to have a go and learn in the process of doing so. I think that’s fairly fundamental. I think it’s also about connecting to really having meaning and purpose behind our work and an ambition for the team that everyone can get behind. So, the clarity of the vision and goals for that team are essential. I can remember many years ago working on the stroke unit and it was a Sunday afternoon. I overheard a healthcare assistant speaking to a relative. She was conscious that the wife had been with her husband all day. He’d been through emergency care. He needed a scan to confirm his stroke. And with compassion, she turned to the wife and said, “look, you’ve had a rough day. Can I get you a cup of tea? Can I get you something to eat?” And it happened to be a Sunday and it was high-tea, so there were scones involved and cake. And I obviously looked a bit like that had been laid on, especially, and the woman was quite struck by it. She said, “oh, I’ve never been treated like this in hospital before”. And quick as a flash, the healthcare assistant said, “Madam, you’ve never been with the stroke team before”. I was following on to provide care after she’d done that, but she had so beautifully set the scene for what mattered and what we represented and that ownership of ‘this as what we stand behind as a team’ is really important. I think teams need to meet really regularly to be clear about what that goal and ambition is. And people, as well as having clarity, they also need to have cohesion, if you like. They need to understand how their role fits within the rest of the team to deliver that ambition. That spirit within a team, when you’re genuinely part of a clinical team sometimes or managerial team, where you genuinely have a sense of trust being strong, people having your back and that we’re all in it together is really critical. It links, as Kate said, to a culture that is inclusive, where we value difference and celebrate that difference and that when that difference, (and it will incur results in conflict, because we need conflict sometimes to help us keep innovating and changing) that we found good and constructive ways of dealing with that conflict, so that it’s not a lasting impact for the team. And finally I think for high performing teams, and I would say this in my role, but I think it’s absolutely critical, we’ve really got to understand impact of the work that we do so that we can share that story of our work. We measure well and measure often and openly share those results, even the stuff we’re not proud of. In fact, I would say, especially the stuff we’re not proud of, then we have an excellent foundation for improvement. 

Michael West: That’s really profoundly helpful. Both. Thank you. The themes there, I think are fundamental themes in human experience. So the theme of psychological safety is fundamental in the sense that we are only likely to take risks, to try new and improved ways of doing things when we feel safe. So, we know from the research on attachment theory over the last 50 or 60 years, that children who have strong attachment with the parent/ parents with the mother are much more likely to explore their environments, to build a sense of confidence than children who are insecurely attached. We take risks, we explore, we try new and improved ways of doing things when we feel safe; when we feel we’re not going to be punished or blamed, when it’s safe to make mistakes within certain boundaries. I think that’s the truth about human ability to develop new and improved ways of doing things. Part of the motivation for trying new ways of doing things, as you say, I think is about having a really clear purpose or vision that there’s a meaning that comes from having a real purpose. And I’m really struck by what you’ve both said about hearing constantly, the voices of patients and service users, shaping quality improvement, shaping what we need to provide for high quality care, rather than them just being supplicants, recipients of healthcare processes, if you like. The importance of the relationships that we have with each other; how we manage conflict, in creating that psychological safety. The other point, I suppose, that feels fundamental is that innovation comes from diversity. Whether it’s diversity of professional background, diversity of voices, patient service users, diversity of people from different demographic backgrounds, different cultural backgrounds, different countries, different skin colours, different genders, different ages, different sexual orientation. Diversity is fundamental to innovation. The idea of making sure that we continue to measure, because that’s the basis of quality improvement, I think is fun but as a researcher, I would say that wouldn’t I. The research I was involved with that focused on cultures of high-quality care across the country, one of the key learnings for us was the most effective organisations had executive teams and boards like Northumbria, where leaders were out there sensing problems that they didn’t know about as opposed to when they did go out there, just seeking comfort (‘tell us everything’s okay’). The other area that I want to explore with you is my sense that we need to create time and space for people to come together and to innovate, to reflect on what we’re trying to do. How are we going about it? What do we need to change? But of course, the constant question people come back with is, ‘well, how do you make time when we’re under so much pressure in our services?’ 

Kate Thompson: Absolutely, the reflection/ the time is something that many people would say, ‘we just don’t have the time’. Given the past couple of years, I think that’s more evident. What I wanted to bring in was the importance of that immediate line manager in that element and the immediate line manager, facilitating that time for reflection and holding really close in the core of that team, that relationship you’ve got with your line manager. In Northumbria, we’ve started to really measure that in our pulse surveys at a local level about ‘can we have open and honest conversations with our line managers?’ ‘Do they support us when we need them?’ ‘Do they ask us the right questions?’ For me, that is a step where we can then look at that real granular detail and say,’ who needs some help with this?’ That’s not a bad thing at all, because it’s a very difficult role being the immediate line manager, but it’s ‘how can we support you and enable you to give your team the time and the space to have those great, honest and open conversations?’ As I understand from what you’re saying, what you do is you have surveys on a regular basis, and it would be interesting to know how often you do those, where you’re getting feedback from staff about relationships with their line managers. But also, you’re reinforcing the point that it’s a managerial responsibility to ensure that people have the time and space to come together, reflect learning. Yeah, it is. And I think we also encourage our staff to take that responsibility as well and ask those questions. And I think I mentioned earlier, the staff networks allow that time for reflection in that space from a diverse range of people – that is something that the organisation promotes and gives the time to staff to do. We started off with one staff network. I think we’ve probably got about six or seven now and they’re evolving. The most recent one being ‘Family Ties’, working parents. Annie, I don’t know if you want to address how often we do our surveys. 

Annie Laverty: Yeah, we established our staff experience program in December, 2019. Originally set up pulse surveys that were themed around key things that we thought were important. So, whether that was about happiness at work, health and wellbeing, we’ve looked at belonging and inclusion. Kate had a really good influence in the last survey, just around those key relationships with managers and what we need to learn. And because we get thousands of responses with each one, that level of engagement, a key feature of the staff within Northumbria, we can really learn across the organisation at team level. I would argue that measurement without the support to improve is disrespectful. I think if you’re going to ask people what their opinions are and that’s patients and staff and communities alike, don’t do that, if you’re not following on close behind with the plan to stay close and improve and work together to make better. Releasing people for improvement is key and that’s been a feature of our program. We’ve worked with teams with using experience-based co-design to release staff. We’ve particularly looked at the recovery from COVID, learning from the armed forces and how they’ve recovered from Iraq, how they recovered from Ebola and giving teams time to reflect on a weekly basis about how we’re doing. Actually, it makes us more efficient. We can make time now for people’s wellness or we will be making time for their illness further down the line. It’s that important. And if what we’re focused on is compassionate care, then prioritising that reflection; that ability to come together in the room in a really meaningful way and honestly reflect where we are and what needs to change, that’s critical for us. 

Michael West: I think that concept of measurement without improvement is disrespectful is a very powerful observation. What I see as part of the difficulty we have in the NHS is we’ve created these complex hierarchies where we have reporting levels in double figures in organisations. The observation we have from research in organisations is the most effective organisations, regardless of size, usually have no more than three or four reporting levels but in a typical NHS Trust, we’ve got at least a dozen. What that does is somehow makes it more difficult to transmit messages up and down and side to side. It inhibits decision-making. It inhibits innovation. You’ve alluded to it a bit already, but how do we move from what many people see as a dominant ethos of command and control, hierarchical leadership? How do we move to the more collective leadership that, it feels like you’re describing, is in place in Northumbria?

Annie Laverty: I know Kate would want to say more about this, but I just wanted to pick up on the importance of the strengthening the patient voice and how important it is. As well as following up people after care, we have 700 conversations every single month with 700 people whilst they’re with us in hospital. It’s our real-time programme. We spend 20 to 30 minutes talking to those patients and learning how their care has met their expectations, if we’ve disappointed them in any way or what they’d hoped from us and whether we’ve delivered on that. We get that message back to our teams within hours of speaking to patients. So, it’s about that working week that they’re experiencing. They can see that in the round. Now, when we set that up, I don’t think we had any idea of how important that feedback would be for staff. We designed it as a way of delivering person-centred care. But actually, it was because our people needed that feedback so much about the work that they were doing, needed to be noticed for the works they were doing and that all of our staff, not just the doctors, not just the nurses, but the role of everybody contributing to that high quality, compassionate healthcare was noticed by patients and talked about in those reports. During COVID, we had to stop some of that and it was really obvious how much our staff meant. That isn’t by all intents and purposes, a governance framework/ a measurement framework that tells us how we’re doing, but actually for me, it’s about the connection to purpose in healthcare that is just so critical. If we don’t have that we can lose our way. We’ve been able to restart that again and it’s meant everything to our teams. Again, what we’ve seen is incremental rises over the last six months as teams recover. Based on that feedback and that loud voice of patients. But Kate, I know you’ll want to say something. 

Kate Thompson: Well, just firstly, to touch on the hierarchical element of the NHS. I have worked in private sectors of what you described, Michael, with that flatter structure. I think there’s a couple of things fundamental for me moving into that executive role. What we’ve demonstrated very well at Northumbria, especially during COVID times, is people want us to be accessible and they want to be able to reach us. They want to look at a team of leaders that they can think, ‘I can get there and I can be that person’. They want to hear us talk. They want to hear our ideas. They want us to ask questions and talk to them. I think we’ve led from the front in that respect, especially during COVID where it’s been extremely hard, but we are still getting out there. We’re still talking to people and having those discussions. So, almost fighting through that hierarchy and talking to people and giving them that empowerment and autonomy to say, ‘this is what the problem is. How do we deal with it?’ We’re very good at that and we’ve got some really good examples. In Northumbria, we recruit on our values. I think that probably came in now more than five years, I’d say 10 years ago. We train people to recruit and we have what we call ‘super recruiters’. So, these people receive a body in programme, they receive support and training, where we give them the autonomy and that responsibility to say, you recruit who you need in your team using our values. We have some fantastic examples of some great recruitments within the organisation. And I think that’s an example of us saying ‘have the tools, have the support to do it’ and then they feel that ‘that’s the individual that I recruited, and this is where we’ve got to with it’. It’s feeling that responsibility and that actually credit where credit’s due and the values-based recruitment, I think is a really good example of that. 

Michael West: That’s building in the values into the DNA of the organisation I’m really struck too, by what you describe about listening to staff, voices and patient voices. It’s very much compassionate action. It’s attending, being present with patients and staff. Listening. Seeking to understand what works well, what’s been really helpful, what’s been difficult, what’s not working well and the real sense of empathy and care and love for patients and for staff. Then as you say, we must have improvement, otherwise it’s disrespectful. So, having the courage to help, to make a difference. I suppose my observations of the extraordinary successes of Northumbria is that it feels as though patient and staff experience shapes the strategy. So, how are the voices of patients and staff represented in board and executive meetings? 

Annie Laverty: We open every meeting with a story from both patient and staff perspectives. I’ve really learned that stories are often told at a price by the storyteller. And again, it’s about fundamental respect. We’re asking people sometimes to revisit harm, revisit distress in the process of telling their story and that’s staff and patients alike. So, whilst we open every board meeting with a patient and staff story, it’s always linked to an arm of improvement that is existing in the organisation. I can’t separate that storytelling with the improvement that follows. They’re themed, they’re relevant. Then I can actually say to the person that has given us the time to tell the story, ‘This is what’s happening as a result of what you’ve shaped and what you’ve influenced’. Just as a clinician learning quite early on in my career about the influence that strengthening patient leadership can have in terms of directly improving your service. More than 15 years ago, we created patients as peer supporters for patients on the ward that’d been newly diagnosed with stroke, for example, and that really challenged the medical model. It goes in with the way of spending time with patients making that bridge between hospital and home, allowing for conversations that the clinical team may not have prioritised in the here and now. We trained and recruited 30 patient leaders, put them through a 30-hour programme, paid for their time. In the first 12 months, they made more than 250 visits to our wards. It was a service in its own right but one that really flipped that relationship between staff who are providing services and patients who are receiving it and recognising that when we really strengthen that partnership, we emerge with something so much more. And that was on the back of learning that we might have been very focused in a clinical service around hyper-acute care and time to scanning and all of those really important things that save lives. But actually, when we spoke to patients, they were worrying about finance, they were worrying about losing their jobs. They were worrying about the likelihood of carers. 50% of family members of people with stroke have experienced anxiety and depression within six months. So, we get a much richer picture of everything that needs to be better when we strengthen the patient voice. And then we’ve learned, we can’t do that at the expense of staff. I think we’ve done a lot of work to strengthen the patient voice. And it’s only in recent years that we’ve thought ‘we’ve got to get that balance completely right. Our staff need to know that we are as invested in them as we are in the quality of care that patients receive’. That’s why, beautifully, they sit side by side as the very foundation of our improvement work. 

Michael West: We’ve been through these COVID times and I’ve been struck by how what that context did, was to just create the circumstances where Northumbria could continue its cultural strength of responding to diversity and challenge in really profoundly, innovative ways. I think that the story about your reaction to the shortage of PPE equipment early on, I think people would love to hear about that. 

Kate Thompson: Well, very early on, in fact, just as we went into lockdown, we wanted to stay close to the mood of our staff, the emotions of our staff, and really feel that. So, we’d been working with a brilliant group of technology geniuses at Newcastle University and developed an online platform. And instead of going for pulse surveys, every three months, we were pushing out very short, brief surveys every week to our staff to understand how they felt. And one of the key fears at that time emerged around, ‘keep me safe, just keep us safe’. We were conscious as leaders in gold, PPE supply was running short and I think the inspiring story was just an organization that thought, ‘you know what, we just have to take this into our own hands. This is within our control. If we’ve got good relationships with local communities with local industry, what can we do?’ So on top of an old car show room, the beginnings of our factory began. Volunteers from the community came forward, started making equipment for us. We took guidance from industry about the quality of all of that PPE. And it just took off, really. We’ve now got factory in its own right in Seaton Delaval, it’s employed 60 staff in roles in manufacturing that are critical to the area. But really interestingly, when in the week that the factory opened and our staff became aware of it, we saw a real spike in the mood of our staff in that weekly pulse survey – a positive lift around motivation for work, with a genuine belief that the organisation was doing things, acting quickly to keep them safe. So a whole lot of needs of our staff emerged in that free text data. We got 10,000 responses in just three months and we were able to analyse that and feed it through gold command every week, feed it through our health and wellbeing responses. Some of Kate’s teams organising the way we stayed connected to people that were isolating at home, feeling disconnected, feeling lonely in that process, the health and wellbeing hubs, gift boxes at Christmas, brown paper packages tied up with strings. Sometimes it was massive things like opening a factory. Sometimes it’s tiny things like ice cream vans driving around in the summer or giving people sustainable goods that tell them to take a break and it’s just ways of saying, ‘we notice you; we know how hard you’re working and we’re in this together. We’re with you’. Really powerful stuff. 

Michael West: There’s a deeper message as well about the role of leaders is to address the most difficult issues we face. Lack of PPE equipment, problems of discharge of people from beds because we don’t have support resources in the community, financial pressures that staff face. The sense I get is that in Northumbria, what you’re doing is saying, ‘give us the most difficult challenges we face so that we can bring our attention to bear on that and find ways of solving the problem. It doesn’t mean we’ll find the right solution the first time, but we keep looking at it until we can find a way forward’.

Kate Thompson: Yes, that’s exactly right. And I was going to mention some of the initiatives that Annie talks about. What was really great was it was such a team effort. People from all the different functions across the organisation helped in that setup of the PPE factory, for example, the recruitment team, finance – that just felt really great to people that they’d had been part of something really great. Annie touched on the health and wellbeing. That has been absolutely at the forefront of our mind; the impact that COVID has had on our staff, not just at work, but personally and how we’ve been able to look after them through the resources that we’ve got but also help them to look after their family and point them in the right directions of signposting them, if it’s financial issues, if it’s bereavement guidance. I’ve mentioned it before, but really personalise those conversations and that care to staff, listening to them. One thing that really struck me through COVID: no one person is exactly the same and you can have a whole wealth of health and wellbeing resources, but it’s up to a line manager, a member of your team, a friend, a peer to say, ‘have you see this?’ and point people in the right direction for what they need and everyone’s just very different in that respect. It was so important that we personalise that care for our staff. 

Michael West: I’m really struck to see that we’re expecting to see staff survey data for 20/21 quite soon as we speak and we’re having this discussion. But from the previous year, the first year of the pandemic, when we know that the percentage of staff reporting being unwell as a result of work during the previous year was around 40%. And then that first year of the pandemic, it went up another 10% (and the point I want to make is that some people could say, ‘oh, well, we hear all of this kind of rhetoric about looking after staff’) 44% on average in NHS Trusts, in Northumbria it was 27% a year. I mean, of course it’s still too high, but Northumbria was almost half the average for other Trusts in terms of levels of staff stress. And also, the same with engagement, which we know is the key predictor of performance of Trusts and you have very high levels of staff engagement. What are the one or two or three things as a Trust you’ve done to enable that?

Kate Thompson: I could bring in here, because it’s been extremely important and it always is in Northumbria, is our really strong relationship with our staff-side representatives. During COVID, we stayed close in terms of making sure they were updated with where we’re going, consulting on initiatives, having conversations with them because then staff will go to them and have that conversation and we want the staff-side representative to feel prepared for those conversations. And we have really great relationships and I can’t stress enough how important those relationships have been during the pandemic and how they’ll be even more important going forward as we enter into recovery. Along a similar line, Northumbria have a freedom to speak up guardian, which all Trusts do. We’ve recently won an HSJ award for that process. And that again, gives staff another route to have those conversations, to open up concerns, to filter through to the people that can help them and the relationship with the speak-up guardian and the trust and the confidence that we have in each other has paid dividends in moving forward with that. 

Annie Laverty: I think it’s two things that are important for me. I talked about our way of understanding how people were feeling in the moment and I think that’s true. I think it takes courage of an organisation at a time of a pandemic to actually ask staff, how you are because there’s a natural fear, perhaps, in leaders around ‘what if we can’t help with that?’. And so, I’m really proud that the Trust was courageous enough to ask the question, because I think it was really critical in terms of keeping our staff engaged. When we looked at what staff told us, seven core needs emerged and they were: Listen to me. Care about me. Lead me. Keep me safe. Keep me connected. Keep me going. Notice me/ honour my work. And my belief is I don’t think that’s just relatable to a workforce in Northumbria and nor do I believe it’s just around the context of a pandemic. I think it is a framework for leadership that can help us in terms of engagement and improvement, if we pay attention to addressing those needs and recognising how universal they are. And then the final point that I think is really critical and it’s the strength of the exec team overall. We had a quality and innovation festival recently celebrated across the organisation and we interviewed Jim [Chief Executive]. He described his role as whatever the noise outside, it was his role to buffer and to act and respond to staff, to keep them safe from what they didn’t need to be hearing but at the same time, act with conviction around the things that he could directly influence and control. I think in the establishment of a factory with the support of so many colleagues and teams across the Trust, he modelled that strength of leadership beautifully that enabled people to feel fundamentally safe and looked after. And I think that helps massively within engagement and has contributed to some of our national results.

Michael West: It’s profoundly inspiring and you’ve shared so many insights, so much learning from all of your experience. And I’m really struck by the courage that the community that’s Northumbria Healthcare and patients and service users have shown in innovating. Here is a tough question. If you had one recommendation, practical recommendation, you would make to others working in health and social care from all of your experiences, what would that recommendation be? I cheat by not having one. Just have a go. That’s a core message from Jim. Just keep going, have a go. Make a start. Don’t wait for the perfect moment when you’re going to have the perfect resources or the perfect situation, it’s probably never going to happen. Just have a go. There’s a lovely quote from Goethe that says ” Whatever you can do or dream, you can. Begin it. Boldness has genius, power and magic in it. Begin it now”. 

Kate Thompson: I was going to add to Annie’s around have a go and don’t be afraid to have those open, honest, and difficult conversations with people because ultimately it helps them. We get to a really good place with people when they trust us, they open up to us and we engage in those conversations. That would be a recommendation from me for any immediate line managers, anyone that has the access to staff to make sure you’re having open and honest conversations. And you’re asking how they are.

Michael West: And those themes that I’ve heard throughout our conversation exemplified in what you’ve just said, Kate as well. It’s about being present with each other, listening with fascination, honouring each other through our attention, understanding the challenges we face individually/collectively. Caring, connecting through care, through love, through empathy, through nurturing and then seeing our role as helping, being altruistic, being compassionate, making a difference for the people we provide care for, the people we serve, indeed, everybody we interact with. So, all of this, I think is, underpinned by compassion. I want to say a huge thank you. It’s been the most inspiring and wonderful conversation and I wish we could go on for the rest of the day, the rest of the week, the rest of the month. Thank you both really warmly for all your contributions.

Annie Laverty: Thanks so much for including us. 

Kate Thompson: Thank you, Michael.

Paul O’Niell: I hope you enjoyed this conversation. Please look out for others in this many series and subscribe to the ‘Leadership Listens’ collection for more content like this.

Episode 3: Creating a compassionate culture in organisations

This recording is a conversation between Michael and DrDeborah Lee, Consultant Clinical Psychologist, Lead for Compassionate Leadership at BerkshireHealthcareNHS Trust, Honorary Associate Professor, University College London and focusses on Compassion in Health and Care and creating a compassionate culture in organisations.

Transcript

Paul O’Neill: Hello and welcome to Leadership Listens. Curated podcasts for leaders in health and care. My name is Paul O’Neill, Head of Strategy, Research and Development at the NHS Leadership Academy, part of the People Directorate of NHS England and Improvement. This mini series of podcasts as part of Leadership Listens, is a series all about compassionate leadership. It’s a collection of conversations between Professor Michael West and a leader of the health and care sector. This recording is a conversation between Michael and Dr. Deborah Lee, consultant, clinical psychologist, lead for compassionate leadership at Berkshire Healthcare NHS Trust. Honorary Associate Professor at the University College of London. And it focuses on compassion in health care, compassionate leadership and the myths surrounding it. 

Professor Michael West: Hello, everyone, my name is Michael West, I’m senior visiting fellow at the King’s Fund and professor of organisational psychology at Lancaster University. And this series of conversations about compassion and compassionate leadership in health and social care has been just a privilege for me to be involved in. And today, I’m delighted to be joined by Dr. Deborah Lee, who is consultant, clinical psychologist. Deborah, it’s just a privilege and a pleasure and an honour to have this conversation with you. Welcome. 

Dr. Deborah Lee: Thank you, and thank you very much for inviting me. I’m really excited and I feel privileged to have been invited along to contribute to it, so thank you. 

Professor Michael West: Well, I want to say a little bit about you. As I said, your consultant, clinical psychologist, you have an honorary associate professorship with the sub Department of Clinical Health Psychology at University College London. And you’ve been working in the area of trauma and post-traumatic stress disorder for nearly 30 years now. And and I know also, I know a lot about your work at Berkshire Traumatic Stress Service in South Central England Veterans Services. You’ve been a real pioneer in developing compassion and compassionate leadership in Berkshire, and that something that be a real delight to talk about. And I know you’ve been a member over the last two years of the University College London Expert COVID Trauma Response Working Group, which has been working hard to develop guidelines and do research to promote trauma informed care, natural recovery and psychological first aid to reduce the psychological impact of COVID 19 on hospital staff and patients. And you also, and for some years now, you were a founding board member of the Compassionate Mind Foundation, and for some years that’s been a really influential body in developing our understanding of compassion. The work that you do with Professor Paul Gilbert. So, you’re the ideal person to ask this question. Passion’s one of those words, it sort of shimmers a little bit. And I was thinking as I anticipated this conversation, that it’s one of those words that appears in poetry and it can be can be seen as something a bit amorphous and a bit vague. But how would you describe what compassion is and why it’s so important in human experience? 

Dr. Deborah Lee: Yes, that’s a good first question, Michael. For me, compassion is rooted in a motivation and a basic human motivation to want to care for ourselves. So for me, I contextualise that motivation and our human experience, and it’s therefore rooted in a very biological neurobiological part of our minds and our bodies. And it gives us the capacity to be deeply caring for ourselves and for others, and to allow others to care for us. So we’re kind of primed and set up to allow our human nature to flourish through the kind of the the underpinnings of our neurobiology. But it’s the capacity and that to me, is important because what that says is it’s something that we need to develop, and we need to pay attention to developing it. So we have the capability and we need to nurture it within us. And. Throughout all of our lives, whoever we are, whether I’m working with my patients, whether I’m working on myself, where I’m with my family and friends at the heart of our human nature ought to be this sense of being caring for others because on the other side of that, of course, there’s the other part of our human nature, which is cruel and unkind. 

Professor Michael West: So your understanding of compassion is that it’s in some sense hardwired into us neuro biologically. 

Dr. Deborah Lee: The capacity, I think, is I mean, the way I like to describe it to people is it’s rooted in caregiving. It’s the human capacity to notice distress and to want to care. And it’s the glue that keeps us working and functioning and flourishing without compassion. I don’t believe we can psychologically flourish. And the extraordinary thing, I suppose when we think about human beings in our day to day lives is we’re often taught how to, you know, eat healthily. In fact, we’re all taught how to eat healthily at school. These days. We’re taught about exercising, but we’re not talked about how to look after our emotional wealth. And it’s so central to the human experience and the more that we can foster our capacity to be compassionate, to engage with suffering and distress, and to be motivated to want to do something that’s helpful. The more that we can benefit from much more safer, closer nurturing relationships in our worlds. 

Professor Michael West: And so compassion is about, I suppose, is a collective value. It’s about creating safe conditions for people in their human experience, whether it’s children growing up feeling safe, warm adolescents or adults. 

Dr. Deborah Lee [00:05:59] Yes, I mean, for me, it’s rooted in attachments. And when we understand the motivation of caregiving and we understand the attachment systems that humans need in order to be looked after and to grow, then we kind of see a system approach where we learn to care for ourselves by being cared for by others and we care for others the way that we have learnt to care for ourselves and we allow others to care for us. So the system then becomes compassionate and at the root of our attachments, we find the story of human distress, but we also find the hope and the solution for human connectedness. 

Professor Michael West [00:06:37] But can you say a little bit more about that, about that concept of attachment and distress and connection and why that’s been so important? And I’m also reflecting that you talked about and there’s another side to us, too, which is about threat. So could you could you just explain that a little bit more? 

Dr. Deborah Lee:Yes. So if we start with the idea of attachment, you know, very, very basically human babies are so vulnerable when they’re born and they need to be looked after and they need to be protected. They can’t survive without protection from a caregiver and a primary caregiver. And as they grow and as they are fed and as they’re educated, they will develop, you know, drive capacity and goal focussed behaviour. But what they also need, which is the golden experience of psychologically being human, is emotional nurturing and emotional nurturing, as found in our attachment. So we look to others, our primary caregivers, to teach us how to regulate our emotional worlds. And that creates safeness and safeness is a biological physiological felt sense. It’s a sense of connectedness in the minds of others. So for instance, we think if we just think in this moment who out there is holding us in mind, is wishing as well, is hoping our day is going the way we want it to go? This notion that we matter, that we’re held in mind, that we’re important to others, that we’re safe in their minds, is this for me, this golden experience of human connectedness because it becomes the template of which we understand that other people’s minds are safe and that we can find in other people’s minds help and comfort when we’re in need. So that is a golden human experience, but unfortunately, we don’t all get it and we get various cocktails of it or various experiences of it was different, you know, ingredients mixed into it. So when we’re looking at our attachment histories, we’ll find lots of information about who we are, how we conduct ourselves, how we walk in other people’s hearts and minds and lives, and how we expect them to walk in our lives. And, you know, just basically how we treat each other and is all on a continuum. It’s all on a continuum. My daily life, I work clinically with people who have been really hurt and harmed by others. They’ve experienced such human cruelty and they’re traumatised and they have lots of complexity around their difficulties. They also have technically something that’s preventable because they’ve been hurt and harmed by others. Other human beings have walked into their lives, and at the other end of this continuum, somewhere we are. And on daily basis, we may hurt and harm others just by our actions and our thoughtlessness without even realising it. And if we can really contextualise the human experience in our evolutionary social context, we can see we’re all on this continuum and we all need to do a little bit of self work. We all need to take stock of the version that we are and the version that we launch ourselves into other people’s lives and hearts and minds. 

Professor Michael West: And so the notion that this is a capacity that we have in that capacity can be developed and that it is so fundamentally important in human experience in human society, and yet we haven’t really focussed on developing that other than in religions, in philosophy. But it’s not something that we’re focussed on in developing and maybe children, young people in education every day. And I’m also struck by the idea that the fundamental to this understanding of compassion is the sense of interconnectedness that our attachment, our safety flourishing, is dependent on the interconnections that we have and that when we conceptualise ourselves as interconnected rather than separate, that changes, in a way our perspective. And I suppose the other theme that seemed implicit in what you were saying is that that connectivity is also about the relationship we have with ourselves. Can you say a bit about that? 

Dr. Deborah Lee: Yes. I mean, we talk about this in our compassionate leadership programme. You know, the sense of we know we’re better together. We were never meant to do this alone. And you know, if we can form safe connections with each other, we can help each other. We can’t stop the pain of life. We can’t orchestrate our lives to avoid being hurt. What we can do is help and support each other while we are hurting. And while we’re struggling and that requires a sense of connectedness, that’s safe. And it does go right back to the heart of the number one relationship that we have, which is the one we have with ourselves. I sometimes make this joke at the workshops, you know, tell me how long is your longest relationship? And then, you know, everyone’s, you know, um-ing and ar-ing, and I just say, well, just tell me your age. That’s the answer. You know, that’s the longest relationship you’ve had. And it’s the most important one, actually, because wherever you go, you know, guess who’s coming to? And if you could work on that relationship, if you could really foster a sense of self-compassion, then you begin to nurture something, your glow, your fire. Then everybody feels the resonant sort of warmth from you. And to me, that’s so important because if we forget to look after ourselves, forget to have that connection with ourselves, then the idea of abundance is just depleted. You know, we are. We’re running on empty. You know, we get into dangerous states of burnout, especially in health care, unless we really foster this need to develop our own relationship with ourselves. And it is extraordinary, Michael. We’re just learning now in recent decades the need to teach our children these core messages about emotional nurturing and fitness is central to physical health and our diet and everything that holistic approach to the humanness within us. 

Professor Michael West: And so that brings us on to the question of compassion in health care and the rather depressing statistics that in 17 out of 18 studies, compassion amongst medical students in training declines. And it’s the sort of obvious question to ask you, but it feels important to ask it anyway. Why is compassion so important in health care? 

Dr. Deborah Lee: Well, because health care is caring for others who aren’t in your gene pool or in your kinship. Health care offers us the opportunity to demonstrate this wonderful capacity of humans to care for people outside the gene pool, and kinship, extended caregiving. Health care embodies compassion and allows us to really foster our deep motivation, and it’s extraordinarily touching health care. It really is extraordinarily touching, and it links back to your points around connectedness and this sense that if we see ourselves as connected and interdependence, the notion of caring for people that aren’t actually immediately genetically linked to us begins to make sense. And I think it’s the real tragedy that we’re even asking the questions like. Do we need compassionate leadership? You know, that or, is effective. That quite extraordinary questions to be asking, actually. And the other thing that I just sort of always baffles me is the workforce and health care. You have got a committed group of people who have dedicated the careers, the working lives to help others, they already have deep humanitarian motivation. Extraordinary. And the question we ought to be saying is one earth, have we done to create conditions where we are disenfranchising and disconnecting people who want to do something that is extraordinary and deeply touching and just plays to the beautiful nature of humanness to extend our caregiving to those who are in great need? 

Professor Michael West: And it is extraordinary when you have conversations with patients and service users. What they recount to you is the times when they’re treated with compassion, and that makes such a difference. To to their experience, how profoundly that affects them, and it affects, of course, health outcomes as well. And it is tragic that with this amazing workforce, as you say, so skilled, so so motivated, so caring that we have sufficiently yet created compassionate cultures, but also focus on caring for them, ensuring their wellbeing, their flourishing. And I know the work that you’ve been doing in the Compassionate Mind Foundation over the years has been really powerful in shaping our understanding of the role of compassion in in society and in health and social care. Can you tell us a little bit about the Compassionate Mind Foundation, its genesis and what’s happened over the years? 

Dr. Deborah Lee: Well, I’ve been very fortunate to have had the significant majority of my career shaped by knowing Paul Gilbert, my friends and colleague and the work that Paul has done pioneering compassion and compassion focussed therapy has transformed my clinical practise. So although I’m here talking about compassionate leadership, my day to day job is as a clinician working with compassion focussed therapy and experience of going to a workshop actually and just being transformed by listening to Paul talk, I’m thinking, my goodness, this just resonates with some of my core values and my spiritual and philosophical frameworks about engagement and therapy. And over the years, we’ve been able to really disseminate compassion not only into human suffering through therapy, but into fields of compassionate leadership and compassion in schools. And the foundation now, has a whole new kind of organisational underpinning. It’s now a charity and it has a wonderful, committed team that it’s their job to to run the foundation. And it has an international reach. And it is so wonderful to see all our international colleagues all beating and wanting to beat to the same drum of alleviating suffering, whether it be in therapy, whether it be in schools, in politics and in leadership throughout various organisations. 

Professor Michael West: And I think that the Compassionate Mind Foundation has been very effective in disseminating research evidence, demonstrating that the most powerful intervention there is in health care is compassion. Whether we’re looking at long term disorders like diabetes and HIV or therapist behaviours in the treatment of mental health problems or palliative care. The evidence is clear that compassion is the most profound intervention and that that, I suppose, relates to the point you made earlier. That connection attachment, feeling safe, are fundamental to human experience and flourishing. Yeah, and I’m always struck by the epidemiological evidence that social isolation or loneliness has a much more powerful negative effect on health than smoking, excessive drinking, obesity and so on. We’re more likely to die from loneliness, and we are from the effects of smoking heavily. And you’ve been a pioneer in Berkshire Health, which is a mental health learning disability, NHS Trust, a pioneer in developing compassion as a core value of that organisation. And I’m sure people listening to this. We’re really interested to know what you’ve done, what that process has been and and maybe a little bit about the outcomes of that as well. What’s changed? 

Dr. Deborah Lee: Hmm. So the story of compassionate leadership in Berkshire health care goes back to 2015/16, and the then head of psychological therapies had put on a one day conference called Angels and Demons. If I remember correctly. And it was really in the light of the outcome of the Francis report and some kind of platform of which we could look at ourselves and our care. 

Professor Michael West: So the Francis report was the report into the scandal at Mid Staffordshire of poor quality care for patients and avoidable deaths that occurred. 

Dr. Deborah Lee: That’s right, yes. And I was asked to give a talk on human behaviour and why do people end up doing bad things and really to sort of contextualise our behaviour? So I gave a talk on human behaviour and the capacity of us to be deeply caring, but equally deeply cruel rest within the evolutionary context of understanding our human history. And then I talked about compassion and the fact that it’s within us all to be motivated in terms of which side we choose to feed, you know, a competitive, cruel nature or a compassionate caregiving nature. And I asked the audience how they felt Berkshire health care was. A lot of them thought it was very threat focussed at the time. I asked whether they had compassion for their management. I think there was a groan, actually, and there was a kind of disgruntlement around that. And I thought, you know, that’s just really sad to hear because we’re all trying to do our best to. And, you know, even our managers have got really difficult jobs. And it struck me that it wouldn’t be a very helpful place that I imagined it to as a ship really in stormy waters that actually what we can’t have is this dissent within the crew. We need to be together to navigate our way through stormy waters. And it struck me that the one thing that is free is how we treat each other. You know, as the cavalry isn’t coming, loads of money isn’t coming, loads of resources and coming. We’ve got terrible crisis in recruitment. But what we do have is a choice about how we treat each other on a daily basis and how we hold in mind our managers. Yes, there are hierarchies. We need structures. But there is an emotional engagement, which is equality. There’s an emotional equity in all of us that we could bring to our daily interactions a sense of inclusiveness and collectiveness in the way that we conduct ourselves. So the outcome of this talk was the audience going basically, well, this is very nice, nice day. But you know, it’ll be a distant memory next week. And I said, Well, maybe, maybe it won’t. Maybe what happens if we could do something different? What happens if we could go to our Exec and say, you know, can you give us a chance to do something different here? And I did, myself and head a psychological therapist, managed to get a very prised moment on the exact board where we’ve had a 15 minute slot to present our ideas around compassionate leadership. And I think I managed to make it last 45 minutes. And that was the strategy, so they’d say yes, so get me out the door. I mean, one of the reasons it took 45 minutes is I’m very passionate about compassion. So it’s hard to and that’s, you know, an important thing to convey the hope, the hope of change, the hope that we can inspire people to want to develop their capacities to look at themselves. So the timing was right at the moment where they said, yes, yes, let’s go for it. And they gave us the backing to develop a compassionate leadership programme, and I was seconded out to run it initially for 18 months. And it’s been five years in the making of to try and create a culture of change. And it’s been a lovely eye-opening and delightful and challenging experience. 

Professor Michael West: So how many people have gone through that programme, Deborah? 

Dr. Deborah Lee: Well, we were trying to find the stats. We’re a trust of four thousand five hundred, roughly so not not a huge trust. The initial rollout programme, we got over 1200 people through it and positions of, say, management supervision kind of influence. We then moved to a business as usual model where we integrated compassionate leadership within our excellent managers programme. And we then put on workshops for the workforce. So we had these one day workshops for everybody because that’s, you know, compassionate leadership is a groundswell, actually. So we went up down, so everybody was exposed to the principles of compassionate leadership. And then we got it into our induction programme. And I think I come on fairly soon after Julian Emms CEO, welcomes everyone to our trust so that every new starter hears about compassionate leadership and Berkshire’s commitment to to create compassionate leadership as an atmosphere and emotional atmosphere of which people will come to work. So we’ve had a big rollout and I saw last count, we were tipping the balance of over 50 percent of people have been exposed to the principles. One thing I do remember, one day workshops, which we do for everybody, are about self-compassion, so we can talk about that in a moment the way that we approach the actual programme. But the one day workshop is all about self-compassion. So people sign up to the compassionate leadership one day, and they’re a little bit baffled to discover it’s all about them. They weren’t necessarily expecting the focus to be on their wellbeing and how they can foster compassion habits, really. And we ended up being one of the most popular training courses, as such, we ended up developing a waiting list for this one day course, which is just marvellous because, you know, it was through its reputation. And, you know, I was sort of feeling really kind of chuffed that my goodness were getting there. And then someone said, Well, Deborah, the competition, it’s not hard. It’s compassionate leadership or hand-washing and information governance. Oh yeah, you’re right. Fair point. But it is a context, but it’s been wonderful to do.  

Professor Michael West: So, Deborah, can you say a little bit more about the self-compassion workshops and what they involve? You know, briefly, what are the kind of key themes that you cover? 

Dr. Deborah Lee: So for me, one of the most important parts of the workshop is education. So I like to start with educating people about the science of being human, so they have a context to understand their behaviour. We didn’t mention this earlier on, but it’s probably really important to say that compassion is an antidote to a state of disconnection and shame. And shame is a threat focussed state where we are focussing on social threats, so the minds of others and and in our own minds. So I think that’s quite important to mention for a moment because if we are in a state of social threats, we behave in all sorts of ways that aren’t necessarily that helpful. We behave in safe ways as opposed to pro-social flourishing ways. And those threat states can take on an individual premise in our own minds and bodies, but then they become team threats and then become system threats. So going back to the workshop on self-compassion, for me, it becomes really important to de shame and to bring in common humanity to the human experience, to shed light on private processes that, you know, we know that we’re all thinking and doing because we’re all human. And so I like to start with a big sort of section in the morning around the likeness of human nature and, you know, shame states and if they can be light, but you can bring lightness to these things and all ways that we behave in order to kind of hide our shame states. And then I like to link that in to the antidote to those threat focussed, disconnected states being compassion and explain how compassion is a basic human motivation that we’re all capable of developing. And that sometimes we just don’t know what to do because it hasn’t been on our family curricula for whatever reasons, the language of compassion we haven’t been exposed to, we haven’t been taught it, but we can develop the capacities. So the next part of the workshop really hones in on what I call the kind of compassion habits. And there are four habits that I particularly focus on helping people develop. And the first is awareness, mindful attention to become aware of yourself, to see yourself rather than be yourself, if that makes sense. So rather than us sort of getting through our days phonetically with our 10 tasks to do, got 10 does tasks to do, got 10 taskst to do. How do we notice we’ve got 10 tasks to do? And how do we engage in each one of those tasks with sort of mindful presence? So mindful attention and awareness of our psychology and what we get up to and all our shame states actually and our vulnerabilities becomes really important. And then the next compassion habit is learning how to regulate, regulate our physiology, you know, physiology rules the humans shows, referring to threat state. It will colour the way we think and the way we behave. But if we’re in a a calm, settled, compassionate state, a soothing caregiving state, our physiology changes and there are very basic things that we can do to help that physiology. One of them is breath practise. So we teach a particular type of breath practise, resident breathing, soothing rhythm, breathing in order that our staff learn to do something really of the moment to settle their breathing. And then the third compassion habit is using compassionate imagery to bring online that caregiving state to just be mindful of what it feels like to be the best version of you. The version that you want other people to experience you today that when you go through your daily business, you want people to notice your ability to pay attention or to listen, or to be curious or to bring kindness to that work today. So this idea of paying attention to our best version and we use imagery exercises to kind of bring that system online. And then the fourth compassionate habit that we teach is what I call the compassionate lens so that we begin to see our day to day business, our day to day conflicts, even with the lens of compassion. How can I be helpful? How can I use my knowledge, my understanding and my wisdom and courage to be helpful to you in this moment? So there are four habits we teach on the self-compassion course, which we hope that people then kind of take off and kind of like infuse into their own lives as well as their lives at work. 

Professor Michael West: That’s really helpful to have those four themes that inform us about how we can help to develop compassionate behaviours and leadership and orientation in organisations. I suppose one of the obvious questions people will ask is how is it affected Berkshire Health? All of this? How has it greened the organisation? I mean, I have to look at your staff survey results in Berkshire over recent years, and it is amazing to see what a positive culture there appears to be there. Are there other indications of how this is greened, the organisation? 

Dr. Deborah Lee: Well, I think just to sort of note about self-compassion. One of the things that’s really helped green it is team compassion. It’s funny when you say the word greens, you know, you know, compassion, focus therapy. And we have a holistic model of the three circles and the green one is soothing and caring and the red one is threatened. The blue one is drive. So we do use the language of I’m in the red zone. I’m in the green zone because that was language we taught on the compassionate leadership programme. There is something really important about team compassion of course, the version of yourself that you turn up with in the team is then consolidated through the lens of team compassion, and part of the programme was to help teams develop compassionate pledges. This is how we do things around here. This is how we treat each other. This is how we commit to treating each other. And then a little bit like the group rules once we’ve stated our commitment to the rules. We give each other permission to call each other out, you know, whether that be as basic as, you know, finding ourselves inadvertently chatting about a colleague rather than to them. You know, we have permission to say, Hey, we agreed we wouldn’t do this. Let’s not do this. You know, let’s just move back to the core, you know, value that we have as a team. So team pledges have been a really helpful tool to keep compassion alive in the organisation. And we did do some qualitative research at the time. We took teams and we evaluated the before and afters really with the impact of the flow of compassion. And we did demonstrate quite clearly an improvement, a dramatic improvement in self-compassion and allowing others to be compassionate and receiving that care from others. And over time, six months later, there was a slight fall off of it. And that, to me, was a really important feature around compassion habits in order to really bed down this, this culture change, we need to keep compassion habits alive in the Aether and have reminders everywhere around our compassionate commitments to each other. Our staff survey, as you know, Michael, is incredibly impressive. I think we’ve got 75 percent engagement and the talk on the ground from the people that I come across is how different they feel that Berkshire is from other trusts that they’ve worked in. And I myself have worked with other trust, and I’ve got many friends who work in other trusts and Berkshire does feel different. We have a very available and reachable exec team. We have a real sense of presence of our exec team. We feel held in mind and I think we have an openness. We have a lot of structures and methods within that framework of compassionate leadership that allow for open, authentic engagement with stuff that’s difficult. So you’d have to ask the people that are leaving Berkshire. Actually, I think I’d be interested to ask those that leave what we could do better. But certainly those that stay notice a difference in the commitment and the emotional landscape of which we all kind of conduct our business. 

Professor Michael West: And so in relation to the difficult, one of the questions that I think always arises when we talk about compassionate leadership is does it just mean that we are nice to people and we skirt around performance problems? We don’t deal with abusive behaviours or difficult behaviours. And I think my sense is that compassionate leadership actually takes quite a lot of courage and quite a lot of self-awareness. But can you say a little bit about then in Berkshire health and in your experience, how we deal with difficult behaviours, inappropriate behaviours or with poor performance in a compassionate context or in a compassionate way? 

Dr. Deborah Lee: That’s a very big, pertinent question. And it’s probably the question that comes up the most when we’re doing our workshops, which is, what about this? What about if your manager is not compassionate? What about this team member that seems to be on a completely different page to everybody else? And you know, I would not want to suggest that I have the golden answer for these experiences, but I can talk about some of the processes that I think can help. And going back to your point about courage, I am absolutely in agreement with you. Courage is at the heart of compassion. Courage, the courage to engage with difficult, painful stuff, difficult painful experiences, interpersonally with our colleagues and with the suffering of our clients that we work with and the courage to do something different. And so often I see a confusion around what people think is compassionate, which is actually a kind of a subjugated appeasement it’s actually driven by threat. People that want to be liked as opposed to kind of lead, if that makes sense. So we have sometimes people at the workshop, they say, I couldn’t have done more for this person. I’ve bent over backwards to accommodate them. And when I say, But what’s your motivation? What’s your motivation here? And is it because you want to be liked or is it because you want to do the right thing for the greater good? And when you ask that question, oftentimes people are able to say, actually, it’s my fear of not being liked. It’s, you know, my fear of, you know, my team thinking that I’m not very nice person. And that, of course, goes back to self-compassion because if we develop our self-compassion, the fear of not being light starts to reduce because we’re motivated by a very different system. We’re motivated to do the right thing for the collective, the greater good. So when you’ve got a team member who isn’t seemingly on the same page as everybody else. The question is, what’s for the greater good here? And how can we engage with that person in a way that’s kind, and understanding and curious, because nobody really turns up at work going, You know what I’m going to make everyone’s life a misery today. You know, I’m coming to work today. And you know what, Michael, you’re my target. I’m going to make this absolutely miserable for you today. That’s not the motivation. People come with lives, you know, home life stuff going on for them, and they are often behaving in difficult ways because they’re frightened, actually. In essence, if that makes sense. And if we can engage with what’s the fear and if we can shame people and this is so important, this is why compassion is so important in the landscape of engagement, because it’s about being curious and being helpful and not being hierarchical and looking down. And, you know, would, you know, sort of judging. It’s about saying, Let me help you. What can we do to help? How can we make this better for you? And within conflict, there’s always opportunity, there’s opportunity. Someone’s got a viewpoint. So let’s listen to it and let’s seek to understand how we can make that better. That would be my starting point. And in the the team compassion day of our compassionate leadership programme, we teach a compassionate problem-solving model developing the compassionate lens for these interpersonal conflicts that emerge. And that’s why courage has to be at the heart of that, because we have to be compassionately assertive in our interpersonal dealings. And I think that sometimes really hard for health care workers because we think we’re being mean or we’re being horrible by being assertive. I think we’re a bit vulnerable actually to burnout and extending ourselves and not taking on difficult behaviour because we don’t want to be mean or seem to be cruel, but ultimately the rest of the team suffer. So there is something really courageous about compassionate engagement with difficult behaviours and difficult managers. What’s going on for you? How can we help? How can we understand? How can we make this better for everybody? 

Professor Michael West: So there is so much in what you say, so many themes that it would be wonderful to explore, including that amazing phrase subjugated appeasement that we don’t want to be mean or we want to be liked. And you referred quite often to shame as being. Kind of quite a big star in the constellation that we need to be aware of and the importance also of compassion being grounded in self-awareness in the moment of being aware of what I’m feeling and this interaction here and now. And I think the other concept that seems to me really important in what you’ve said is what you’ve said is the concept of the team. I’m very often asked by people, What do we do if we’ve got a leader or a manager who isn’t compassionate? And I suppose when I think is, well, we all have it in our control to regulate our own behaviour so we can choose to be compassionate to ourselves and to those around us. And I think there is something about the team as an entity, being an important vehicle to be able to deal with the problem of when there’s a manager or a leader who’s not behaving compassionately because it can be actually quite perilous for individuals, I think, to pursue maybe a difficult conversation with a manager alone. I think we need to do a lot more about developing a really good team working in health and social care so that the team becomes much more the unit of analysis and the people within the team develop their relationships with each other. Is that an observation that you would concur with from your work in Berkshire? 

Dr. Deborah Lee: Yes. I mean, we’ve very much had at the heart of our leadership programme team compassion and fostering that within various settings, and we very much encouraged, say, for instance, team away days to be committed to looking at compassionate practises. But what that means, of course, is having the courage to go to where it hurts, and that is difficult for people if they fear repercussion. And it’s incredibly difficult when you have a manager who isn’t on board with compassion. But you’re right, there is something that’s powerful about a team cohesion and sticking together and staying with each other and being motivated by what is morally the right thing for the greater good. So when we do our teamwork, what we do is invite people to actually shed light on the threats. What’s the threats? What’s the fear within our team? What are our external threats and what are our internal threats? And how can we find collective solutions to this? How can we help each other now? Of course, managers are involved in those discussions because the team is in all of it. So we bring managers on board with the idea that there is to be equally as committed to the team pledge as the team members. When you have something like a compassionate pledge or it becomes like a group brawl, it becomes a marker in the sand that you can then call it everybody’s behaviour out against you. You effectively giving permission to say, come on a minute. We thought we weren’t going to do it this way. Now your manager may not like it or react to be involved in the process of discovering it’s they’re going to be more engaged with the process of keeping it alive in the team. And I always go back to what’s the threats? What’s the threat? As I say, people don’t come to make life miserable for people. People end up behaving in ways that aren’t their finest moments because they’re stressed, because they’re threatened, because they’re up against it and our behaviour becomes reductionist. Get safe, get safe, get safe in those environments so we can always remember that and think, how can we move ourselves to a physiological state of calmness? Then we will be accessing much wiser capacities to navigate through our daily work. 

Professor Michael West: That notion of team pledges, I think, is really powerful. One of the techniques I was use with teams was to agree three things we must never do and three things we must always do. And compassion always was very visible in those pledges, and it provides a powerful handrail for teams in terms of their behaviour over time. One of the questions I’m also asked is, well, it’s fine to introduce initiatives, but could we sustain change in teams and organisations over time? 

Dr. Deborah Lee: So I’m particularly keen on thinking about this because so often when we have leadership programmes or we take staff out of their team and to another place for them to learn in a silo and then come back to the team. And you know, the learning is very quickly diluted. So I think if we can learn within a team and we invite teams to our compassionate leadership training, we want them to come in their team so that they’re already beginning to think about it in that way. That, of course, gives rise to another problem. And some people go, What’s the definition of a team? Is it that way or that way, you know, sort of lateral or horizontal? So lots of people have different teams, but coming to the team creating that opportunity for change and then fostering it. We can do that through structures, I think, and the most obvious way of keeping that alive is having some type of reflective practise space. So we’ve developed a compassionate staff reflective practise model. And if I just talk about my own team, which is, you know, it’s incredibly important that we have this space because we’re working with trauma day in and day out. But we have various settings of which we engage in compassionate, reflective practise and that is in part working on ourselves. So we talk about our own journeys of self-compassion, how we’re all getting on with our own practise, and then we talk about the interface between ourselves and our clients. And we also are mindful of what our clients want for us. How are we doing for that? You know, we’ve got to always hold in mind that we just want to provide good care for our population and Berkshire. So we’re only as good as how they experience us. That’s the most important interface. So it’s really important that we hold a mind reflective practises with clients and focus groups so that we can shape how they experience us. The other thing that I think is a really kind of helpful idea, and I’m hoping that Berkshire may be able to think about taking this on board as we emerge from the pandemic is to have compassionate, reflective leadership forums. So across Berkshire that we have a group of people that find themselves in similar roles, having their own leadership reflective practise. We’re very used to doing this as clinicians, but actually, in terms of leadership, compassionate leadership reflect practises will keep alive the notions and the commitment to compassionate leadership as a sea change. I think for me, those kind of structures bringing together methodology under the framework of compassionate, inclusive leadership is going to be really important going forward in terms of really committing to the sustainability of culture change. And of course, with that longevity is so important. Longevity, you know, not tick box, not tick box, but commitment and longevity of seeing it out through the end and learning from it as it evolves, I think, would be a really important point. 

Professor Michael West: So Health Education Improvement Wales has committed to a 10 year strategy for developing and sustaining compassion and leadership across the whole of health and social care. And I know some Native American communities have a timescale for change, which is 70 years or three generations. The other reflection I have is that perhaps the most extraordinary characteristic we have is awareness and consciousness that we have the capacity to stop and reflect on our own experience. And I’ve been convinced over my career that taking time out to reflect on what we’re trying to achieve, how are we going about it, what we need to change? Reflecting on what I’m experiencing in this moment requires courage, but it’s also the opportunity for growth and learning and nurturing and contribution and the development of compassion. Well, what’s the one tactical tip you would give to people listening to this, that one thing they could maybe take away from this conversation that will be helpful to them? 

Dr. Deborah Lee: Start with yourself. The longest relationship you have is the one you have with yourself. So start with looking after yourself. The graveyards are full of irreplaceable people and it’s so important that we look after ourselves. The work we do is so deeply rooted in humanitarian concern. It’s a wonderfully privileged job to have a life serving others and a career serving others. And you matter. So look after yourself, the cost yourself, be the drop in the ocean that creates the ripple that creates the wave and lead by inspiration. 

Professor Michael West: That’s amazing. I feel really inspired and nurtured by our conversation today. Deborah, it’s been a lovely personal experience for me and reinforces for me the importance of self-compassion and self-awareness and recognising that we have to make a difference for the collective good for other human beings around us, for the other species around us, for the planet as a whole looks interconnection is what this is all about and is the basis of our salvation. So it’s been wonderful. I would love to speak with you every day because I think it would make my day profoundly better. So thank you very much for being prepared to give your time and contribute to this conversation. Thank you. 

Dr. Deborah Lee: Thank you so much for inviting me. It’s been a real pleasure. Thank you. 

Paul O’Neill: I hope you enjoyed this conversation. Please look out for others in this mini series and subscribe to the Leadership Listeners’ Collection for more content like this. 

Episode 4: Compassionate leadership as part of working in and across systems of health and care

Transcript

Paul O’Neil [00:00:02] Hello and welcome to Leadership Listens curated podcasts for leaders in health care. My name is Paul O’Neill, Head of Strategy, Research and Development at the NHS Leadership Academy, part of the People Directorate of NHS England and Improvement. This mini series of podcasts as part of Leadership Listens, is a series all about compassionate leadership, but it’s a collection of conversations between Professor Michael West and a leader from the health and care sector. This recording is a conversation between Michael and Fatima Khan-Shah, Programme Director, Unpaid Carers and personalised care programmes, convenor of the Race Equality Network in West Yorkshire, and Harrogate Health and Care Partnership. This conversation focuses on the importance of compassionate leadership as part of working in and across systems of health and care, and its role in engaging with citizens and service users.  

Michael West [00:01:04] So welcome everybody. My name is Michael West, I’m a senior visiting fellow at the King’s Fund and Professor of Organisational Psychology at Lancaster University, and this series of podcasts is just a huge pleasure and a privilege for me, particularly because I get to talk to some of the most inspiring people and lovely friends across our health and care sector. And today it’s an opportunity for me to be with and learn from Fatima Khan-Shah. Fatima a warm, welcome to you. You’re a multi award winning director known regionally and nationally for actively championing patient involvement, carer support, health inequalities, leadership and diversity and inclusion. And I suppose formally, you’re currently leading the West Yorkshire and Harrogate Health and Care Partnership programmes for long term conditions, personalised care, unpaid carers and you also convene the regional West Yorkshire Regional Equality Network. And I know you were recently recognised in the Health Service Journal’s top 50 influential Black, Asian and Minority Ethnic leaders, as well as being recognised in the British Muslim of the Year awards for your work nationally. So it’s a delight in an honor to be with you.  

Fatima Khan-Shah [00:02:26] What an introduction Michael I feel a bit fraudulent just sitting here with that description. But thank you, one of the conversations I often have with people is when I try and explain to people what my day job is. They don’t understand. And so I just say positive disruption, I just go cause trouble wherever I go for the greater good.  

Michael West [00:02:46] Well, it’s a trouble that comes out in wonderfully positive form, I must say, and I want to start by reflecting or acknowledging the context we are currently in, which is sadly far from positive. We’re still in the throes of this global shiver that is a pandemic, and it’s had a huge impact on health and care staff in terms of stress levels. And I know many of them have been under such protracted stress. They’re exhausted and tired of being exhausted that they’ve either quit or intending to quit. And I think it’s also had an effect on moral distress, people not being able to provide the care they want to provide. So it’s a really difficult time, I think, at the minute, and was difficult even before the pandemic with staff shortages. What’s your perception of the experience of staff and the experience of the health and care system at the minute?  

Fatima Khan-Shah [00:03:41] I mean, I think you summarised it very accurately. The pandemic has been something, I call it a nightmare, that just doesn’t seem to want to end. The moment you think you’re going to wake up, something else happens and you just back in the middle of the nightmare again. And I remember, sort of, at the beginning feeling absolutely helpless because I wanted to do something to help. And there was this really divisive language about frontline staff and frontline care and everyone, you know, in sort of battle formation and thinking, What can I do to help people who genuinely cares about our communities, our people, my loved ones? This genuine feeling well how can I contribute or make things better? Because there’s nothing in my control and people were going in at one hundred and ten thousand miles per hour, and I remember doing a video for the King’s Fund, where I just spoke really honestly and I said, I’m exhausted. I’m going 120 percent in the day job trying to deliver and support people as best we can. But because of the momentum and the longevity of what we’ve experienced, there’s been no let up when I can’t recharge and I feel really guilty for saying that out loud but it’s how I feel. And I think what video did was it gave people permission to acknowledge that. And I think one of the reasons why I admire you so greatly, Michael, is because you advocate a slightly different leadership, which is not the hero leadership that some people feel like they need to demonstrate in emergency situations like this. This is a marathon. It’s not a sprint. And if we’re going to continue to support people through what I call the nightmare but the pandemic, then we need to recognise that people are multidimensional, they’re multifaceted. We have different factors that impact the individual that you see within the workplace. One of the things I discovered, particularly talking to colleagues and providers of health and care, is that there are things going on at home as well, so when they’re coming into work, they may have a relative that is dealing with cancer, they may have caring responsibilities. They might have a child currently recovering from COVID, and they’re bringing that into the workplace, giving a hundred and twenty percent and then going back and dealing with that and there is no chance to recharge. And there was this culture and, because it was all hands on deck, not having the bandwidth to recharge and self-care. And my new mantra as a consequence of having those conversations was that self-care is not selfish. It is, it is essential in being a good leader. The ability to demonstrate and role model those behaviours, that actually I do need to look after myself in order to look after you because you would gives your car an MOT. Why wouldn’t you look after yourself? We’re not machines. I think the other thing I would say is we’ve seen some really amazing examples of people stepping in and dealing with uncertainty with real honesty. And I think some of the anxieties that come from people that I’ve spoken to has been, I don’t know what’s coming and I’m really scared. Some of the most inspirational leaders I’ve spoken to have responded by saying, Yeah, I don’t know what’s coming, but I’m going to deal with it when it comes and we’re going to work on it together. And I honestly don’t have the solutions. I will find the people that have the expertise. I will bring them to the table and we will resolve it together. And I remember sitting with you one time when we were talking about the captain, was it? A major of a submarine. And he came on the submarine and he didn’t understand the controls, but he didn’t need to because he was there to facilitate and enable the people with the expertise. And that, to me, was a real penny drop moment of, yeah, actually as a leader, I don’t want to have all the answers. I just need to have the skill set to support people to develop the answers together.  

Michael West [00:07:31] So there’s, I think, really powerful lessons, the importance of self-compassion, not as some sort of selfish, self-indulgent orientation in life, but is a fundamental way of being that enables us to connect more deeply with ourselves in order that we can connect more deeply with all of those that we provide care for. We lead, we interact with. And I think that second observation about leadership is, it’s not necessarily about having the answers, but it is about bringing the attention and the resources of everybody to bear on the most difficult things we face. And then there’s the learning as well I think that you’ve talked about from the pandemic about how compassion has been at the heart of this, the compassion that health and care staff have shown and the compassion they shown patients and service users and the compassion they shown each other. And I think also what’s really struck me is the huge compassion that people in the community have shown for each other. So my mother, who’s 95, going on 96, her neighbours have been dropping in regularly to check on her. And there has been this huge upwelling of compassion from the community as well as, as it were, from the professionals. And I suppose in thinking about the future, I’ve begun to think that we can’t go on with the paternalistic health care system that doles out health care to a so-called supplicant population that we have to move towards a situation more where the community genuinely co-owns and co-designs their health and care services. Is that just an idealistic kind of dream, or is that something that you’re seeing beginning to happen in reality?  

Fatima Khan-Shah [00:09:21] If it’s an idealistic dream, then I want to go wherever you are because I’m totally behind that vision. I think you’re absolutely right. If the pandemic has taught us anything, is that the walls are meaningless anymore. We’ve come together across sectors, across organisational silos and really transformed the way in which we design and deliver care at pace. And it’s just shown us what is possible. Actually, if we parked the usual, sort of, mantras and way working the old ideals are actually fantastic, change is possible. And we saw this during the vaccination particularly in West Yorkshire, where I work, where we were using grassroots community influencers, we were delivering caring venues that we wouldn’t have thought of or considered about delivering care in before that, we were trialing and doing different ways of having conversations with the public about the way in which they perceive and manage their own health and wellbeing, which is absolutely what personalisation is about, it’s what personalised care is about.  

Michael West [00:10:19] So can I just ask you the grassroots influencers and venues you wouldn’t have used? If you can just say a little. Give me a couple of examples.  

Fatima Khan-Shah [00:10:28] Yes, definitely. So one of the key things that we have found absolutely instrumental, particularly with the vaccinations, is using trusted influencers, people that are within the grassroots of our community that are connected like the mafia for want of a better phrase. Knowing loads of people in the shops, in the community centers, in their homes, articulating some really key and simple messages about certain elements of health and care. Whether it is about the debunking of the myths that people have regarding vaccination, whether it about addressing some of the systemic barriers when it comes to health inequalities and using those influences and using venues like mosques like community centres where people feel comfortable and safe to receive care, has actually really, sort of, ensured that people are accessing care in record numbers. Another thing that has worked particularly well for us was the work that we did with the vaccinations on the Unpaid Carers Programme, so it’s taking an opportunity to go okay. One of the biggest issues we’ve got at the moment as a system is there’s no consistent definition of how we define a carer and a carer is that provide some time and support to a loved one. They don’t have a formal title. They’re often not recorded in the Department of Work and Pensions that don’t receive benefit. I certainly don’t because of my working situation. But actually, I’m instrumental to the health and care system. I wouldn’t normally be seen as part of the workforce, but I am part of the workforce because I’m keeping my loved one out of hospital and God forbid, if they were in hospital, I’m instrumental in that effective discharge. So developing that consistent definition, developing a process, a way of working where the local authorities and the voluntary community sector and the health system all work together on a standard process to identify these individuals, to invite them in for vaccinations early and delivering care to them in the places they were comfortable, enable those in three months to identify fifty one thousand new carers. So these new ways of working are shown that, one innovation is possible, two when it’s done right can be absolutely astounding when it comes to impact. But three shows that actually we are redefining what we mean by our workforce. We don’t just mean the people in the scrubs in a hospital estate, we’re talking about people in our communities that can talk about social prescribing. We’re talking about individuals, that are in community centres that provide peer to peer support on things like diabetes. We’re talking about someone in a voluntary community sector organisation that can support a carer with the navigating of the health and social care. All these elements in this new world, this new exciting world, particularly with your vision, could enable people with the skills and expertise and knowledge to make informed decisions about the care they actually need, not care that they’re expected to need because of the old ways of working. And it may mean that they take a decision that the usual course of treatment is not for them, and that social prescribing is a better way. Just one example. 

Michael West [00:13:25] Can you say a bit about what sorts of things social prescribing involves? I mean, I always get confused a little bit by the term, but what little I know about it suggests it’s a really exciting way of thinking about how we care for people around us.  

Fatima Khan-Shah [00:13:40] I mean, social prescribers, I think, are instrumental within primary care networks and they work alongside our primary care colleagues, our colleagues in the community. Quite often somebody will be signposted from a primary care setting to go and see a social prescriber for possibly things on diabetes or another long term condition. And it may be that the social prescriber connects them into something related to physical activity or a peer support group to help that person manage their long term condition. Because quite often the cause of the manifestation of the individual in front of you is actually a little bit more complicated than just treating the condition before you. You may be that they’re in a situation where the housing isn’t supporting them to have the best health and wellbeing outcomes. It may be that the socioeconomic circumstances in which they’re living is having a negative impact. It may be that lack of social contact. I mean, we often start to medicalised things like unhappiness and loneliness. Where actually a social prescriber can be instrumental in connecting people back into their community to do things like gardening or befriending others, which has not only a positive impact on the person receiving those outcomes, but also the person doing that, volunteering or linking in with that group.  

Michael West [00:14:53] I guess it also recognises the fundamental importance of a feeling of belonging of relationships and how damaging loneliness and exclusion are and the sense of isolation for us as human beings, as a species. And that interconnectedness, which is so fundamental to who we are.  

Fatima Khan-Shah [00:15:13] And that’s why ICSs is so incredible me now our partnership, I think, and I’m biased because I work with it at have been really innovative on things like loneliness. We’ve had a campaign called “Look Out for your neighbours”. It’s been running for a couple of years now, and that is just a very simple concept, as you describe with your mother Michael, of just looking out for neighbours, just knocking on the door, making sure they’re okay, popping round for a cup of tea, dropping off a casserole or a curry. Whatever it is, those small things matter, and I always say that kindness is free, but its impact is priceless.  

Michael West [00:15:47] And its impact both ways. The love is at both ends, the being cared for and the caring. Both have really beneficial outcomes for us. I mean, my sense of what you’re doing in West Yorkshire, in Harrogate, in the integrated care system is, I have a sense that it’s a pretty enlightened system that you’re developing, that you’re making really good progress. And my sense is you’re involving lots of organisations, voluntary sector organisations, local authority, community groups, social care and health care. So I’ve got two questions. One is how is all of that going and seeking to interconnect all of these entities? How’s that going and what’s difficult? What’s really hard about that? Because I have an intuitive kind of expectation that trying to get organisations across boundaries to work together sounds good in principle, but it’s really hard when you try to do it in practice.  

Fatima Khan-Shah [00:16:40] I mean, you’re a very wise, man Michael, and you’re always on the money, particularly with that last point, that it is difficult. But going back to the first part of your question, I mean, I am extremely proud to live and work in West Yorkshire’s Health and Care Partnership. The reason why I am proud is because we have a leadership that’s led by Rob Webster, but others like Ian Holmes and other colleagues that very much are the paramount, and visible example of a values based leadership, and a values based leadership to me is somebody or individuals who collectively have a series of values that they’re very open about that are very accessible. People can connect with them, they can believe in it. We can get it. And they’re brave. You know, one of the things that I always remember about meeting Rob Webster in particular was his mantra of the distributed leadership model. So I started my journey as a patient public advocate champion working in the grassroots of West Yorkshire. And the first time I had a conversation where I felt empowered to act was so liberating because I was given the opportunity to lead a solution to a problem that I knew I could fix. I just needed someone to give me the platform the permission in inverted commas to go in and deliver the change. And he was one of the first leaders that I met that was like, Yes go and get on with it. So what are you waiting for? Type conversation, which I found absolutely refreshing and really empowering. The other thing I would say is, you know, we’ve always been really clear about what our shared vision is. We’ve got 10 system ambitions. The very easily accessible and, sort of, I always say, is if someone stops in the street and says, Well, what joke do you do? I tell them that I work for an organisation that’s committed to improving outcomes for people with cancer. We want to diagnose cancer earlier. We want to address the problem with people with a life expectancy that is lesser because they happen to live with a learning disability. We want to support the wider determinants of health and address things like climate change. All those examples are really simple and that most people can connect to and start to go, Yeah, I get that. I can buy into that. I want to join the West Yorkshire party, which creates this feeling of momentum and a social movement, rather than a bureaucratic organisation that’s got to deliver certain key objectives and which have to be measured in a very sort of nugget like way. And I think the other thing I would say is we’re not afraid to be ambitious. We always think really big because we’re thinking about the long term and a mantra we’ve always got is, you know, we don’t sit around and admire the problem. We want to do something about it. And, you know, we roll up our sleeves and get our hands dirty, which I think is really important. But that’s only worthwhile if you back it up with the action. So the other thing that we always try and do, I always try and do, but I emulated the leadership by their example. Is if we’re going to do something about it and we’ve got to back it up with the doing, haven’t we, because words are easy, doing the actual doing, as you just described, can be really difficult Michael, and I think it’s important then to share with people that we have done it. So one of the fantastic leaders in our system, a lady called Karen Coleman often portrays and develops case studies which demonstrate the impact of our partnership is making because it’s important to be able to tell that story to get people to connect into again the vision of what we’re trying to achieve in our system. And then the thing that I would always say is my which I find really inspiring is we’re not afraid to give power away. So one of the biggest challenges I give to leaders nationally in particular. And Michael, you’ve seen this with colleagues that I’ve been with is saying, OK, if you genuinely are committed to this and give the power to the people to go and make it happen. And that’s scary because it comes with risk and sometimes it might go wrong. But unless you give the power back, then the balance is unequal and you’re never going to get the change, the dynamic relationship that you need to make that change happen. And that very much is the case with the patients and the public and the carers that we engage with in our system. We advocate and have adopted patient leaders. I’m an example of that. We’ve also got voluntary community sector organisations that sit in our leadership forums as equals. They’re not there as a tokenistic thing they’re there with influence and power and the resources are shared equally as well, which I think is really important because we’re not just talking the talk, we’re walking the walk. And I think the final example of that I’d say about how amazing it can be, but also challenging is the work we’ve done on health inequalities and race equality. So we acknowledge that our leadership is not what it could be. It’s not reflecting our communities, and we took a long term approach to do some systemic action to make that happen. Some of those things were, well, let’s get people in the room. Let’s get some representation and let’s back it up with influence. You’re not just there as a token, we’re giving you an infrastructure resource to give you some influence and some teeth, dare I say it? But also, when it comes to health inequalities, we have addressed some of the more complex issues. So we’ve just given away, for example, a million pounds away to support people with fuel costs because of some of the fuel poverty that we’ve experienced in the region. And I think what this is showing is the power of an integrated commissioning system can go far beyond health and care. Actually, it’s a huge anchor within a region that works alongside West Yorkshire Combined Authority. Or likewise, organisations such as businesses to really address some of the complex issues affecting our health and care and the wider determinants of health because you might treat the condition that’s in the room. But some of the issues might be more complex, might be about racism, might be about adequate housing. It might be about the experience of people caught in the criminal justice system. It may be the economic recovery and all those elements and all those relationships are really crucial in the integrated commissioning system was instrumental in making sure that we’re working in collaboration towards the same goals.  

Michael West [00:22:42] You just gave me an amazingly rich feast, and there are so many morsels and so many dishes that I want to savor. And so it does seem to me, from what you’ve described, that this group of organisations formal and informal and group of communities that constitute West Yorkshire and Harrogate is in a sense bound together by a shared vision of creating a place or nurturing a culture in that area focused on enabling people to live, fulfilling happy lives, feeling safe, feeling loved, feeling as well as they can feel. And that binding together is also a consequence of an explicit commitment to core values to do with sharing responsibility, sharing power, caring for people, and that honesty and transparency and a recognition of the reality of what’s happening, there is inequality, there is racism, there is discrimination, there is abuse, there is poverty and values focussed on how we can address it. So the values and the vision in some sense, giving people a shared sense of purpose and a shared identity is what I’m hearing. And then there’s something around. This is about a focus on the long term. You know, it’s not just we’ve got objectives for the next three months or six months. We’re talking about how to change things over the next ten years. I was reading recently about some Native American communities where it’s traditionally been the case that you think about the future in terms of the next 70 years or the next 150 years and what we want to achieve. And that’s a very, very different perspective from what are we going to achieve in the next three months, this kind of obsessive, target driven culture? That’s what I hear you saying as well. Is this the sense of a long term commitment?  

Fatima Khan-Shah [00:24:41] Absolutely.  

Michael West [00:24:42] And then the idea of giving power away to people, you know, I’ve always thought that the co-design and co-ownership of health and care services must be what we aspire to. But that means this incredibly complex set of structures that is our health service and health service organisations and sectors that’s about them genuinely seeking to be owned by patients that I remember, particularly the NUKA system in south central Alaska, where Native American leaders now lead that system. Patients are called citizen owners, and all of the different agencies work together. And it’s not just, you know, this is a good idea. The outcomes in terms of reduced suicide, drug addiction, alcoholism and maternal health are extraordinary. And then your point about sharing the resources. This is a shared budget, as you’re doing in West Yorkshire and Harrogate, and I guess it was a hallmark as well of the Canterbury New Zealand Christchurch system, which responded so well to the earthquake because they were already sharing budgets and resources. But I’m aware that all of this is achieved by working really hard. What is there are hard yards to be ploughed. I’ve always thought that if you’re not having conflicts, you’re not innovating, you’re not changing anything if you’re not having conflict. So how do you manage conflict within West Yorkshire and Harrogate? Because they must arise continually.  

Fatima Khan-Shah [00:26:10] Oh, absolutely. And debate is a really important element of leadership. You need to be in a position in a system where people can tell you what you need to know and not what you want to hear. Because if you’ve got an echo chamber, that’s a very dangerous place to be. And we do operate on a principle of subsidiarity. So you are trying to deliver care as close to people as possible and supersedes the system. And all those elements are very important. But I totally agree with what you are alluding to Michael, which is the job is really difficult. I remember when I first started working in a system role that I really struggled with it, because it does create conflict. There are competing priorities. You’re very much delivering through others. And sometimes that can be really difficult, especially if they have not bought into the vision or they don’t agree with the new way of working. And I remember sitting with one of my most inspirational leaders and colleagues, and I remember him saying to me that. The job isn’t the work Fatima, it’s the people. You’ve got to work with the people, you’ve got to develop those relationships and invest in those opportunities as organisations and if they’re presenting conflict, you’ve got to explore it and explore and understand why, where they come from, they’ve got those challenges and also they’re the ones with the expertise and we need to tap in and utilise that. So I think debate is really healthy. I think it’s really important we have to always agree on stuff, and I don’t think there’s any way in the world where everyone always agrees on everything. But I think there’s a real positive element in our system where we feel safe to articulate our concerns and challenge back and we always assume the best of intent. So there isn’t an assumption that you’re out there for your own agenda or benefit. But if there is a challenge coming in and it’s coming from a good place and we need to explore and understand why that challenge is, and how we can work together to develop that solution. And I think going back to your point, everyone needs to feel invested and equally committed to what you’re trying to do, otherwise you won’t succeed. And I think there’s also something about really investing in developing those relationships. And I think one of the things I’ve learnt on this job particularly, and it is something that will take with me wherever I go, is it’s not always about the system, process and policy. It’s about the ability to pick up a phone to someone to go I need your help with this. Can you give me a hand? Just need to deliver this, and that person and yeah what do you need? Let’s sort it. That is far more instrumental than any standard operating procedure or policy practice that you were ever going to get. But it again, it comes from an ability, and belief for all structures within the organisations to have those uncomfortable conversations. And we did that on health inequalities. We did that on the race equality stuff. The reason why we commissioned the independent review was because we knew that we were doing enough on health inequalities. The faces of the people that we were passing away in front of us was showing us that something was wrong. And the fact that we got an independent chair to lead that review and the fact that we did it at pace showed that we were committed to having a cold, hard look at ourselves, answer an honest response about whether we were doing enough when we were told that, yes, we were doing some good stuff, but it was far more we could do and we took that bull by the horns and went with it and went with it at pace, which is why we delivered so much in the year after the review. And I think they are really important elements that I would encourage anybody to consider in regards to leadership. That ability to really be able to take that feedback to really welcome challenge and to explore the issues and rationale behind that challenge and not assume that it’s coming from a bad place and recognising that there will be situations where it might be right for elements of West Yorkshire, but it won’t for others. And to be able to have the relationships are mature enough to deal with those things. The same with sectors as well, and we’ve had many of those situations where we’ve worked through those issues. But you’re right, it’s never rosy everywhere.  

Michael West [00:30:01] So what I understand from what you’re saying is, firstly, there’s a kind of leaning into conflict. It’s almost like an orientation that says we’ll welcome disagreement and we’ll welcome different perspectives, because that’s going to enable us to have a more comprehensive understanding of the situation that people are facing here in West Yorkshire and Harrogate. So we’re going to lean into that, but also that leaning in is also about spending enough time together so that we really listen deeply. And I think one of the things that has struck me about the development of more integrated ways of working is that sometimes it seems it doesn’t really work very well because the key people just don’t spend enough time together. If they do spend time together, it’s a formal meeting with a long agenda that they’ve got no hope of getting through, so they never really connect. I guess what I’ve really been impressed by, and it’s what you were saying about relationships, I think, is that if the job is about relationship, that means that’s what you need to be spending your time on is having contact with key people across the system.  

Fatima Khan-Shah [00:31:10] What you were saying reminded me of an example, about two years ago now where we were facilitating a workshop very early on our journey to race equality. And I was working with a chief executive called Owen Williams incredible man, and we were organising the workshop together with a number of other leadership colleagues and colleagues from the core team. And we developed a range of videos with some really uncomfortable and provocative questions. And I remember saying to everybody that I was worried about this, and he said no it’ll be fine, it’ll be fine. And he was really challenging me in a coaching type of way to push the boundaries a bit more. And I was like, Wow, this guy’s either really a genius, or really dangerous territory. And I remember when we were doing the workshop, and I was sort if saying to him these conversations were incredible. But I need to nail some outcomes Owen, I want some one action that I can follow up afterwards to make sure they do. And he was like Fatima, that’s not why we’re here. What do you mean that’s not why we’re here. He goes, I just want them to leave the room thinking differently. And I’m like what, so we’ve got no takeaways, no actions. I’ve not got a plan. And he goes No, I don’t want any of those things. I just want them to leave the room thinking differently. And obviously, he’s a very wise man. Everyone who knows him knows he’s incredibly intelligent and wise on these kind of things. But it was one of the most important lessons I learnt on that agenda, which was plant the seeds let people go through on their own journey. Let them come back to you and have some more exploratory conversations. But give people the opportunity to get behind an agenda. I know I’ve always been a carrot, not a sick person. But I do think that some of the most successful ventures we’ve ever done, particularly in the programmes I’ve led in, the work I’ve done nationally has been by winning over the hearts and minds of people to get behind something rather than making them do it because it’s in an SOP or they’ve got a target, because you could hit the target, couldn’t you Michael and this wouldn’t?  

Michael West [00:33:08] Well, I certainly see in parts of the NHS and I certainly see this in some integrated care systems that we create, almost like artificial palaces in the sky. So I think sometimes our national bodies, they have a rationale and a discourse and policies and procedures. There was a book that I read in my youth called the Glass Bead Game by Hermann Hesse and it’s this elite group of people who play this elite game. But it’s somehow removed from reality. And I think sometimes some of the structures we create and some of the processes and some of the policies feel like they’re removed from reality, and that actually they don’t effect any real change on the ground. They become an end in themselves. But it sounds like we some of the principles you’re talking about in West Yorkshire and Harrogate, about relationships, about sharing resources, about power being distributed, not just given away but being distributed. I guess the other point I heard you say was this kind of underlying principle that all of the organisations, voluntary associations, community groups, are oriented to asking How can we help you so that together we deliver and that being in a way a cultural norm, I guess.  

Fatima Khan-Shah [00:34:27] I wouldn’t say that’s always true. So I think going back to your point about conflicts, one of the most insightful pieces of work I ever did with colleagues in our system was developing the Independent Voices Panel, which was the structure: now part of our governance processes that consists of people from voluntary community sector organisations from ethnic minorities. Who have a role in holding up a mirror to us on the delivery of our review into health inequalities. And they very much challenge the status quo and ask us some very hard questions about the distribution of wealth, particularly when it comes to not just the voluntary community sector as a whole, but certain grassroots communities. So you can have something right in principle, well we’re distributing the wealth and giving it to a group of individuals. But are they the right individuals with the right focus, with the right infrastructure? And they challenges us back and go, actually, you know what? You might need to think differently on this. Or you’ve started a really good journey, but you’re missing this. There’s a whole load of direction to go in. So I think that’s equally important and again, going back to the healthiness of that debate and the ability to constructively challenge and tell you what you need to know has been really instrumental to our success with the launch of these intersector organisations, but also that we need to work collaboratively as partners to make sure that we deliver the care and the vision that we want to get into. But I think the other thing I wanted to say was, a key element of our partnership model are our local authority colleagues. We’ve got amazing leaders like Robin Tuddenham and Kirsten England and Tom Ridge, and in that system who have amazingly large and complex jobs but are always deeply embedded in the work that we’re doing within our system. And again, if you go back to the work that we were doing in the vaccinations and dealing with the pandemic, some of the conversations we had about utilising resources both in care within the communities, freeing up resources, getting things like iPads to people in care homes and creating a digital infrastructure for people that are in poverty to be able to access health and care via the digital means, they would not have been possible without our local authority partners moving heaven and Earth to develop an infrastructure for us to make it happen. And I think it’s really, again, as I said before, changed the dynamic by which we can deliver care and where the boundaries and the walls used to be Michael, I now do not believe in assuming that there are any walls anymore or any boundaries. I’m kind of like, No, let’s just think outside the box and see whatever is possible. And that is really instrumental by making sure that we have got the right partners around the table who are equally brought into our values. Hold the mirror up when they think, Oh, actually know what? I’m not quite sure that’s the right call to make. You might need to think about this or actually you need to be supporting. So one of the things that we recently did was increase the living wage for social care colleagues you know our people working in our care homes. And that was very much led by our local authority colleagues who was saying, Look, we’ve got a situation where a number of our colleagues in this part of the system are going into health because the infrastructure in the renumeration isn’t there, we need to make sure we level up to create that parity of esteem. These are the kind of really difficult issues that we danced around prior to COVID, or prior to integrated commissioning systems. But we’re now moving towards dealing with those rooted issues, and that’s only possible with this new way of working.  

Michael West [00:37:49] So, rather than avoiding them you actually directly address them together. And I think the other message I hear from you is there’s a kind of humility in what you’re saying that in a way there isn’t some hubris or arrogance or power and control orientation from particular parts of the whole system. There’s a humility that says, we don’t know, but collectively we’ve got more chance of generating creative ideas about how we can respond to this. And I suppose there’s something about the pandemic enabled all of that because this was a don’t know situation writ large. And suddenly it did require a recognition that there were no walls. There could be no walls if we were to respond effectively. So that humility sounds really, hugely important. I think the other thing I want to say in response to what you’ve been saying, Fatima, is that I’m not sure how optimistic I feel sometimes about climate change and our health care system and our political system. I don’t feel naturally optimistic, but I do feel hope. I feel hope when I hear about, see witness people doing great things together in small ways, in big ways, and it does feel like what you’ve been describing is really hopeful because if West Yorkshire and Harrogate can make progress like this, then everywhere can do it. But it does take these lessons that you’ve been describing. I think that’s critical. One of the questions that feels kind of slightly unfair to ask you, but I’m going to ask it anyway, because I think a lot of people need help, and they need simple direction is, for people who are struggling with these issues to do with working across boundaries, to do with collectively caring for the people in our communities. What’s the one or two really important practical principles that you would advocate?  

Fatima Khan-Shah [00:39:46] I mean, I think the first thing would be to go about what you just described as our humility. So I started in this system as somebody who was a grassroots positive disruptor, really focused on empowering communities, empowering carers to work in a different way. I would email chief executives, accountable officers of organisations in our system. And I was never once made to feel, Who do you think you are emailing me asking me for a favour, do you know who I am? Never once. I’ve always had a response of. Absolutely, I really want to support this. What do you need? And I remember one time when we used to meet in the physical world before COVID going to one of the venues that we used to meet in, in Brighouse and accosting various leaders who I didn’t know very well and I was probably scared of and saying Oh, I’m just doing some videos for Carers Rights Day, and I really would like you to just do a quick thirty second video on your commitment to supporting carers. Would you mind doing a quick video on the phone for me? And bless them, they’d go into this little room or wait outside and do a quick video for me and then wrap it up and carry on. And it’s just those little human and humble ways of working and leadership that just empower anyone in your system to think, Oh, I can lead the change I want to see. I can do something slightly differently without feeling that, Oh, I’ve gone above my pay grade or actually I shouldn’t have spoken to you. Those kinds of values and behaviours I think are instrumental to success. The other thing that reminds me when you’re talking about climate change was, one of the aspirations towards our work on climate change was we were at the NHS assembly meeting Robyn and I were, and we saw Dame Jackie Daniels talking about climate change and some of the work she was doing and how exciting it was. And I remember sitting in the meeting going, Wow, this is incredible. We need to be doing this in our system and we’re going to I’m going to go and talk to some people before I even got home from the train, Rob had tweeted. Fatima says she sees something in climate change. We’re going to make it happen. It’s just that thing is there is no bureaucracy structures. Yes, we have governance processes. Yes, we have ways of providing assurance. And yes, we meet all our statutory legal obligations. But we also are nimble and innovative and pacey and exciting and creative and I think all those things are absolutely crucial for a successive system to work, and they don’t come out of nowhere Michael, they come from a development of time and thinking and system leadership and OD are things that we very much focus on in our system, developing relationships, developing ways of working, agreeing what we’re going to do together, really galvanising momentum behind things and being brave so that you know your point about how do we get people, communities to feel that bought into, and are part of what we’re trying to do. Our anti-racism movement is an absolutely incredible example of coproducing a piece of work which was sensitive, risky, emotive about people’s experience of racism. It was about us doing something quite provocative. So, you know, we use the juxtaposition of some really positive messages which could have been perceived as quite triggering for some people on the images of people from ethnic minorities. And we put them on buses and on billboards, etc, to stimulate an uncomfortable conversation within our communities. And it wasn’t just to deliver a work product, it was because we wanted to create a better place for people to live and we recognise our responsibilities anchor institutions in leading the way, in those things. But what it did as a consequence was create a belief in our communities that we’re committed to change and we mean it and we’ve got integrity and they can trust us. And just think of the transferability of those values into some of the wicked issues that we’re seeing in health and care today, which is why I think ICS’s are incredible. If we harness their potential appropriately, and we’ve got the right leadership behind them.  

Michael West [00:43:45] I agree. That’s what I’ve been thinking for some time now. It’s how we harness that potential and see that that’s a step along the way to the interconnectedness that is the vision for the integrated care system in West Yorkshire and Harrogate. So the themes that you’ve described about the shared vision, about the kind of interconnected communities we need about the values of openness and trust and courage. To make a difference, the wisdom to ensure that we distribute power and create a sense of autonomy and control for people and build that sense of belonging and interconnection. I mean, all those themes, I think, are really powerful and I suppose I just feel really humbled now. Listening to you because you’ve been inspirational and it just feels an absolute privilege for me to listen to you and to learn from you and not just want to say thank you for your courage and your wisdom and your compassion. It’s a model for us all. Thank you so much.  

Paul O’Neil [00:44:50] I hope you enjoyed this conversation. Please look out for others in this mini series and subscribe to the Leadership Listeners’ Collection for more content like this.  

 

Episode 5: The importance of compassion and inclusion
Transcript

Paul O’Neill [00:00:02] Hello and welcome to leadership listens, curated podcasts for leaders in health and care. My name is Paul O’Neill, head of strategy, research and development at the NHS Leadership Academy, part of the People Directorate of NHS England and Improvement. This mini-series of podcasts as part of Leadership Listens, is a series all about compassionate leadership, but it’s a collection of conversations between Professor Michael West and a leader of the health and care sector. This recording is a conversation between Michael and Dr. Habib Naqvi, director of the Race and Health Observatory, and focuses on the area of the importance of compassion and inclusion.  

Michael West [00:00:54] Welcome everybody. My name is Michael West, and I’m really delighted to be joined by Dr Habib Naqvi, a very old friend of mine and a wonderful inspiration for me in the work that I do in the National Health Service. Habib, a really warm welcome to you.  

Dr Habib Naqvi [00:01:12] Thank you so much Michael it was an absolute delight and honour to be talking with you today.  

Michael West [00:01:19] So a little bit about you first Habib, you have a background in public health and health care policy and strategy development. And I know you’ve played leading roles nationally in seeking to create a more inclusive and compassionate and diverse health service. You’re now director of the NHS Race and Health Observatory. Can you just say a little bit about what that role involves?  

Dr Habib Naqvi [00:01:44] Yes, absolutely. I’ve been fortunate enough to be leading the NHS Race and Health Observatory, an organisation that looks to identify and help tackle some of the systemic health inequalities that we have within the country. We are fortunate, Michael, to have a fantastic health care service that is perhaps the most visible expression of a social contract between people. But to be proud of our health care services, not to be blind to some of its imperfections and we see within our health care service some of those imperfections that play out in some of the ethnic health inequalities that we have in society. So our goal of a remit within the NHS Race and Health Observatory is to help to tackle some of those longstanding health inequalities that we have.  

Michael West [00:02:44] And what sorts of work is the Race and Health Observatory currently doing, just to give us a sense of its activity and the likely impact.  

Dr Habib Naqvi [00:02:55] So at a very practical level. We are looking at themes such as maternal health and of course, the very sad statistic that we have today, which is that black mothers are up to four to five times more likely to die during pregnancy, childbirth or soon after Asian mothers being up to two to three times more likely. Of course, we’ve got all the issues around mental health and access to talking therapies for all different, diverse communities. We have issues as we are going through the pandemic at the moment, a world that’s becoming very much digitalised. But to ensure that actually those new innovations help to reduce rather than increase health inequalities for our diverse communities. And then, of course, we have a work stream, which is a very exciting one, I believe, which is looking at some of the common solutions to some of the common challenges that we have around ethnic health inequalities globally so that we can learn from other societies, other countries and apply some of that replicable good practice and learning within our own society as well. So it’s a whole kind of breadth of work that we are focusing on at the moment.  

Michael West [00:04:12] So those are really shocking statistics in relation to maternal health, Habib. And it does seem to me that it’s really important that we understand the issues of diversity and inclusion are not simply moral issues. Of course, they’re huge moral issues, but they’re really huge health issues. And I suppose what I’ve been struck by as well is research in social psychology on belonging and the importance of belonging in human behaviour, we’re more likely to die from the effects of loneliness or as likely to die from the effects of loneliness as we are from the effects of smoking or of obesity. We also know that, you know, if children are excluded from their friendship groups in the playground, then that has an impact on inflammation of the central nervous system with health consequences. And I suppose it’s the kind of the knowledge that you’ve been very involved in developing and how when we scale that up, we see that for people who experience discrimination and exclusion over the lifespan, there’s a biological weathering effect could you say a bit about that?  

Dr Habib Naqvi [00:05:13] Yes, absolutely. I mean, I think the first thing to keep in mind is the fact that when we look at different types of discrimination and I focus on racial discrimination, as an example. We know that racial discrimination and racism, you know, these are global concepts, system wide issues. And of course, they require a system wide response if we are to have sustained and meaningful positive outcomes from any of the interventions that we put in place. And that’s why, yes, of course, health care system has a role to play in focusing on this agenda, but it’s not, and it cannot be the only enabler. For equity. And that’s why we need to join up with all aspects of society in order to get those better outcomes for people for their well-being in a very equitable way.  

Michael West [00:06:07] And so my understanding from the research of people like Dr Williams at Harvard is that when people experience discrimination over the life span, black people, for example, that the impact on their health is cumulative, resulting in a greater incidence of disease and also early mortality. And I guess that was really powerfully and tragically demonstrated in the pandemic. And you, in the Race and Health Observatory would have been monitoring the indicators of that.  

Dr Habib Naqvi [00:06:40] Yes, absolutely, Michael. And it’s the weathering effect, the drip, drip cumulative impact of discrimination and racism and its direct relationship with health outcomes and experiences of health care is absolutely critical for us to focus on. And there is a lot more research in this area, perhaps in the United States, but a growing body of evidence now beginning here within the UK itself. And when we look at the context of COVID 19, we know that this has played and continues to play a huge role. And I have to say, Michael, I’ve been working in the field of equality, diversity, health inequalities for over 20 years now. And when the pandemic started, I knew that issues around equality and inclusion would take the backburner. But I have to say I was very surprised as to how quickly these issues were almost thrown out of the window and not paid full attention to until it actually dawned on leaders that these issues are absolutely critical in order for us to navigate the challenges of the pandemic when it comes to issues such as trust, confidence, the take up of services throughout the pandemic, and we are still seeing that today.  

Michael West [00:08:10] So I’ve been really struck by some of the data and the pandemic internationally and discrimination. So data for Hispanic people in Chicago being ten times more likely to contract the virus and many times more likely to tragically die as a result of infection than white people in Chicago. And data from Brazil on differences between black people and white people there, particularly striking data from the NHS of the  disproportionate impact of the pandemic. As you said on people from minority ethnic groups, people with disabilities, people from lower socioeconomic groups, but within the health service, how there was a disproportionate impact on health service staff with a hugely greater number of deaths of people from minority ethnic groups, members of staff and also infection rates. And some of the data on whether people were involved in frontline care of COVID patients, whether they had access to PPE equipment. And you must have seen some of the data that has emerged from that. Can you tell us just a little bit about what you’ve learnt from that?  

Dr Habib Naqvi [00:09:14] Absolutely. And we put the statistics on behind every statistic is a human being and we need to keep that in mind and so know we cannot escape a very sad reality of the disproportionate impact that COVID 19 has had and continues to have on our staff within the health and care sector and particularly our ethnic minority staff. But what we can do, Michael, is to learn lessons from the different waves of the pandemic and be on the front foot in order to tackle some of these issues as we go through the recovery phase of this current pandemic. And, of course, be on the front foot in terms of any potential pandemics that may emerge in the future. And there’s a huge amount of learning to take with regards to what we can do differently and how we can be a lot more proactive in being at the basic level, inclusive and compassionate in our approaches to health care.  

Michael West [00:10:16] So I believe that as a consequence of all, we’ve learnt about the impact of discrimination and exclusion and the importance of belonging and connection. It’s really clearly such a profound health issue in our society, and it’s a profound cause of inequalities. And it seems to me fundamental that in every training programme, in every educational institution, every programme that’s involved in training, health care professionals must be teaching them about the health consequences of discrimination and of whatever the opposite of inclusion is exclusion. And that should also be part of the. Training of leaders. But there’s another dimension to this as well, which you’ve hinted at. And obviously, you’ve had a huge amount of influence on thinking about inequalities and discrimination in the health service. I neglected to mention at the beginning in my introduction that you were awarded an MBA in 2019 in the Queen’s Birthday Honours for  

your services to equality and diversity in the NHS. And as you say, you’ve been deeply embedded in this for 20 years now. And I think what’s also not really well understood in this domain is the importance of diversity for good performance in health services.  

Dr Habib Naqvi [00:11:33] Absolutely. And that’s absolutely critical when we know of the benefits of inclusion and diversity, not just in terms of the diverse thinking, but also in terms of representation at senior levels of organisations. Because it’s that diversity, Michael, that leads to the more inclusive, the more equitable outcomes that we want for our workforce and for our patients and communities and where that is not in place. We know what the outcomes are. And of course, the NHS and the health care system is not alone across different parts of the workforce and society to have a long standing challenge of increasing its representation at senior levels within its workplaces and for there to be absolute levels of inclusion and diverse thinking in the decisions that are made around board tables and in the boardroom. And that is absolutely critical if we are to have a health care system that is fully equipped to meet the diverse needs of our diverse communities. And it makes me think actually, Michael, of some of the work that we are doing within the NHS Race and Health Observatory. I can’t just give you one example. We’re working on a programme of work that is carrying out an independent review of something called the AFGAR score. Now the AFGAR score is assessment that’s used within maternal health to determine whether or not a baby is healthy minutes after its birth. And as part of its criteria, the app score asks whether or not the baby is pink in colour. Now the AFGAR Score, has been around for exactly 70 years, so it was established and rolled out in 1952. Not only is it still used across all maternity units in the UK, but it’s also used internationally as well. And as you can imagine, having a criteria around the colour of skin, basing it on the pinkness of the colour of the skin may well have been the right thing to do in 1952, but it’s not the right thing to do. It’s not the right thing to focus on in 2022. And so some of our policies or processes, assessments, medical devices etc have not kept up to speed with the diversity of our communities. And that’s why we need that level of diverse thinking, diverse representation. And if we are in the business of tackling health inequalities, which we are, then we need that diverse representation at all levels within organisations.  

Michael West [00:14:32] That’s just an astonishing example and is for me, an indicator of just how lacking in diverse leadership and diverse awareness our leadership and our organisations have been and that that should have endured for all of that time is extraordinary. And for me and the work I’ve been doing over the last, I suppose, 30 odd years finding that we come up with again and again is how important diversity is. So you know about our research, looking at the performance of Trusts and where frontline staff are representative of their community care quality in those organisations is much better. And in fact, financial performance is much better, too. But also, I started looking at team working in health care back in the 1980s and every study we’ve done, we’ve included a measure of diversity to look at the relationship between diversity and outcomes. And we find consistently that diverse teams, particularly when they have clear shared objectives and they meet regularly, are much more productive and much more innovative than more homogenous teams, if you like. So that’s true whether we look at primary health care teams, community mental health teams, executive teams, breast cancer care teams, and it mirrors the research around the world of how diversity and teams and organisations is a benefit, and it makes sense because you know where you have diversity people from different professional backgrounds, different cultural backgrounds, different life experiences, you have a greater wealth of knowledge and skills and abilities to draw on. And I always think, you know, diversity is the nature of our universe. As a species, we’re diverse. Biodiversity is diverse, our planet is diverse, the universe is diverse and we have to embrace diversity. And again, I think that everyone who’s a leader in health care should have an understanding of the research evidence on the benefits of diversity for performance. So the big challenge, I think for many people is they kind of get a bit paralysed about all of this and think, Oh, well, what can I do? How can I make a difference? I guess what seems important to me is to explore. First of all, what compassion means in this context. Some why it’s important.  

Dr Habib Naqvi [00:16:49] I think compassion Michael is absolutely critical because it enables us to understand not only ourselves, but others better. And I guess in the context of health and care, the more we understand others, the more we want to relieve their suffering. So it defines us as human beings. As you say, it promotes meaningful connections meaningful interactions. It facilitates problem solving and it helps to improve health and well-being. But it pushes us to address inequality, discrimination and the struggles of others. Others that may not look like us. And in my view. Those that are not compassionate are those that do not have the ability to see things from someone else’s perspective and are unable to sympathise, empathise with their emotions. And as we move through this awful pandemic now more than ever, it’s important for leaders to demonstrate compassion. Leaders must embody the quality of having positive intentions and a real concern for the well-being of others. Michael, you talked earlier about health care workers on the front line of facemasks and deployment, etc. All of those issues are really important. Our senior leaders must embody having the real concern for our most vulnerable within our workplace and within our society. Compassion is leadership that creates stronger connections between people of different backgrounds, improves collaboration, and it raises and enhances levels of trust and confidence, something that we know have been important concepts throughout the pandemic.  

Michael West [00:18:55] So when I talk about compassion, I talk about four behaviours attending, understanding, empathising and helping and reflecting on what you’re saying. I mean, for me. You know, part of being with other people and diverse others is being present with them is having the self-awareness to be present in the moment to give my attention to let go of all of this thinking about what’s coming next and what’s this, but just to be present with each other. And we know that compassionate presence leads to a blurring of the boundaries between self and other. So one of the problems we see is this othering of people who are somehow different from us. I mean, I feel continually astonished and appalled and sometimes quite depressed about how we treat each other, you know, on the  

basis of things like the hue of our skin. I mean, it’s just kind of it’s utterly bizarre when you step back from it and it feels just so, I don’t know, obscene.  

And we somehow have to rise above all of this and see that we are we’re one where one, we’re interconnected. We’re interconnected with all of biodiversity, with the whole planet. And so compassion is about an inclusion of the same thing. Actually, they’re both about belonging. They’re both about the sense of being present with the other feeling interconnected, seeking to understand, to learn from to benefit from the richness of another person. And as you say then to empathise to mirror with them. I mean, we’re hardwired to mirror each other’s feelings and emotions. And I’ve been struck by the research that shows that when we seek to empathise with others from different backgrounds, then we’re much less likely to be unconsciously discriminatory and biased and then always asking the question, Do you know, how can we help? And I guess that’s a kind of key question in a way that people need to address. How can I as a leader? How can I, as somebody working in health services, help to change this discriminatory environment so it becomes more inclusive and compassionate and positively diverse where we value difference, whether it’s differences of skin colour, cultural background, professional background, gender, age and I guess what would be wonderful is to hear your words of wisdom about what can we do to change all of this?  

Dr Habib Naqvi [00:21:26] So I think, Michael, this, as you say, boils down to belonging issues around inclusion, compassion, but also, you know, with that inclusive leadership and inclusive leadership is something that we can all embody in our day to day lives. And that’s about not just making sure that we have diverse thinking and that diverse thinking is heard. But ensuring that that diverse thinking is respected. And applied in a meaningful and consistent way. And that’s absolutely critical, it’s absolutely critical for the success of individuals, of teams of organisations of systems, inclusive leaders support and bring out individual potential. In others, they sponsor and support others through their challenges and to overcome hurdles. They enhance the collective power of teams, and you’ve done a huge amount, as you say, Michael, around team working. But when it comes to organisations and this is, I think, critical for the health care system, particularly when it comes to organisations and systems. Inclusive leadership supports an organisation’s ability to adopt innovation and growth, and we know from other parts of the labour market, other companies, global companies. Where they have that inclusive leadership, where they have the compassion, where they have diversity of thought at all levels, then they are more likely to be innovative, more likely to grow and more likely to be successful. So, you know, there are a huge amount of benefits for us just on a daily basis. Be more inclusive, be more self-reflective about the levels of our inclusion.  

Michael West [00:23:26] So that’s really, I think, profoundly helpful. And it marries with what we think about compassion that being compassionate is about being present with the other, but it’s also about being present with myself. So being self aware in the moment, here I am having a conversation with somebody who is from a very different background from me. They’ve maybe come from a quite different country, like maybe Nigeria, and here I am, having a conversation with them. Am I self-aware enough to be aware of what my reactions are and to be open, to be present, to be here and now? And you use the words open to another’s thinking and that’s about hearing and listening. And the most important skill of leadership, I think all the research tells us is listening is hearing deeply and then the importance of seeking to understand the other’s perspective, not imposing some understanding, but through dialogue arriving at shared understanding. And that, sometimes, is difficult because we have different perspectives. But that’s what in a sense, being inclusive is being prepared to have differences of perspective and exploring those. So we come to a more comprehensive, helpful shared understanding. And then that ability to empathise, I always say to people, you know, think about what would it be like to be a black person going into work the day after one of those bombings that happened in London? What would you experience as you go to, let’s say you go to work on the bus when you arrive in work, so putting ourselves in the other’s position so that we more deeply understand. And then asking how we can help. And I do think that, you know, given the challenges we face in healthcare at the minute, both because of the pandemic and the challenges we faced anyway, we need all of our resources. We need all the creativity and the innovativeness we can muster. And that comes from embracing diversity. That the challenges we face as a species dealing with climate change, dealing with pandemics, dealing with weapons of mass destruction require us to work together across boundaries. So I think what you say is really profoundly important for us and I guess there are various practical things that leaders can do as well. One is, I think, as you say, inclusive leadership is about attending, understanding, empathising and helping not just equally, but creating an equity in that so that we are helping to improve so that there is an equity of experience. And what are some of the practical things that leaders can do? I know you’ve been involved in schemes like reverse mentoring and so on. Can you say a bit about that and about some other practical methods that we can all use for changing the culture of our organisations and societies? 

 Dr Habib Naqvi [00:26:25] Yes, absolutely. Michael, I think that I think the first point to highlight I think I would start with is the fact that when we look at the NHS with 1.4 million people working within it. The NHS is a microcosm of wider society. What happens in the wider world, and you touched upon things like terrorist attacks, Black Lives Matter and all the other things have happened over time, Brexit, etc. Those views, those issues are bound to come into the workplace. And so. The culture of wider societies in effect reflected within our larger organisations, and we need to keep that in mind when we think about, you know, what can we do in terms of cultural change within an organisation? Your specific question, therefore, links to that, I believe. Firstly, we need allies, we need people that can help and support us along that journey, and we need to be supporting those allies on their own journeys and the sudden reversal. Reciprocal mentoring is perhaps one example of that. If it’s done properly in the right way. Reverse mentoring is generally when a person in a more senior role is mentored by somebody who’s usually in a junior role, from a different background to that particular leader. So firstly, we need people to practice compassion and inclusivity as we said Michael. I believe with an open mind and an honest heart, and that is absolutely critical in any kind of mentoring, reverse mentoring relationship.  

Michael West [00:28:18] You had a reverse mentoring relationship with Sir Simon Stevens, who was then head of NHS England. How did that go?  

Dr Habib Naqvi [00:28:28] I was fortunate enough to have a reverse mentoring relationship with Simon and that kind of relationship still continues, which I’m very honoured and fortunate to have. I think Simon, without getting into the details of the reverse mentoring, is a different kind of leader to any other leader that I’ve known. If you just look at his approach to race equality and his approach to inclusion, he came into his role as chief executive of the NHS by talking about racial equality and the importance of inclusion, and he left his role as chief executive of the NHS by setting up the NHS Race and Health Observatory. And between those two milestones was absolutely pivotal in highlighting the issues and doing something about issues around racial discrimination. But we need people to be genuine and to implement these values, just as Simon has done, because we want people to not just focus on this agenda because they have to, but because they want to. And that is absolutely critical when we look at the issues around inclusion, the strategies around diversity and compassion and those concepts, self-awareness, the awareness of others in that reciprocal relationship is absolutely critical. Listening to others in a way that I believe does two things firstly, increases your own understanding of others’ perspectives and secondly leads you to implement in a practical way what you have heard. Now those are the fundamental principles of good mentoring and good reciprocal mentoring and practical impact that actually changes the way you think and the way you do things on a day-to-day basis.  

Michael West [00:30:35] So I think, you know, we’ve had The workforce race equality standard and you played a key role in developing that and then directing the workforce race equality standard. And there was a sense, I think, and there has been of late that sometimes people are very good at putting in place organisational policies and procedures, and it doesn’t lead to any change that somehow the change we need has to be also in people’s day to day experiences in their work teams and that that’s the responsibility of every single person in health services. And it’s not just about, you know, a select group of allies or a select group of leaders that somehow everyone who works in the NHS. I mean, we can take this to wider society. But everyone who works in the NHS has a responsibility for creating an inclusive culture, and that means that everybody has to work harder with everyone that they see as somehow other work harder in the sense of being more present, seeking to understand listening more deeply, being empathic and asking how to help so that it’s not just some passive process that we think, Oh, I hope things get better over time, that each of us, every interaction by every one of us, every day, it seems to me, is an opportunity to create a more inclusive culture in terms of how compassionate we are. And that’s what I draw from what you’re saying.  

Dr Habib Naqvi [00:31:59] Yeah, I would absolutely agree with that. We know that in the NHS, changing some of the operational procedures, whether that’s has to do with recruitment or whether that’s to do with disciplinary processes or whether that’s to do with continued professional development opportunities, etc. Those will kind of have a limited impact, but we also know that changing those processes and those metrics does not necessarily mean that the culture of an organisation also changes in a positive way. And that’s the kind of the picture I think that we’re getting from programmes such as workforce race equality standard. And so therefore, we need to focus as much on culture and issues around compassion and inclusivity as we do in terms of the operational processes that we use on a day-to-day basis within our workplaces. But learning from others, as you say, Michael, and learning from ourselves is absolutely critical. You know, making the changes you need to make on a day-to-day basis to improve. Because for me, you know, there’s no end point to this being compassionate. being inclusive is a journey of continuous learning and exploration. And so there is no endpoint. We need to be on that journey, but we need to be respectful also of where people are at different points on that journey.  

Michael West [00:33:36] So I kind of have five questions that I think every organisation should ask itself.  

Are equality and inclusion, vision and values, a robust part of the leadership strategy for your organisation.  

Do all leaders and leadership groups have agreed goals around developing positively diverse and inclusive leadership?  

Do all leaders, model inclusion for all team members, patient service users and all they interact with, I think we should be measuring compassionate and inclusive leadership at every level.  

Are all leaders involved in QI projects in relation to equality and equity and inclusion, and  do all leaders demonstrate compassionate and inclusive behaviour in their teams and in their relationships with other teams and departments? So, you know, I think those are kind of questions that get to. Are we incorporating this into the DNA of our organisations and our leadership? One of the key questions you and I have discussed over many years and we come back to it again and again is where are the good examples of where this is already beginning to happen, that we can learn from that give people hope and inspiration?  

Dr Habib Naqvi [00:34:55] So I think there are good examples around not just within the health care sector, but beyond as well. And these are examples where if you think about teams, teams that value diverse voices have a level of clarity in terms of their goals and direction of travel that have some of those objectives that you mentioned, Michael, and not just have these objectives, but have a level of feedback on how well individuals are doing on those objectives are kind of examples of good practice, common purpose, common goal. Common goals that are articulated consistently and as a leader of a team myself, that’s something that I try to check with myself on a regular basis. But also taking regular time out and having those strong team values that are agreed upon in the NHS Race and Health Observatory. One of the first things we did within the team and with our board was to establish our own values. And we came to five values that we hold very close to everything that we do within the observatory. Those are the values of independence, objectivity, integrity, collaboration and effectiveness. But we are absolutely committed to those values as an organisation and as a team. So having a common purpose is absolutely critical for the success of any kind of intervention or any programme or any team or any organisation that you need. The other thing that I think it’s important here, Michael, is not to have a level of concrete structured hierarchy within teams or within leadership. A leader should not dominate, but should instead support and facilitate the development of others. Give others opportunities to grow and to flourish within the workplace. Give them opportunities to develop, to create fair and just cultures within the team or within the organisation. And in order to do that, you have to be self-reflective. You have to acknowledge that actually as a leader, you are not the finished product. You always have to learn and you always need to and want to do better for yourself.  

Michael West [00:37:45] So in terms of what we can do within organisations to achieve change, one of the concepts that I’ve heard a lot about is Allyship. Can you say a bit about what that means in theory and in practice?  

Dr Habib Naqvi [00:37:57] I think, Michael, allyship is absolutely critical as we move towards building a more inclusive, fair and just society, not just organisation, but society as a whole. We knew that doing more of the same will no longer suffice. And this should not be a reset moment for us as we come out, for example, through the pandemic, but a complete refresh moment for us. And what we need are people to practice compassion. We need people to practice inclusivity. We need genuine concern for each other. And as we mentioned, that allyship is absolutely critical listening to others in a way that increases your own understanding and other’s understanding of difference leads to better outcomes for everyone and including on the on the metrics and the measures that you’ve done a lot of work on yourself, Michael, in terms of staff engagement when it comes to organisations better outcomes for the people that we’re serving better, kind of, organisational efficiency at the same time. So allyship has so many benefits, but it has to be carried out, as I said before, with an open mind and an honest heart.   

Michael [00:39:24] Our friends Safina Nadeem who has done a lot of work in developing greater inclusion and equity, and across the health service talks about five important elements in allyship she talks about listen with fascination to perspectives different from yours. And be open to learning about the barriers that people face. And I’m one of those that I always reflect on is, you know, we know that people from minority ethnic groups, for example, are often not given challenging projects. And so they’re prevented invisibly, almost certainly from developing new skills. So part of recognising those barriers is ensuring that everybody, particularly people who’ve been held back, have opportunity to take on challenging projects with support, of course. The third is owning your privilege and using it to make the change you want to see, knowing that you have a privilege and then helping to make change and amplifying the voice of underrepresented groups at every opportunity with their permission. And that might mean challenging inappropriate behaviours, for example, in meetings little subtle acts of discrimination. Because when somebody from like a majority group like me, a white male speaks up when somebody says something that is discriminatory, it’s more powerful than sometimes those from those groups that are discriminated against. And the last one, she says, is about creating safe spaces for people to share their lived experiences. And so those, I think, are useful pointers to allyship as well.  

Dr Habib Naqvi [00:41:06] I think that’s absolutely right, Michael. And, I always say that this agenda when we talk about race or any other protected characteristic. Yeah, it should not be the burden for those that are most affected by it. Everyone has a role and everybody must have a role to close down the gap between the promise of our ideals and the reality of our time and the reality of our time is the levels of stratification in outcomes of access and experience that we see day in, day out. So the concepts of respect, civility, compassion between people, understanding and acknowledging the issues and struggles of others is absolutely critical and educating ourselves around discrimination and its impact is critical to that. It does remind me of a quote from J.R.R. Tolkien, which goes something on the lines of “all we have to decide is what to do with the time that is given to us”. And I personally believe that those individuals that spend their time on making sure that we have a more fair, just and compassionate world are spending their time wisely. 

Michael West [00:42:27] And benefiting from that time as well in terms of their own well-being and their own sense of meaning and purpose. We feel hugely passionately about this issue, and I think most people want to help create a better society. So what’s maybe the one or two things that those listening to this podcast could go and do that will make a difference?  

Dr Habib Naqvi [00:42:50] I think the first of the most critical thing to do is to self reflect about ourselves, look at where we are on the journey of inclusion and compassion, identify what is it that we can do to move forward on this journey because this is critical not just for ourselves, but essentially and very importantly, for others. So making sure that we can actually understand where we are is a very good first step in order to shift that dial of inequality that we see in society and to ensure that our own moral compass is pointing in the right direction.  

Michael West [00:43:37] So values, that principle is, I think, really important. You know what we value means what’s important to us and the NHS was created with, I think, two founding values compassion and inclusion. It was created with the commitment to provide high quality free care for everyone who needs it, regardless of their skin colour, their age, their gender professional background, what class? It was set up as a compassionate and inclusive system. And in a way, I think the NHS must be a model for the rest of society. I always think, you know, if the 1.3, 1.4 million who work in the NHS come into work every day and encounter increasingly compassionate and inclusive cultures, then they take that back out into their families and their communities. And if all the people who use NHS services, I think it’s something like a million people every 36 hours. If they encounter compassionate, inclusive cultures, then they too take that back out into their families and their communities. And it’s clear to me you’ve done an enormous amount over your career of changing cultures across the whole of the NHS, and I think you’ve had a huge impact also therefore in raising awareness and changing the culture of our society. And it’s been a huge privilege to work with you over the years and just a delight to have this conversation with you this morning. So a huge thank you Habib.   

Dr Habib Naqvi [00:45:07] Thank you so much, Michael, it was an absolute pleasure as it always is to speak with yourself. 

Paul O’Neill [00:45:16] I hope you enjoyed this conversation. Please look out for others in this mini-series and subscribe to the Leadership Lessons collection for more content like this.  

Episode 6: The importance of compassion in developing leaders

Transcript

Paul O’Neill [00:00:01] Hello and welcome to leadership listeners curated podcasts for leaders in health care. My name is Paul O’Neill, head of strategy, research and development at the NHS Leadership Academy, part of the People Directorate of NHS England and Improvement. This mini-series of podcasts as part of Leadership Listens, is a series all about compassionate leadership. It’s a collection of conversations between Professor Michael West and a leader from the health and care sector. This recording is a conversation between Michael and Caroline Chipperfield, director of leadership development and delivery at the NHS Leadership Academy, and focuses on the importance of compassion in developing leaders now for the future at a national level.  

 

Michael West So a warm welcome to these conversations about leadership in health services, and I feel really pleased to welcome Caroline Chipperfield, director of leadership development and delivery at the Leadership Academy. Caroline and I are old friends and colleagues, and we’ve seen many changes in the leadership landscape in the NHS. It’s lovely to be with you again, Caroline.  

 

Caroline Chipperfield [00:01:17] Lovely to be with you, Michael. Thank you. Thank you for the invite.  

 

Michael West [00:01:21] So you, you’re director of leadership, development and delivery for our amazing National Health Service, for this huge sector, a new leader on the delivery and marketing and the engagement of the NHS Leadership Academy flagship programmes. And it’s currently worth just saying a bit about those programmes so that people are aware of what they are. I mean, they’ve been going for a few years now, but they’re really prestigious, powerful development programmes for people in the NHS.  

 

Caroline Chipperfield [00:01:52] They are, and of course, I’ve got a complete bias on that, Michael, that I think that they are amazing, but the feedback we get from our participants is absolutely amazing. And it is a privilege to actually be able to be the director of the flagship programmes, which started online foundational level. And you know, Edward Jenner right through to our aspiring chief execs through to our aspiring directors. And really, they build on a philosophy around self-managed learning, but a philosophy of inclusive, compassionate leadership styles. We want leaders to create the climates where people will thrive, not survive within their organisation. And we know that it makes a huge difference from the testimonials that we get from our programmes. And interestingly, as I was coming in and preparing for today, was thinking about our online programme. We were closed down during COVID. So the 20th of March 2020, I was asked to find some volunteers to support the bringing back staff, and the academy was literally closed down over a weekend. I was asked to find 35 people to volunteer, 100 turned up on the Monday. And so the commitment of our academy to that, but the programmes are shut down and interestingly, our long line one, which historically would be 2,000 to 3,000 people that would enroll on it by the end of 2020, 20,000 people had enrolled in it. That found us in any case, and people believed that leadership was as important, if more important than ever, going through the crisis of the pandemic. So actually, we’ve turned things back on. We’ve turned them on virtually they’re far more accessible for people now. But the philosophy around developing inclusive, compassionate leaders, which means that our NHS staff and health and care staff actually can really be looked after has been really, really critical.  

 

Michael West [00:03:45] And the evolution of those programmes has been remarkable. I meet people regularly who talk to me about, for example, doing the Elizabeth Garrett Anderson programme or the Nye Bevan programme, and I often hear people say it changed my life. It’s not just that it changed, in a sense, their approach to leadership to be more inclusive and compassionate, but it changed their life. And I guess what it implies is leadership is maybe as much about a way of being as it is about the doing or a set of skills that we add on. And compassionate and inclusive leadership is now the core of the people plan in the NHS and you and I have, I suppose, involved with the evolution of our understanding about what makes for effective and compassionate and inclusive leadership. Listening to staff, seeking to understand the challenges they face. Empathising with them, caring with them for them and then helping them to do their jobs more effectively. But one of the, I think, reactions of some people to the idea of compassionate leadership is that it all sounds a bit soft cushions and scented candles. You know, how do we then manage difficult people in poor performance?  

 

Caroline Chipperfield [00:05:04] I think it’s definitely not the soft and fluffy to be compassionate and inclusive. So for me and part of our learning together, actually over the last 10 years and more, around sort of developing this style of leadership is that actually it’s having those difficult conversations, actually doing it with, as you say, listening with fascination but listening to people and helping to really hear them empathise with them. And actually sometimes challenge those behaviours and those performance issues. Actually, it’s more compassionate to do that. And often senior leaders will say to me that, you know, I don’t get the feedback. I don’t know what my impact is. And actually, if we don’t give sometimes the more challenging feedback which is very compassionate, then people don’t know their impact and intent on others. So people will carry on for many years, behaving in a way that’s actually completely unacceptable by today’s standards or any standards. But because they’ve never had that feedback, because people for whatever reason haven’t given it to them, then they can’t change. And sometimes people are shocked. So I’ve often used “talk about don’t make a judgement, ask a question.” So how might that have landed with somebody, you know, so actually seeking to understand them as you talk about a lot? Michael, in terms of that, but seeking first to understand why that might be the case, but actually, it’s not fluffy at all. It’s actually quite challenging, particularly when people are more senior than yourselves and you’re trying to give that feedback. But it comes from a place of compassion.  

 

Michael West [00:06:44] Very often we don’t give feedback. I mean, I think that we don’t give enough positive feedback. First of all, we don’t appreciate and say thank to people and actually we human beings consistently underestimate the power of being appreciative and the power of saying thank you, that’s something we all do. So as a consequence, we’re less appreciative overtly than we could be. But also then, it makes it easier to give that clear feedback about behaviour that perhaps has been negative, difficult, problematic. And also the point about understanding, I think, is that behaviour is usually more often a consequence of the situation people find themselves in, rather than some mythical personality defect. So taking the time to seek to understand feels really hugely important. And I’ve certainly come across many situations where people have no idea that their behaviour was having a negative impact on those around them. So I guess what I understand you to say is that actually it takes more courage to be compassionate and to have the courage to be direct about the feedback that we give in the context of being generally appreciative.  

 

Caroline Chipperfield [00:07:59] Absolutely. And it is a leadership piece to take that courage to take that step forward, to be perhaps curious in that way of understanding how that behaviour has come through. And I was interested; part of reading some of the work that you’ve done, Michael. One question for you. You talked about it’s not the people are difficult. Sometimes it’s their behaviours and, sort of, how do we really start to build on that so that we can not de-personalise it, but be able to give really clear examples of the behaviours and therefore take a positive approach to those conversations when you go into them? And the experiences that you’ve shared on that I thought was very insightful because sometimes I know myself as a leader and going into difficult conversations, you want to avoid, sort of, thinking about the person.  

 

Michael West [00:08:52] So your focus on behaviour rather than people, it mirrors what we understand from psychology. It’s called the fundamental attribution error that we tend to attribute people’s behaviour to them as people rather than to the situation they find themselves in. But it’s usually the situation that determines behaviour. It’s also, I think, from my perspective compassion is inclusive leadership is how we achieve a collective leadership. It’s not just about changing individuals, but how our leadership is consistent across our teams and organisations. And I think that’s a real challenge. So we often end up as it were converting the converted or preaching to the converted.  

 

Caroline Chipperfield [00:09:32] Yes, Michael. And the importance of teams was loud and clear in our 2020 leadership survey that we did – where at the top of literally the top of everything that leaders want is how do they manage their teams effectively? How do they lead effectively? How do they build their teams? So it’s absolutely critical because the evidence is showing us that people want to be able to do it differently. So I think it’s really important that we help build that confidence to develop those teams to make the difference within the health and care system.  

 

Michel West [00:10:04] How do we achieve a more collective leadership?  

 

Caroline Chipperfield [00:10:07] So it’s such a great question because change happens, doesn’t it? That one conversation at a time. But actually, we all need to sign up to the shared purpose that this is going to make a difference, and I think the standards that we walk past of the standards that we set. So I think collectively we can start to think about doing things differently. I think importantly, we at the leadership academy as part of the People Directorate, really thinking about the standards that we set from behavioural perspective. So we talk about the heart, the head in the hands of our leadership way. What do I mean by that? So we set those standards. The heart is all about compassion. So how do you really think compassionately, act compassionately as a leader? The head is, how do you remain curious? So how do you seek to understand? How do you ask questions, not make judgements? And then with our hands, how do we collaborate? How do we do things together? Build that trust, that motivation? That’s really, really key. So I think there’s something about how we build that together. Collectively, we set that behavioural, if you like, standard for want of a better word. But actually, then when it’s not happening, how do we have the courage to call it and call those behaviours? And that starts to really set climates are very, very different to what we’ve got, but the leadership will be key. So that needs to go from board to ward, as we’ve often said, in terms of hospital or from any part of the health and care system. But the senior leaders need to walk the walk as well as talk the talk. So for me, the value base of the NHS Constitution, the behaviours that we set, we know people come to work in the NHS, from a social justice perspective, from a values perspective. They come because they want to do good. And so therefore connecting to the values will start to shift. I believe the climate and build those compassionate, inclusive climates. Because without that and without that collective achievement, we will not see the change that we need to see across the health and care system.  

 

Michael West [00:12:16] And so the evidence we have from research on organisational culture over the last hundred years tells us that leadership is probably the most important intervention or the lever that we have to help change culture. Although every interaction by every one of us every day is an opportunity to shape culture through how warm or kind or irritable or cynical or compassionate we are. But for me, another issue is that I think that our institutions also need to model compassion. So when we look at, for example, national organisations like NHS England and NHS Improvement, Health Education in England and our NHS trusts, it seems to me that needs to be also the kind of awakening of intent that is institutions we should be attending, seeking to understand, empathising and then seeking to help the other organisations and institutions we interact with, rather than being seen as top down control in monitoring, criticising and so on. So I suppose it’s exploring the notion of what institutional compassion would look like within our healthcare system.  

 

Caroline Chipperfield [00:13:30] Absolutely. And it has to be for everybody, doesn’t it? People have to say that it’s their role, well, every level within any organisation. And for me, the data isn’t showing that we’re compassionate. Many occasions we talk about the staff survey, it’s all in the public domain. We know that people do not feel as though they belong within many of the organisations. So how can we use that data to change for the better? So when we know it’s happening, when we’ve got to focus on it? So how do it every level? Do we talk about behaviours? So for me, it would be instigating all through my organisation if it was me. In terms of appraisals, we often look at the technical side and we assess people on the technical side of their work, but we don’t always assess them on the behavioural side of their work. So why can’t we change that conversation that starts with not what you did, but how you did it? And when you start to have that conversation, then you get a very different conversation as part of your institution. Some of the organisations that I’ve seen that do this amazingly well do it on value based. I would use Frimley as an organisation that I work closely with. Everything is about the values and about how they get feedback from their staff, from their patients and the service users. They start every board meeting with a staff story or a patient story. Let’s bring it to life, let’s talk about the people. If people are truly our most important asset, then let’s talk about them first. Not the money, not the quality. Because if the people are doing the right things and doing the right things well, everything else follows, in my view. So you have to change what gets focussed on gets done. So if you focus on the numbers, that’s what people talk about. But if you focus on the people, you make a huge difference as an organisation and you do that at every level. And there’s some tools that we’ve got there, like an appraisal that we can use very, very differently if we just switch it. So for me, it would be saying talk about the behaviours and how you did things, not just the what that you’ve done, because technically we’ve got some of the most highly skilled people, in my view, in the world working across the NHS in England and Wales and Scotland, Northern Ireland, our four nations we’ve got amazing people. So let’s focus on some of the positives that they do, build on a strength based approach to it and take the conversation in a very, very different way. That’s what I think collectively and institutionally you start to change it. So it’s not just one or two people talking about it being the right thing to do. It becomes the right thing to do because that is the way that is around here. You set the culture, you set the climate because you’re talking about your people and then you get less stress, you get less workplace stress, you get less absenteeism and presenteeism. And we see a lot of that, too. So how you start to shift the dial on your data, but you do it through and with your people, of course, we’re public sector, of course, we’ve got to have value for money. Of course, we can have high quality care. But my view is where does the conversation start? And if the conversation starts with our people and the behaviours, then I think that’s what shifts it culturally within the institutions. 

 

Michael West [00:16:49] and that focus. Seems to me is fundamental because organisations, work organisations, hospitals, mental health units. Or simply another form of human community. And I think when we see them in that light, it changes the way we think about how to nurture enabling cultures. And it does seem to me important to acknowledge where we are in our health services. You know, we’ve, as you say, probably got the largest, most motivated and most skilled workforce in the whole of industry. Yet the sad reality back in 2019 was over 40 percent of them had been unwell as a result of work stress in the previous year, according to the national staff survey, and one in four nurses were leaving the NHS within three years of joining. And they were very high levels of intention to quit. GPs have been quitting. We’ve been unable to increase the number of general practitioners, and absenteeism, of course, has been running quite hot.  

 

Caroline Chipperfield [00:17:55] I completely agree. I mean, the moral distress that colleagues have had over the last couple of years and the increase in work related stress due to the pandemic. I don’t think the survey is going to show it any better when it’s publicised later in the year. Part of my focus of the last couple of years is to be really mindful about asking leaders and each other, team members, to spot the signs of stress, you know, within each other within self. We’ve done some work on health and wellbeing and how you might be able to just by focussing on it, acknowledging the stress, being able to walk away sometimes from the situation. I mean, you will have heard as well as I, the stories on PPE, particularly the early days of the pandemic, but also the fact that people couldn’t see their loved ones and or couldn’t be with their loved ones for births. For deaths and the stress that that put on our health and care system cannot be underestimated. So the piece for me around being able to psychologically put people in a better place. So thinking about recovery, whether it works for you, for going for an outdoor walk, so that’s my bag. You know, I need to go out and walk the hills and sort of relax and get away from things, whether it’s yoga, whatever it might be for individuals. But, how do we make sure as a team, we talk about health and wellbeing? So I think it’s really important at team meetings that you check in. So what do I mean by a check in? I mean, literally checking into that meeting, how are you today? How are you feeling? What are you bringing? What do you need from each other within the team in which you’re working will really help to support that workplace stress and know that it’s OK not to be OK. I think that that’s been really, really important messages over the last couple of years that people have heard and we have seen a massive increase, haven’t we, in mental health issues over the last couple of years, but actually people talking about it in a way that they’ve never talked about it before. It’s been really, really important because it is okay not to be OK in a global pandemic, looking after loved ones and not forgetting that the workforce and the NHS workforce and social care workforce are also patients and service users themselves over the last couple of years. So some of the absenteeism is because people have been ill themselves. So there is something about acknowledging that, but in a way that is really value based, that is compassionate, that is inclusive. We’ve learnt so much, haven’t we, in terms of inclusion in the last couple of years, the disproportionate impact of COVID on colleagues from black Asian minority ethnic backgrounds, that whole stress anxiety within the workplace, how people have felt been treated. We have to be able to acknowledge that that’s OK, but also that there is help and support available. And that’s been a lot of our work putting people into health and wellbeing spaces, psychologically safe spaces to have a conversations at every level. So senior leaders working to that as well.  

 

Michael West [00:21:11] So that I think has been hugely important in raising awareness of the wellbeing of staff. And it’s important also not only in and of itself, but because we know that there is a direct link between staff wellbeing, staff engagement and patient outcomes, care quality, actually financial performance, avoidable patient mortality and so on. And I think that it’s been hugely important this last two years how we’ve each managed to take care of ourselves. I’ve been, I suppose, even more focussed on ensuring my wellbeing so I can do my work effectively. I practice meditation every day. I have done all my adult life. It’s a really important part of my life. I go for cycles in the countryside, spend time in the country my wife and I have had far more time together this last two years and that sense of spending lovely time with people you love and who love you is so nourishing as well. And also, I suppose from the work I’ve been involved with, I’ve become much more aware of the danger of focussing our reaction to the difficulties staff face primarily on health and wellbeing programmes that are about things like yoga and meditation and mindfulness and exercise and spending time in nature, but not really addressing the workplace factors that are creating the difficulties in the first place. And as you know, I had the privilege four years ago now of co-chairing an enquiry with the late Dame Denise Coyne wonderful, wonderful person, an independent enquiry on behalf of the GMC into the mental health and wellbeing of doctors and medical students. And then, two years ago, an enquiry commissioned by the Royal College of Nursing Foundation into the mental health and wellbeing of doctors and midwives. That was with colleagues in the King’s Fund. And what was clear from all of the research we reviewed and the conversations and focus groups was that people were suffering because we were not getting the work conditions right, so people didn’t feel they had voice and influence. I mean, we called it the ABC of core work needs autonomy and control, belonging and contribution or competence. And what we had was people didn’t feel they had voice and influence. They felt they were working often in climates of fear and blame. Rather than learning. They couldn’t even control some biological needs getting access to water when they were working, or nutritious food, on night shifts or having time to go to the toilet or being able to influence work schedules and rotas so they could balance home and work lives. So voice and influence or autonomy and control, if you like, was a huge issue and does feel that our leadership in the future has to be a leadership which is focussed on creating more collective leadership where people feel they have leadership, responsibility and control.  

 

Caroline Chipperfield [00:24:13] Absolutely. And you touched on something that’s really close to my heart as well, Michael, who in terms of having a voice. We talk about freedom to speak up across our workplace and actually in the past year, having freedom to speak up Guardian’s that are non-Execs within all of our organisations. So how do you really give voice to how do you again create that climate collectively that people can speak up without fear of retribution and blame? And again, you’ve got to create the climate for that because the moment that it happens and somebody does speak up and then the behaviour is the traditional behaviour of, well, actually, they’re just sort of cover it up, then that’s not how it works. You’ve got to be able to say, we’ve got this wrong, you’ve got to be able to publicly say, we haven’t quite got this right. Let’s collectively, as you say, get the autonomy to do it together. You know, that sense of belonging and teamwork and teaming really sets for me the culture and the leadership, that sense of belonging. And if people don’t feel as though they belong, that they will leave, you talked about the nurses leaving within three years of their career. We’ve got to be able to not have that and retain people, and that’s so important collectively to do that.  

 

Michael West [00:25:27] So that, I think is about making sure we’re meeting people’s core needs. The importance of teams in health care is it’s kind of almost taken for granted good. Yet we know there’s a lot of work to do to really develop effective team working and to develop more effective leadership are their creative ways of thinking about all of that?  

 

Caroline Chipperfield [00:25:47] So I think there’s been some great examples of how you might think about it differently. Often people see perhaps the programmes that we put on from a leadership academy perspective are seen as individuals. One of our system leaders took her 500, if you will, 500 leaders, so people who are new to leadership roles are getting a foundation in leadership in which they can do online and anybody can do. And then newly appointed line managers took them through the first line management all Mary Seacole programme. Then the middle managers were taken through the Rosalind Franklin programme in teams, and then the aspiring and senior leaders went on their own leadership programme as well, and at each level did it in teams. So all 500, if you like, within a system taken through, but not as individuals, but as teams, I think that is hugely innovative. But I also think it made a huge difference to the way that that system now runs. And I believe that if we took that approach, of course, with integrated care systems, working with our senior leaders to be able to develop each of their 500 leaders, maybe more than that, but how might we do that at every level within the health and care system fundamentally shifts it as teaming and team ways of working, not just about individual learning  

 

Michael West [00:27:12] to create a team in ecosystem for growth? I think your point about team working is really important. How do we build more effective teamwork in the data we have suggests that only about 40 percent of staff working teams with clear goals that meet regularly. And yet all of the evidence we have is the more people who do work in such teams, the better the care quality, patient satisfaction, lower levels of stress, better financial performance, dramatically lower levels of avoidable patient deaths. But we have to develop that team base working. We have to really focus on developing compassionate leadership that nurtures effective team working. I think we also have to have the courage to start addressing the hierarchical nature of the NHS. The most effective organisations in the world, regardless of size or sector, usually have no more than three or four reporting levels. You know, when you look at the typical NHS Trust, reporting levels are in double figures. And I was reading a paper recently suggesting that every reporting level you add, that’s about 10 percent to bureaucracy. So I think there’s something for the future. How do we transform our teams and organisations for the future, how we create more collective, compassionate leadership of developing supportive team working? And I was really struck by the 2020 staff survey showing that the main factor in helping staff cope during that first year of the pandemic was their colleagues and their teams. So there’s something about developing really effective team working, but also having the courage to say, we’ve got to reduce all of this hierarchy in the system. It’s just oppressive. It’s not helpful. It disempowers people. I think that’s a really tough challenge, but I think it’s one we have to face.  

 

Caroline Chipperfield [00:28:56] We absolutely do. And I think in terms of developing teams, obviously, and the leadership role, inclusively developing and compassionately developing the teams where you create those cultures that people can speak up within the team that can speak up within the organisation really transforms it. Some of the examples that I’ve seen during COVID, actually when people who’d never met each other, ever came together for a collective endeavour. They were given the autonomy to move through that work. They cut out so much of the bureaucracy in terms of levels of permission, shall we say, that actually achieved some of the amazing stuff. So the volunteers bringing back staff into the NHS, the teams that were put in and they were doing it in majority virtually. So have never met each other and maybe still have never met each other, but we learnt to build teams in a virtual way. We learnt to have a clear goal and purpose given the autonomy and people just went. I mean, I just saw some amazing work by every level within our organisation, and these were people that that’s not what they came in to do. They came in to do leadership development, but what they did was they led teams because they knew how to lead teams. Yes. So and they did it in a way that built that trust that relationship, which meant that people can make decisions and were left able to make the right decisions. I am really hopeful on the ICS, ICB world. It’s been a horrendous couple of years. Let’s not underestimate what we’ve been through, but let’s take some of the good of that of how if you get autonomy to be able to lead across your system, to be able to take out some of that. If you like decision making so you do it collectively for the benefit of your population health, so you’ve got a common goal and you’re not competing against organisations aren’t competing against each other, they’re collectively working together. So then you build teams at every single level, in my view.  

 

Michael West [00:30:53] So, Caroline, I agree. I think integrated care systems are a really important step towards much more community ownership and community involvement in our health and care services and working across boundaries. I think many people still don’t know really what integrated care systems are. They sound like abstract concepts of organisations. Can you say this about what it means?  

 

Caroline Chipperfield [00:31:17] Yes, of course. And I’ve been privileged to be part of if you like some of the recruitment to some of the integrated care boards. So our ambition with the NHS Bill and Health and Care Bill is to be able to ask the system when I talk about the system. So it will be the collective of the organisations within a defined geographical area that will be given the, if you like, the statutory responsibility to look after the population health within that area. So we will develop two things really. An integrated care board, which will be predominantly around NHS organisations that will be within that, that will look at commissioning standard. Quality of care and workforce and leadership of that system. And then they will work collectively with all of the other partners in the integrated care system. So health and care voluntary sector for  

 

Michael West [00:32:14] local authorities,  

 

Caroline Chipperfield  [00:32:14] local authority. So anybody that has an interest in health and health care will be part of that. So they collectively look at perhaps three or four things that only they could look out for me. System perspective to be able to really drive change across that place or that system so that they have the autonomy and you have a sense of belonging in terms if you belong to those more locally defined systems. And then they find their own contributions. Also, they define their workload. They define things that they will bring in. So within that, we can make the change happen.  

 

Michael West [00:32:54] So it’s a kind of vision for the future of having all of the agencies, voluntary sector, community agencies, health care, social care, working together to nurture the health and well-being and happiness and fulfilment of the populations in their area.  

 

Caroline Chipperfield [00:33:11] Absolutely. You put that so beautifully, Michael.  

 

Michael West [00:33:15] It seems to me a really powerful and promising vision. I think the area that worries me, most of all in terms of our staff, their well-being. And it may be that integrated care systems are part of the solution is the problem of chronic work overload or chronic excessive workload. And I think it’s a bit like the pattern on the wallpaper we no longer see. And some of the conversations we’ve had in these podcasts have really brought to the fore just how much pressure people are under and how utterly damaging it is. And we know that chronic work overload is the number one factor in staff stress the number one reason why people quit, whether it’s primary care or secondary care. You know, we know from the research it has a huge impact on staff health, on cardiovascular disease, on addictions, alcoholism, cancer, diabetes, depression and I do feel that somehow leaders don’t talk about work overload. It’s almost as though there’s a fear about talking about chronic excessive workload because we don’t have the solutions. I think that’s a mistake. You know, that’s not the role of it is necessarily to have solutions, but it is to bring our attention to bear on the most difficult problems we face. So over the last four years, I’ve, first of all, have the privilege of being involved in co-chairing an independent enquiry with the late Dame Denise Correa. Wonderful woman. We undertook this enquiry on behalf of the General Medical Council into the health and wellbeing of doctors and medical students. And then two years later, leading the enquiry commissioned by the Royal College of Nursing Foundation, along with my colleagues in the King’s Fund, into the mental health and wellbeing of nurses and midwives across the UK. And then the pandemic came along with all of the associated increases in work demands in the fears that staff had for their lives and the lives of their patients, the lives of their loved ones. And we’ve seen a big increase in staff stress over the last two years. And I find it personally harrowing to talk to staff very often because the stories I hear are so painful to hear what staff are going through. It does feel to me that leadership individually and collectively must be focussed on that issue. And chronic excessive workload has such an impact on staff wellbeing on their lives, but also on patient safety, patient satisfaction, care quality. And I feel that people are really reluctant to talk about it in the NHS because they don’t have solutions, but I think we must talk about it.  

 

Caroline Chipperfield [00:35:54] We need to make it part of our everyday conversation, don’t we? We know that some of the staff ratios and particularly through the pandemic, has not been right. The nursing ratios and the workload has become hugely excessive actually, even more so. So I was talking to a nurse actually only a few weeks ago around sort of that four days, 12 hour shifts. They used to be able to perhaps get some additional incomes through banking and doing an extra shift here and there. But they’re exhausted. They’re so tired that they’re not able to physically do any additional shifts because of the workload and not the hours, but the amount of work. So there’s something about hours worked as well as the workload within those hours. And how do we get to a place where people can start to discuss the workload, start to set what are reasonable workloads within that and start to address that as a team? And collectively, why can’t teams start to think about or what should be our workload? What should be a working pattern? How do we take responsibility and accountability for the rotas that we set and do it in a way that’s going to be manageable for a particular part of the health and care system. So from GPs intensive care units, you know, we’ve got to be able to start to have a different conversation and use again some of the ways of working that we’ve learnt that can be more efficient. So I heard that people didn’t like having the face to face over Skype with their GPs, so I was poorly. It wasn’t COVID, but I was quite ill a couple of weeks ago. Eight o’clock, I did an e-consult, so I went online, did what I needed to do. By 9:15, I had a telephone call. By 11:00 o’clock, I was seen. So there’s something about actually the diagnosis was done, whether or not I needed to be seen online. So how can we use some of those ways of working? Our people promised talks about being able to work flexibly and be able to have manageable workloads and have good goals at work. So if you go back to setting your objective, setting your workloads, doing that as a team and then having the courage if we come back to courage to push back, if the workloads aren’t right because of ways of working, have to change first to be able to deliver the health and health care that our population deserves to the standard that it deserves.  

 

Michael West [00:38:17] Absolutely. And I think that those conversations should happen in teams, as you suggest. I think every executive team meeting and every board meeting, there should be conversations about workload, given its significance in the landscape of health care, that every appraisal should be a conversation about workload. And that means leaders having the courage to have those conversations at every level and continue to have them because we’ve just neglected this issue year on year on year on year with huge consequences in terms of patient care, staff, wellbeing, staff turnover and financial performance as well. And so I do think it’s really important we address it. And as you say, the use of new technologies, the use of better team working. East London Foundation Trust, as you know, really outstanding mental health learning Disability Community Services Trust in East London regularly asks its staff what they would reduce or get rid of in their work and staff consult with patients about what they propose to do. And the staff are free to make the decisions themselves, rather than having to be approved by an executive, team members or whatever. And they’ve reduced hugely bureaucracy seeking managerial permissions, certain decisions, unnecessary travel to trust headquarters and eliminated an astonishing 85 percent of clinical audit activities. Because they’ve got this pervasive quality improvement, culture and examples like that give hope for how we can bring about change. But I think the starting place in terms of compassionate leadership is we have to have the courage to start and then keep talking about chronic work overload for staff.  

 

Caroline Chipperfield [00:40:02] Absolutely. And yeah, East London’s done some amazing work and is giving that autonomy to the staff is, as you say, and it’s not difficult, you know, it’s not difficult. It’s really easy to say thank you to somebody. But if you’ve got that quality improvement mindset along with excellent leadership, then you can create magic, anywhere.  

 

Michael West [00:40:26] And the point you made about what we’ve seen during the pandemic is people were given autonomy and the walls, as it were, of organisations came tumbling down and people work together with energy, enthusiasm, supportiveness. And we saw the most extraordinary innovation. I mean, I think some of the themes that you’ve articulated for us about being supportive, about having a vision, about having clear values, about translating that into clear goals, about giving clear performance feedback, you know, creating a sense of direction, aligning people’s efforts around what we need to be doing and building trust and motivation are at the core of effective leadership. I guess I want to ask you two questions to, in a sense, bring all of this together. One is, can you offer one or two examples of places that you see are beginning to get this right? And then what would be your practical tips for leaders in the NHS from all of your experience? What would you ask them to take away? First and foremost.  

 

Caroline Chipperfield [00:41:32] So I think two things where I’ve said it well, I mentioned Frimley early on I work closely with Andrew Morris and now Neil, where they set the values and they give their teams the freedom to operate within set boundaries and people feel that their work is valued. And I think that that gives hope that we know it can be done and we know where there’s reduced variation. People are working collectively together to solve the problems, and I think Frimley is a really good example of that. If I took a national example of that and I would put Emily Lawson as one of my people I have admired over the last two years and how she led the vaccination programme. So from a place of having direction, absolutely clear direction, the vision to vaccinate the population, to reduce the spread of COVID and to reduce the hospital admissions. Everybody knew what they were doing. Everybody knew what they needed to do. Within that. We didn’t know how it was going to work out. We really didn’t because we’d never done this before, but setting the direction, the alignment with clear goals and where people needed to be, what the work force needed to do. And then the amazing commitment of the staff, the volunteers of everybody to do that. The public to get vaccinated meant that as a UK, we have successfully vaccinated a huge amount of people. But that to me, was those organisations like Frimley. And you get it when we need to come together as a country, actually as a world in this case, but particularly I would raise that  

 

Michael West [00:43:14] such a lot of learnings from that vaccination. And your practical recommendation?  

 

Caroline Chipperfield [00:43:19] Some of it is understand self as a leader first. So the only people we can change is ourselves. So unless we understand ourselves as a leader and our impact on others, then I think that’s our starting point. And then we find out perhaps where our strengths are and where our development areas are and we go develop. I believe every day is a school day. I’ve never stopped learning since, you know, I left school or before that. There’s something about our lifelong learning. Just because we become perhaps more successful in our careers doesn’t mean to say we don’t need to learn more of how to lead compassionately, inclusively. Practical hints and tips: Ask for feedback. Don’t wait for it, because if you wait for it, it may never come, and therefore you don’t know your impact on others. Do a 360 if that’s what it takes. In terms of looking at yourself, you can have a 360. You can know your development areas. Take the courage to ask those questions, and if you do ask it, then do something about it. So don’t just listen to the feedback. You have to act on the feedback. And that might mean asking for help in the way that you are leading to do it differently to be inclusive. And then I would take us right back to the behaviours that we need as a practical hint and tip, and to really develop as an inclusive and compassionate leader. You need to lead with compassion through your heart and mean it. You need to lead through curiosity through your head and be able to really ask those questions of self and others and challenge ourselves. And you need to do it collaboratively. That means sometimes rolling up our sleeves, using our hands and actually just getting on with it, whatever our level is. So I think that there’s some know self, start with self because that’s what you can change. You can do it through some practical tools that you can use to find out how you lead. You can ask for that feedback. Don’t wait for it. I think you lead to the behaviours of our leadership way. Therefore, it comes right back to what you and I have talked about for 14 years, Michael, it’s about how do you create the cultures where people can thrive and therefore you act inclusively and compassionately? And you think about everybody. So you take that levelling up agenda it’s not about equality, it’s about equity. So how do you start to make a difference to your population through the way that you behave and lead? But we can only change ourselves, so change has to start with me.  

 

Michael West  [00:45:50] Thank you, Caroline. It’s been a hugely rich, powerful, inspiring, helpful, hugely enjoyable conversation, and it’s been a privilege for me. Thank you very much.  

 

Caroline Chipperfield [00:46:01] Thank you, Michael. Privileges in mind. Thank you.  

 

Paul O’Neill [00:46:09] I hope you enjoyed this conversation. Please look out for others in this mini-series and subscribe to the Leadership Listeners’ Collection for more content like this.  

 

Episode 7: Compassion in primary care

Transcript

Paul O’Neill [00:00:02] Hello and welcome to leadership listens, curated podcasts for leaders in health care. My name is Paul O’Neill, head of strategy, research and development at the NHS Leadership Academy, part of the People Directorate of NHS England and Improvement. This mini-series of podcasts as part of Leadership Listens, is a series all about compassionate leadership. It’s a collection of conversations between Professor Michael West and a leader from the health and care sector. This recording is a conversation between Michael and Dr Rachna Chowla, joint director of Clinical Strategy, King’s Health Partners and a GP at Albion Street Group practice in Rotherhithe. The conversation focuses on compassion and primary care between clinicians and patients between colleagues and underlines the importance of self-compassion.  

 

Michael West [00:01:01] Welcome everybody. My name is Michael West, I’m senior visiting fellow at the King’s Fund and professor of organisational psychology at Lancaster University, and it’s such a privilege and pleasure to be involved in these podcasts, focussing on compassionate leadership. And today it’s a particular pleasure because I’m joined by a friend and colleague and co-worker and fellow traveller in this amazing journey of our lives. Dr. Rachna Chowla. Rachna, a really warm welcome to you.  

 

Rachna Chowla [00:01:33] Thank you, Michael. It’s always a pleasure to be spending time with you.  

 

Michael West [00:01:36] So I must tell listeners a little bit about your enormous experience and varied background. Your joint director of clinical strategy at King’s Health Partners, which is an academic health sciences centre, and you lead on collaborations with primary care and emerging primary care networks with a focus on how we can improve the health well-being fulfilment of local people served by the organisations in that area. You’re also a practising general practitioner at the Albion Street Group practice in Rotherhithe and you’ve been working as a GP for many years, and it’s particularly apposite because today we’re talking about compassionate leadership in primary care. Your clinical lead for clinical effectiveness in southeast London, based in Bexley, also incredibly impressive. You have an MBA from INSEAD, one of the top business schools in the world, and you’re also there, part of the Health Care Management Initiative. You’ve had enormous experience working at, I think, health tech start-up and in strategy in marketing for a large pharmaceutical company in Milan where you learnt Italian and also working with the King’s Fund on compassionate leadership in innovation. And you’ve also done research for the Health Foundation on Innovation in healthcare. So we are in the company of somebody who has an enormously wide range of experience and great richness. So our focus today is on compassionate leadership in primary care, and it does feel really important to begin by just seeking to understand what the context is currently in primary care day to day. What’s it like working in primary care at the moment, both in the context of the pandemic, but, you know, in the years leading up to the pandemic as well, what’s been your experience and what have been your perceptions of the context in primary care?  

 

Rachna Chowla [00:03:34] Thank you, Michael. I think it’s a really important place to start. There’s so much goodwill in primary care. I think I’d start there. We work in small teams most of the time. We have good personal relationships there’s a sense of family, and I think that helps us be cohesive during times of difficulty, which is what the last two years have been in a very acute way. But there’s been a slow drip, drip of difficulty, maybe over the last 10 years or so. Let me talk a little bit about COVID because it was such a difficult time for many of us. But in healthcare, especially, we have to go from seeing our patients face to face to going online or to the telephone literally overnight. And you can imagine that in primary care, we have a bit of a reputation for being slow about taking up technology, but we embraced it and we did it as difficult as it was. But it really signalled the continuous change that we had to manage during that very difficult and unpredictable time. And we did it, but I think it’s taken a toll, sort of this sense of underlying anxiety that was there because of the pandemic. But then you had this additional level of continuously having to change almost from day to day. And there’s this chronic kind of stress and exhaustion that comes from that and then the fear of what was happening to our patients and their families in the midst of the birth of a new disease that we weren’t very sure how to look after at the beginning. So, you know, there’s that diagnostic kind of stress that comes in primary care where you’re trying to do your best, but actually, we didn’t know at the beginning. So there are all of these things. And then I guess on top of that was worries for ourselves because we were in the frontline with this infectious disease. Many of our colleagues did become sick, which then added to the additional pressures. So it’s been really two difficult years. And I think without having at the core what we do enjoy more, I think in primary care is the cohesiveness because we’re smaller teams. It would have been impossible.  

 

Michael West [00:05:42] So the sense of uncertainty in all of this, the anxieties, personal anxieties, the anxieties for patients, the fact that your small teams or small groups of people was a positive but just the overwhelming burden of the pandemic. And I guess seems what’s been really significant in all of this as well is that people sometimes forget that general practice is the first port of call for people with health care problems or health care concerns. So in a way, general practice is the entrance door to the whole of the NHS, and so it places a particular burden, especially in times of crisis. But even before, I imagine.  

 

Rachna Chowla [00:06:23] Yes, and we feel the burden and we also feel the responsibility. You know that the two go hand in hand. And it. Was much more evident during COVID, when in addition to, of course, being the front door to our patients, we were being asked to set up new services in the community to kind of look after patients with COVID that they weren’t mixing with our patients who didn’t have COVID. Normally, it would take us months to create a new service, and we were making things pop up within a matter of weeks. And I think the last few years of sort of highlighting the capacity that we have, there’s a latent capacity that we do have and that we’re able to explore. But I think it’s also highlighted a lot of the gaps. And coming back to your point about being in some ways, the gateway to the NHS. Yes, we are. Of course we are, and we’re happy to be. But perhaps the NHS administrative side doesn’t always represent that, I guess in some ways. So from a funding perspective, for example  

 

Michael West [00:07:28] And how has it affected, do you think GP’s and their well being? I mean, what’s been the personal impact on you of working in primary care over not just the pandemic, but over recent years?  

 

Rachna Chowla [00:07:39] Well, I speak quite honestly and openly about it. It’s something that I have found increasingly difficult. If I look back to when I was a registrar, the job in itself was less complex. And why is that so? I think there are administrative things that happen within primary care that have become more complex. We sort of have a lot of hoops that we need to jump through. You know, you talk about the emotional centres of regulation when it comes to compassion. And I was pondering on the fact that we have QOF (The Quality and Outcomes Framework) and we have all of these continuing targets and we continually in that place of targets and motivation. So that’s one side of it. And then actually patient demand has gone up. We have for demographic reasons and ageing population where problems are now more complex and perhaps some of the support that we used to have in the community isn’t there. So we remain the front door. We’re always open in the same way as A&E is. And so people come wanting support, which we’re not able to always give ourselves or signpost people to. And so we’re always then in sort of this place of firefighting, fight and flight as it were. So putting those two things together, the interactions between a clinician and a patient are just beautiful. When we are there and we’re present and we have time and we can explore and we can listen, there is nothing really better than that. But the context within which that happens can make those moments few and far between. And there’s a moral injury that comes from that. Then there’s the kind of physical exhaustion that comes from most people working 10 to 12 hour days and sometimes painting our days by numbers. So having x number of letters x number of blood test results, x number of appointments, x number of home visits. And it’s just this continuous churn, which when it takes its toll, of course, it does not just on us, but on the interactions that we have with our colleagues, but especially with patients. There’s is much less being it’s doing, doing, doing without drawing breath to reflect.  

 

Michael West [00:09:55] And so I think that paints a very vivid picture for me and I’m sure for others listening. And I’ve been working in primary care doing research over several decades now. And I guess what I’ve observed as well is the continuing increase in pressure. I know that in the last GP working life survey three or four years ago, that GP stress was at the highest level that it had been since the introduction of the GP Working Life Survey in 1998. And of course, then the pandemic struck. And so, in thinking about what we can learn for the future, I mean, there are key issues to do with workforce shortages. I think that we need to address and we need clearly more GPs in the system. We need more paramedics working in primary care. We need more pharmacists working directly with primary care. We need more physiotherapists, more mental health nurses working in primary care to help relieve the burden and to use skills more effectively, I suppose. But you mentioned and you mentioned the importance of the family, the feeling of family in teams. Can you say a bit more about that in terms of how compassionate leadership is or is not important in creating that feeling within the primary health care team?  

 

Rachna Chowla [00:11:14] I think it’s essential the sense of belonging to a place where people care about me, not because of the job that I do, but because of who I am. And the same being for them is essential because our work is around health care and that caring cannot just be one way towards our patients. Of course, there’s a sense of care that also reports out and should ripple out to our colleagues as well. We work in a high stress, high demand kind of environment, and we need those sorts of relationships actually just to get our job done, but also to thrive as much as we can in that sort of setting. And I think there are small things that can help make that happen. It is the way that people behave with one another. It is the Hello, good morning, how are you? Actually, I baked some biscuits there in the corner. Oh, actually, I was a bit short with you. I didn’t mean to be. I’m sorry. This is why it happened and acknowledging that and oh, noticing someone said something and they looked upset. So there’s a sort of paying attention to the relational aspects that I have to be there at the foundation of what’s then the running of a complex organisation? Because I care, of course, can’t and doesn’t just happen inside the consultation room. It’s everywhere. And it really struck me during the pandemic that I think certainly the practice I’ve worked at that was so important it was already there, but we needed to kind of strengthening even more because who wasn’t feeling anxious during COVID? And then you’re working in an environment where we have to make decisions about other people with diagnostic uncertainty. And so that sense of care also adds to the sense of safety and psychological safety as well. So I think it’s absolutely key. It’s sits there at the core of it’s at the heart of it.  

 

Michael West [00:13:15] I remember in one of our research studies in primary care some years ago, now one of the receptionists in a primary care team told one of our research team that they found the senior partner in the practice really difficult because he came in every morning and just walked past the reception desk to his consulting room without ever saying Good morning. And for some reason, this research team member took it upon herself to give that feedback to the GP in confidence. And his reaction, by the way, was, he said, but I had no idea. I had no. He was horrified and they had this call from one of the researchers two weeks later to say, you wouldn’t believe it. He’s coming in every day with biscuits, chocolates, flowers. It’s transformed who he is. So, creating that sense of belonging family psychological safety feels important. But I think, you know, I have a sense from what I’ve observed in some primary care settings is that compassionate leadership is also about being effective and that it’s important that teams have a clear vision of what their purpose is and have a limited number of clear goals. Forget all of the 87, 200, 300 targets that are being imposed, but what are our key goals? And are we meeting regularly as a team to figure out how to work effectively as a team? To what extent in primary care do you feel those basics are in place?  

 

Rachna Chowla [00:14:41] So I think this is also completely key. It’s not just how we are, but absolutely how we work, and we have external targets that are given to us like QOF and CQC inspections and so forth, and these can sometimes become the goal unintentionally.  

 

Michael West [00:15:01] So QOF is the quality outcomes framework that is a structure for helping us focus on how well the outcomes we seek are being achieved in primary care.  

 

Rachna Chowla [00:15:15] And so I don’t think we always engage with the question that you’re asking, which is actually as a practice. How is it that we want to be? What is it that we want to do this year? What didn’t work so well last year? What are we taking forwards? How is it that we’re working? Often team meetings are kind of rolling sheets of issues that come up. Of course, they need to be addressed, but I’m not sure that actually in primary care, the evidence base around team working and effective team working has we’ve become that aware of it? My feeling is that we haven’t. I think that we absolutely do our best, but we could do so in a more intentional way, knowing that there is evidence around it. I mean, we do it for everything else in primary care. If someone has got a blood pressure problem, I know where the NICE guidance is. I know where my local guidance is and I implement it because I know that this is evidence based medicine. And I think there’s something about how do we take a similar approach to evidence based leadership, i.e. compassionate leadership? And I think we need to start having conversations about this. This this feels new and reflecting a little bit on some work that we’ve done at King’s. We are running a pilot around organisational development, which includes aspects of compassionate leadership and your involvement in that, Michael, and the concepts have been new to the cohort that we’ve been taking through. So I don’t think it’s that people would not or don’t want to try and learn and implement these things that are not opening to different ways of working. But we’ve simply been overwhelmed by the external targets that are set to us and then have had the or, don’t have the awareness or haven’t had the sort of education, training or whatever you want to call around the evidence base that it’s robust, that exists around how we can make team working more effective within our practices. 

 

Michael West [00:17:12] It is fascinating. I mean, in a way, primary health care teams, primary care teams, general practices are reasonably sized small, medium sized enterprises with actually considerable sums of turnover in terms of financial performance. And yet somehow it sounds like what you’re saying is we don’t train people to work effectively in those teams or those medium sized organisations. And certainly the data that we’ve gathered over many decades in primary health care teams tells us that having a clear direction in terms of an inspiring shared purpose or mission or vision and translating that into four or five key strategic goals is kind of key indicator of effectiveness. But also what we’ve observed in recording meetings of primary health care teams is that some don’t have them on a regular basis and in others, the meetings, as you say, are just chock a block with agenda items, and those meetings can be dominated by one or two voices, rather than everybody in the team feeling that they have a contribution to make. So it sounds like maybe we should be ensuring that people who work in primary care receptionists, general practitioners practice nurses, paramedics have some basic training, an effective team working so that they can ensure that they are taking shared responsibility for the effectiveness of the entity of the enterprise of the organisation.  

 

Rachna Chowla [00:18:48] Yeah, I would agree with that. I think making this business as usual for us, it’s not something in addition to do, but this is how this is the best way to behave. When I’m part of a team. This is my contribution. You know, making that part of our core training kind of, for me feels like, why have we not done that? We have the evidence. Why have we not done that? I think. Going back to your point around a shared vision versus the tension of targets, we do have to kind of acknowledge that, as you say, we are SMEs and  

 

Michael West [00:19:22] small and medium sized enterprises. Yeah?  

 

Rachna Chowla [00:19:25] Yes. So and we are therefore employers, if we’re partners in a practice, we have colleagues and we have a responsibility to ensure that our organisation is sustainable. And so we have to pay attention to the sometimes myriad of targets I used to do the contract review in my practice, wherever year I would review all of the contracts, all of the incentives and make a big spreadsheet. And it was a big complex spreadsheet to make. It would take two days to do so. Someone needs to keep an eye on that because we have to be sustainable. You know, if we’re not sustainable, people can’t pay their mortgages. You know, there’s that degree of responsibility, of course, but that’s part of the story. You know, it’s not. It’s not all of it. I think we have perhaps focussed on that bit. And then how CQC inspections can completely take over what we’re doing for the next six weeks when we know it’s on the horizon. And I think we focussed on those things more than we have. What you’re talking about, well, as a practice, what is our shared vision? How is it that we want to work together? How is it that we ensure that all voices are heard? How do we make sure that at meetings, yes, we talk about the core business things, of course, and the issues that have to be resolved. But for these four or five things that we have chosen as a practice, are we making progress? I think there’s probably variation in that in primary care, but I would suspect most practices find it hard to do that because of the administrative overwhelm, because of the workload overwhelm. But it doesn’t mean that we shouldn’t. We have to find a way of doing it. But it’s just to acknowledge that there’s a tension.  

 

Michael West [00:21:05] Absolutely a tension and I think that the problem is with that administrative overload and the targets and so on, that the important elements of compassionate leadership can be lost because we then maybe neglect key goals like the well-being of staff, patient experience, the development of new and improved ways of doing things, addressing chronic excessive workload on staff, which are important indicators for the outcomes we seek. Ultimately, care quality and so on. We can become, I think, quite overwhelmed by targets and structures and institutions and inspections and mandates and so on. That sometimes feels as though they suck out compassion from teams and organisations. Are we getting it right?  

 

Rachna Chowla [00:21:56] I think we haven’t quite got the balance right, and we do need to strike a balance when we talk about targets they have, they have a place, you know, I need to be an effective clinician. It is good for me to help my patient with their blood pressure because it reduces their chance of them having a stroke. Yes, it’s important that I’m kind of that might also help with their blood pressure, but I can’t just be kind. I also have to be an effective clinician. So there is, of course, a place for targets that are around clinical outcomes. And yes, they are incentivised, so there’s a place for them. But I wonder if the balance has been a little bit too much in a different direction because being effective as a clinician, having financial sustainability, they are important. But there’s also this importance around our sustainability as human beings within organisations. We talk about the system. Is it a system or is it human beings that are just helping working and collaborating together? And we are, you know, in in my practice or in any practice where interdependent what happens to one colleague does affect the rest of us. So I don’t think we should see in any way as a trade off. Yes, in a practice where you have to, of course, keep an eye on the financial side to make sure that you are sustainable and doing the things that you have to do for QOF outcomes and so forth, that should be part of it. But there is this relational side that is equally important, and you could argue that focussing purely on the financial targets, just you can’t achieve them, really, if you don’t have the relational side that’s been paid attention to. So they’re not a trade off, they’re complementary. But I think the emphasis has been too much on one side rather than the other so far.  

 

Michael West [00:23:47] So we need to take time regularly to reflect on that balance and making sure that we’re getting it right and developing new and improved ways of doing things to be effective for the people we serve. And the question that I think arises for me about compassionate leadership in primary care is who are the leaders? Who is it that needs primary care?  

 

Rachna Chowla [00:24:12] Yeah. I mean, that’s a good question. I guess I’ve been in primary care. I’ve been in I’ve been every which kind of GP you can imagine in five weeks away, so I can give you lots of different perspectives. I think ultimately we all have a leadership responsibility in primary care. Of course we do. I don’t think, though, that we have explored that or articulated that. I think if you came to my practice and asked my reception colleague, does she feel like she’s a leader or if he’s a leader? I don’t know if they say they would. And I think that’s an issue because we all have some sort of leadership responsibility within our scope. I think there is something to acknowledge about. The way that primary care is most structured is there’s a partnership model. So you do have people who whose responsibility, ultimately the running of the practices. And there it’s so important that certainly when I was a partner that it was important to me that I modelled what we’d be talking about in the meetings. Otherwise, you know, I’d lose credibility. So the way that we’re structured might make people have the kind of title of a leader just because they’re perhaps a partner or senior lead. But there is something about how in primary care we come to, the codeveloped understanding that we all have leadership responsibilities within the scope of what we’re doing.  

 

Michael West [00:25:37] And if we asked the receptionist in your practice overall, who leads it, who is the leader, what would he or she answer?  

 

Rachna Chowla [00:25:45] I think they’d say the partners, certainly in my practice, I think that that’s clear who’s the leader of the day or the person in charge on the day, that’s a different question. You know, there’s this part time fluidity that exists in primary care. I think that’s an interesting question. So who is the person to go to on the day for issues when we have this part time culture?  

 

Michael West [00:26:09] So we know that in looking at health care teams, that when people are unclear about who the leader is of a team, that that has consequences in terms of team functioning. And it is an interesting question. I think about these small and medium sized enterprises, as you say, which actually don’t have a managing director, a chief executive officer. I mean, there is the lead partner maybe, but it feels like it’s more fluid than that. And I guess it leads to a question about if we’re trying to create compassionate environments, then one of the potential threats to those compassionate environments is chronic interpersonal conflict. You know, where you have small families, you can get conflicts that inevitably flare up. And you know, in families, we hope what happens is that there’s a brief flame, there’s some heat and then there’s a letting go. There’s forgiveness there’s loving and there’s a sense of deep and safety because we’re able to fall out and make up and we know how to do that. But in teams and work in primary health care teams, I’ve certainly seen and heard about chronic interpersonal conflicts between partners, between other members of staff that kind of corrode what goes on. And I suppose my question is how much awareness is there within primary care of these issues? And how much are we developing the skills of people to be able to manage those sorts of conflicts effectively? So there isn’t an issue like the toxicity of chronic interpersonal conflict?  

 

Rachna Chowla [00:27:48] Yes, how fascinating. My feeling is that I’m sure there’s variation around that. So I give you a politically correct answer. But I think this sort of touches on the point of how aware we are of ourselves a little bit. You know, there’s something about a group awareness, team awareness. And if we’re meeting to talk or just about the transactional things and hiding the conflict or not dealing with it then perpetuates that sort of culture and you need someone to kind of point it out, but in a way that’s safe and with a roadmap of helping to deal with it. But this is also where the cohesiveness in the family like nature can help, even in a practice that comes because there is a sense of love between people who’ve often been working there for four decades, three decades, you know? But I think it’s an area that we need more awareness about because in the end, it ends up affecting patient safety. So maybe the way to approach it is from the perspective of patient safety and understanding what are the different threads that can lead to eroding that patient safety? I’ll give you an example to do with transparency. So in my practice, we have daily debriefs for the clinical teams so that we can come and talk about things that we found difficult or diagnostic difficulties in a way that you just come and share and we will try and support each other. And it doesn’t matter whether you are the registrar or the senior most partner people come and ask and everyone helps and gives their opinion. And in much the same way, we have meetings around significant events, and it was one significant event I was involved with, where by mistake I sent a letter which did have patient, identifiable information to an incorrect email address. So that’s a data governance breach. And thankfully, that email address I went to was kind of defunct, so nothing happened. And you know, I did whatever I needed to do, but I thought when I brought it to the clinical meeting to discuss it, this can’t be the first time that this has happened, even though it’s the first time that we were talking about this. So I then took it to the practice meeting to say, Well, let’s talk about a significant incident that I was involved with, and I wanted to bring it up to show that these things happen. It was a mistake. I did whatever I did to correct it, but kind of opened the door to other people to feeling comfortable about those sorts of things, probably day to day occurrences. We don’t mean them to happen. We have to then think about the systems to prevent them. But you know, I was a partner at the time and I wanted to show that we can all do these things and there’s no come back on this there’s a way of rectifying it. You ensure that this duty of candour and the patient’s been told about the mistake and you try and rectify and so forth, but this is a safe place to discuss things like this. So the kind of modelling, the kind of transparency of communication, I think all of these things then help in the end. Also, when it comes to the conflict resolution, which, you know, was initially what you were asking about.  

 

Michael West [00:30:57] So we create a more psychologically safe environment where we can discuss mistakes and be open about mistakes in order that we can learn from them. We seek to develop compassionate relationships with each other through attending, understanding, empathising and helping each other within the primary care team. And that compassion and that openness translates into the interactions with patients for whom, of course, the relationship with the clinician that they’re seeing. The quality of that interaction is so important in terms of how well they’re able to communicate. What’s their concern, the extent to which they understand the treatment protocols they’re required to adhere to, the extent to which they feel reassured and comforted by the interactions so it feels like this is about. If you like the compassionate culture, the compassionate learning environment that we create in these entities that we call primary health care teams. And I suppose it raises for me the question about the boundaries and the shifting boundaries of primary care and what that means in terms of how we think about compassionate leadership. So I’m thinking about the development of primary care networks now, where groups of practices start to collaborate and cooperate. We’re seeing, for example, the Bromley by Bow practice in London seeking to involve the community in providing care. Volunteers visiting people living alone, encouraging people to go to gardening clubs, encouraging people to link with voluntary sector. And we’re seeing some evaporation of boundaries so that patients and service users become more involved in, if youlike, like coding and co-designing that care. And the idea that primary care begins to work more effectively with secondary care, with voluntary sector, with community groups and patient groups, that feels like a process that’s currently happening. How is that going? Does it make sense? And what’s the role of compassionate leadership in that?  

 

Rachna Chowla [00:33:09] It’s definitely a process. It’s definitely in progress and. I think the initiation of these PCNs or primary care networks being in the formal system are just a start because they again have been given various targets, they’re well-intentioned organisations whose role, it is eventually to reach out and to involve and work with community organisations. But the targets that they’ve been given to meet at the beginning, yes, will help them to kind of coordinate and collaborate. And certainly the vaccination programmes that they have been instrumental in delivering have helped them become more cohesive entities. And my suspicion is that with the vaccination programmes and reaching out and working with community organisations to support that, actually some of that work has maybe been accelerated because of COVID. But I think the scope or the ambition of them needs to still be realised. There’s still a staffing problem within PCNs. PCNs are entities where groups of practices come together. Yes, they have funding to recruit additional staff, which is great, and staff who are not always clinical, which is what we need. So social prescribing, link workers and so forth. And I think the challenge is to really reach out and work with community organisations who are already engaged with the local community and already have built trust and have the relationships so that they can work in partnership with them so that the boundaries of compassion are blurred completely. Because for PCNs to be able to deliver truly on what they’re trying to do, it cannot just happen with them on their own. It’ll become a tick box exercise, which no one really wants. And I think my other reflection is over two years of COVID, we have all become so much more engaged with our health. It doesn’t matter which arguments we identify or don’t identify with. The point is that at a global scale, we are all engaged with health, and that can only be a good thing. I think the question really is now when it comes to learning about trust, which has been an issue during these two years, what do we need to learn so that we bring those two parts of the debate together? So creating trust within the community when it comes to formal and informal parts of the health care system? So yes, PCNs working together with the community for the greater good. So I think there’s something quite profound that might have happened in the last two years, which we can capitalise on because of COVID and also because of the negative sides coming up around trust. But there’s something there I think that can be built upon.  

 

Michael West [00:35:59] Primary care is in really extraordinary sector. It’s the first point of call for everybody in our society to take care of their own health, to get help with their own health and sometimes just to get reassurance or even just to connect. And you deal with such a great diversity of people, of people from different backgrounds, demographic backgrounds, professional backgrounds and a great huge diversity of presenting problems and sometimes with people who are very angry or very difficult or broken or at their wit’s end. How do you deal with all of that compassionately?  

 

Rachna Chowla [00:36:44] Yeah, I think there’s something about seeing it as a privilege. You know, people, when they come into our consultation door, gift us this immediate sense of trust. And that is just an utter privilege. And with that, they open their hearts to all sorts of things that have happened to them and to really connect and to help. You can only do that from a place of openness and from a place of listening and from a place of compassion. And they do so even more when they invite us into their homes and they’re unwell and we go along in a home visit. And I have such funny stories about going on home visits and people have got pet squirrels that will come in from their garden, and one of them kind of poked his head above the laptop when I was listening to his chest and bizarre things like that to really sad things where people are living in the most dire and difficult conditions. And in those sorts of situations, it can be really easy to just think, Well, what is it that I’m actually doing? Am I making a difference? But to remember that for so many people who are living difficult and sometimes isolated lives, we can be their advocate. And in some ways we’re a universal advocate for school letter or housing letter or all sorts of things, where do they come to? They come to us. We’re also someone that’s a human face and someone who can listen. Someone who can touch, hold hands. And I might not get to sort out someone’s housing problems and all the rest of it. But maybe me doing my tiny bit of medicine does make a little bit of a difference. I think it’s important that we try and remember that and remember that it’s a privilege to be invited into people’s lives. So that’s sort of how I see it. And I have to say I learnt so much from my patients as one of my patients who she passed away. She was a lady that I looked after during the last six months of her life. It’s probably one of the most profound experiences of my clinical career, and it’s so I think we’re so lucky in primary care because our job is about people and when we’re more centred in ourselves, it’s ultimately about care and compassion and about love and to remember that it’s a place of privilege and that these small interactions can make a difference. And often even bigger things can happen. And so it’s important that we can play our role. But to do so from a place of compassion makes it all the more fulfilling and more effective, more effectual because people feel it.  

 

Michael West [00:39:26] There’s been a sense this last two years where we’ve all had to take more responsibility for our own and other’s health, and it seems really important that we, as you say, embrace that and recognise that the health and happiness and well-being and fulfilment of everybody in our communities is dependent on each of us, of course, taking care of ourselves but taking care of each other. And that’s what compassion is about. Of course, the danger, I think for many health care professionals and it’s been to some extent exacerbated by some of the public comments in relation to general practice is that. There’s this notion that I as a primary health care professional. Be it practice nurse, receptionist, doctor, I’m here to care for others. And there are enormous burdens and work demands on people working in primary care. I’ve come to feel that self-compassion more and more I’ve come to feel it’s hugely important for all of us to learn, and I think we need to teach children infants early on what self-compassion is about. It’s not about being self-indulgent or about being selfish. It’s about nurturing our being so that we’re able to contribute, fulfil our lives, be happy. In primary care. Do you see an awareness of the importance of self-compassion or an emerging awareness? And how important do you think it is in that context? And why is it important in a context above all?  

 

Rachna Chowla [00:40:58] I think we’re starting to talk about the word compassion and kindness of words that we have started to talk about. And do we have an awareness about how or what? I don’t think that’s there yet, but should we? Absolutely. I mean, I’m happy to kind of share some of my own experiences around that. Compassion has been something that I’ve been interested of for a while, but I think I had an experience a few years ago where I had had a completely typical normal day in primary care. It was a long day. Lots of patients. Lots of things to do, and I don’t quite know what happened, but I burst into tears as I was going home and in my 40s, sought out my father and cried on his shoulder. And I can’t explain what that happened, but something that day was too much. But that’s a completely typical day, and I’m sure that what I felt is something that many people are feeling, but I sort of acknowledged it for the first time and I listened to it. I heard it. And since then, I’ve been much more aware of about how is it that I want to spend my moments in my days at work? What sort of place do I want to be in? When I say place, not physical place, I’m talking about how I am in my being so that then I can support my patients to the best of my ability in those moments and understanding that there are limitations actually to how I can do that. There are a finite number of hours in the day. Appointments are not infinite. I can’t just keep adding them on and when I do, it has an impact on me and it has an impact on my patients. So, you know, we are part of this together. There’s there isn’t a separation between me and my patient when I’m in a consultation. And so the chronic stress the chronic exhaustion, those things at some point they have an impact on our patients. So we have to become aware of that. Becoming aware of that is part of being compassionate to myself. So acknowledging this feeling for myself, but then also doing something about it, taking some sort of action to help. And for me, it’s meant lots of different things. It has meant changing how I work. Yes, it’s meant changing my work plan and that was done in a quite intentional way. Actually, interestingly, at the practice that I am at because of COVID and the unpredictability of work and the difficulties the practice chose. Kind of a year into COVID to try and reduce the workload for everyone because it just would not have been sustainable, the practice would not have functioned if we were just going to continue to sprint round this marathon track, which is what we all sort of think we can do. And we couldn’t, we couldn’t continue. And in order for that to happen, there has to be some understanding for self-compassion to happen at a practice level and therefore compassionate leadership. It has to come from a place of understanding that within oneself. And I don’t know whether in primary care or even in general life, we’re so stuck in the fear, anxiety, fighting for targets achieving place to have not realised that we’re so stuck in those two places and that there is this place of stillness and being and compassion and a sense of love, which in the end is what sits at the heart of a consultation between a clinician and a patient. When I gaze into the eyes of my patients, whether it’s a baby or, you know, one of my patients who was passing away, we both felt that when it’s that, we both feel it, when it’s there. So it’s not something that in primary care we don’t know, it’s not something that it’s human beings that we don’t know. I just wonder whether the context has become a bit too out of control for us to connect with it. But it’s there, it’s there.  

 

Michael West [00:45:13] It’s really hugely helpful and profound and moving Rachna. And my last question? Almost feels too blunt in a way. But what’s your one practical recommendation? For people working in primary care to take away from your experience of working in this context and your wisdom.  

 

Rachna Chowla [00:45:39] I think we will work in primary care because we care. And there is something about us all sort of going within ourselves and connecting with that place because that is the place from which we care when we are with our patients. And you can call that self-compassion or you can call that whatever you like, but people know what that place is, and I think we need to spend more time there. And once we have, there is something about making that into a lived reality. Actually, that is how I wish to spend my moment to moment experience in practice. What is it then collectively, we need to do to make that happen? And that’s the conversation to be had because we all know that we can’t continue as we have been and there’s no need to. Why not find this place of you can call it compassion or presence or stillness, or this place that we have within ourselves, where we connect with each other and with our patients? And let’s try and make that the core of how then the rest of the practice revolves, rather than it being the other way around.  

 

Michael West [00:46:50] Rachna, it’s been an immense privilege and immensely moving and inspiring to have this conversation with you. Thank you. 

 

Rachna Chowla [00:46:58] Equally for me, thank you so much, Michael.  

 

Paul O’Neill [00:47:04] I hope you enjoyed this conversation. Please look out for others in this mini-series and subscribe to the Leadership Listeners’ Collection for more content like this.