Compliance is over-orientation to the needs of others – and under-orientation to your own responsibilities.

Last week and for the next few weeks I’m addressing the experience of staff of working in the NHS. I started last week with a recognition of the fact that that younger NHS professionals have a different relationship with their need to work full time.

Employers not only need to learn live with that, but since they want them to work for the NHS for as many days as they can, employers are going to have to be very welcoming to new staff. In constructing their portfolio careers these professionals will regularly review their work-life balance and will only work more days for the NHS for if they are treated well.

Very few people actually work for the abstraction known as the NHS. Most of them work for specific NHS organisations. It is, therefore, the task of the leadership of thousands of very different NHS organisations – from very large acute trusts to very small GP partnerships – to learn how to manage in a way that is attractive.

This analysis led me to conclude that the key to the whole issue of staff wanting to work for the NHS rests with the capacity and capability of local NHS leaderships to be very good employers. Those one million NHS consultations every day are taking place in locally led organisations.

So back to the core conundrum. It is vital that local leaders have the capacity and capability to lead. But they work in a nationalised service that the public very much want to run as a national service.

As chance would have it, last week the House of Commons Select Committee were hearing evidence about local leadership in the NHS and also, as chance would have it, one of the most thoughtful people involved in this relationship, Matthew Taylor CEO of the NHS Confederation, was giving evidence to the committee.(and – full disclosure – Matthew is a friend).

Starting with the problem of the N in the NHS. He said.

‘It is vital to take responsibility for the overall ask and expectations that we have of leaders in the health service. We can pour ever more recommendations and targets and incentives in but it feels to be very rare for anyone to stand back and say, “What does this all actually amount to?”.’

As the problems with the NHS experienced by the public swirl ever bigger and brighter in the public eye, the pressure on national politics to “do something“about x or y is enormous. (Similar political pressures have already led them to work through the alphabet ‘doing something’ about a to w). And the real-world paradox that Matthew points out is that the more things you tell local leaders to do, the fewer things, as actual leaders, they can achieve.

If, as Matthew suggests, we stand back and say “what does this actually amount to?” we can see it is self-defeating.

‘And the danger is that as we require more, what we develop is a culture of compliance. That all the boards do is try to make sure that they’ re ticking every single box that is put in front of them and that, in the end, is not leadership merely compliance in a context that feels very difficult.

If nearly all boards do is worry about compliance you’re going to get compliance not leadership, and that’s one of the reasons why I think ultimately the NHS is not as responsive as dynamic as it needs to be’’.

Reported in Healthcare Leader 16/04/24

The greater the number of issues national leadership tells local NHS leadership to achieve, the less room for leadership those local leaders will have.

This is an important part of the paradox of a National health service which has 1 million local consultations every 24 hours, all of which have to be local and none of which can be nationally led.

So, let’s use the insight gained from last week’s posts and see how a national intervention might help rather than just create more compliance.

We have evidence that some younger professionals want to develop portfolio careers and will make their own decisions about how many days a week they work for an NHS employer. We have evidence that different NHS employers have different success rates in persuading these professionals to work for more days a week. The question for the centre is how we get the best employment practice – that treats staff well – to be spread throughout a greater number of employers.

Having listened to Matthew Taylor (always a wise thing to do) we have decided NOT to add this, alongside all the other instructions, to next year’s planning guidance. Because to do so would further undermine the capacity of local NHS leaders to lead. We are learning from my previous warnings that the trouble with current performance management is that is that it doesn’t manage performance. We have understood that telling the leaders in charge of our NHS institutions how to entice their staff to work for them is probably reducing the capacity of those leaders to actually lead.

This is pretty near the crux of modern management. Telling these young professionals, they have to work more days doesn’t work. Modern employers need to entice them. Equally if the centre of the NHS wants its thousands of local employers to be better at enticing those staff to work for the NHS, then it needs to entice them to do that because telling them won’t work.

This doesn’t mean that there is no leadership at either national or local level. It just means that one small aspect of leadership (telling people what they have to do) needs to diminish.

How might this look at one of the 1 million consultations that are the business end of the NHS? Let’s see.

A large number of those consultations involve clinicians trying either to change patient behaviours or work with them to persuade them to change. Towards the end of many of these consultations I can sort of hear the clinician saying, “You know Paul, you need to drink less”.

They could try to change my behaviour by telling me what to do (and you know that really doesn’t work!) or they can work with me and my own motivations and find ways of getting me to lead my own life in a better way.

National leaders need to enable local leaders to lead in a better way. Local leaders need to enable their clinicians to lead in a better way. And the clinicians need to enable their patients to lead their lives in a better way.