Why the chief executive should take a walk
Harriet Sergeant and Ivan Tyrrell discuss why people in public services are so often prevented from doing a good job, and what can be done about it.
TYRRELL: As the author of several highly revealing think-tank reports covering immigration, the NHS and the care system, and with a report on the police in the pipeline, you are in the unusual position of having an overview of a range of different public services, particularly the caring ones - which is why I wanted to meet you. How did you get into this line of work?
SERGEANT: I had written three books, one on apartheid in South Africa, one on Shanghai in the 20s and 308 and one on Japan, where I lived for seven years. When I came back to England, with small children, Tessa Keswick, the then director of a think tank called the Centre for Policy Studies, contacted me. I had interviewed her husband for my book on Shanghai. She asked if I would like to do a report on immigration. I didn't even know what a think-tank was, at that time. I opened my mouth to say no. Then I thought, actually, this might be quite interesting, because I knew all about bureaucrats in South Africa, China and Tokyo but had been away from my own country for a long time and didn't know what was going on here. So I said yes.
I found it absolutely fascinating. Then I got interested in the NHS and decided that I wanted to look at management. I developed a real bee in my bonnet about how this was key to understanding what was going wrong with the NHS. So I spent about a year doing that. I went into hospitals and shadowed everybody from chief executives to porters.
TYRRELL: And they let you do this?
SERGEANT: Yes, they did! It took a bit of time.
With all these reports, what takes the time is getting into places. I really wanted just to be invisible but I realised that, if I asked to 'nose around', this wasn't going to go down well. Then, from looking at a staff notice board, I discovered the word 'shadow'. They are very keen on jargon in NHS hospitals, so I said, "Can I shadow someone?" and they said, "Oh yes!" They were programmed to react well to the word 'shadow'.
I told hospitals that I was doing a report for a think-tank and I wanted to find out what was happening in the NHS. Some people working in the NHS are not very engaged with what they should be doing but an awful lot of people do want to do their job well and are very upset that they aren't being allowed to do it. After all, if you become a social worker, a policeman, a doctor or nurse, you are not doing it for the money. I always tell everyone I'm interviewing that I'm not going to identify them or any institution, so most people were very cooperative because they really wanted what is going on in the NBS to be known about.
TYRRELL: That comes across very clearly in your report, Managing not to Manage. 'Upset' is not the word, perhaps, for some of them, but 'furious'.
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SERGEANT: Yes, they are - a lot of the consultants, in particular. Consultants, even though you can criticise them, have been through medical school and they have to have a certain intellectual toughness about how they approach things. Also, a lot of them work in the private sector, where things are run very, very differently. So they despair!
TYRRELL: Yes, we get people all over the country coming up to us at our seminars and workshops, sometimes practically crying with frustration, saying, "Why can't we be allowed to do things properly?"
So, you got sucked into all this by chance and circumstance and found it fascinating. It occurred to me that, because of writing these different reports, you must now have a valuable impression of what went wrong and why. As you say, it is not the individuals and very often it is not the teams, because the teams are trying to do a good job. There must be something else going on. For example, how did the importance of hygiene drop out of the picture and end up causing so many personal tragedies - a calamity - in the country?
SERGEANT: I did a chapter on hygiene in the NHS report and I've never stopped writing about it since because hospital-acquired infection is the visible sign of a bureaucracy in crisis. Hygiene is one of the things the NHS is now bad at – the other is feeding elderly patients. I think what these systems produce is great cruelty. That is what I find extraordinary. Perfectly nice people are overseeing systems that result in old people starving in the wards - and deaths because of poor hygiene such as at the three hospitals run by Maidstone and Tunbridge Wells NHS Trust. I think the reason for poor hygiene is simple – and it is the same reason as for other NHS ills. You look at management all the way down through the structure of the NHS and everyone complains that there is too much management at the top - which is absolutely true. But that management is not focused on its own hospital. I found that top managers often have little idea of what is going on in their own hospitals. The management is focused on the government and on doing everything the government wants and meeting targets set by the government, which actually have very little relevance to real life in the hospital at all.
TYRRELL: Such as?
SERGEANT: Well, for example, what happened at Maidstone: Maidstone passed its hygiene target while people were literally dying in their beds because of poor hygiene!
TYRRELL: The ubiquitous problem of targets not being connected to the real world.
SERGEANT: Right! The NHS has top management and an enormous number of middle managers who were taken on simply to check that the hospital has complied with all its targets but then, as you go down through the hospital hierarchy, you get to the patient - no lower can you go! - and around the patient there is a complete vacuum of management, or else very ineffectual management. For example, I followed 'modern matrons' around and none of them has any power. One said, "I'm here as a listening ear, as people get so angry." If I mentioned to nurses or to management what an old-fashioned matron was like 50 years ago, they would sneer, "Oh, you mean Hattie Jacques!" But that discipline is exactly what hospitals need. In the old days, the matron could sack someone on the spot if they weren't doing what should be done to keep the hospital running smoothly. Matrons can't sack anyone on the spot now, and this is a major part of the problem.
I was once standing with one of these modern matrons and the infection control manager outside a side room where a patient had MRSA. It was explained to me that, outside the room, there was an apron and glove dispenser and that the nurse would put on apron and gloves before entering, see to the patient, take the apron and gloves off, throw them away and then go and see to another patient. As we were talking, I watched a nurse walk in, completely ignore all this equipment, see to the patient, come out, and, without washing her hands, go straight on to the ward. This happened right where I was standing with the infection manager and the modern matron!
I said, "Excuse me, have I not understood something?"
And they said, "Oh, you have to have eyes in the back of your head with these girls." But there was no question of that nurse getting a reprimand. I remember talking to an industrial chemist and he said that, if he didn't wear the protective clothing provided by his employers, he would be sacked on the spot.
TYRRELL: Yes, it's the same in food-processing plants. I think these government-derived problems arise because people are not thinking and behaving organically. Top-down management is like the brain trying to control exactly how all the body's organs carry out their functions, instead of letting them get on with it for themselves, which is what they are naturally programmed to do. There isn't any top-down management in nature. If there were, we would find examples in natural phenomena.
Because government has power and control of funding, they can take responsibility away from the individuals who know what to do, imposing targets without understanding the wider implications of doing so.
SERGEANT: That is absolutely true. The fact that chief executives are, on average, only in their posts for two and a half years is ridiculous. Can you imagine a multimillion pound company being run by chief executives who are coming and going every two or three years? It is also a dehumanising system. I would sit in on meetings with nurses and, when they were chatting generally, they were really nice people. But whenever they started discussing patients, they came out with all this jargon, and that just had the effect of distancing them from the patients, because the patients were talked about as cases or symptoms but not as people.
One of the things I find very odd is that nurses have such good press and yet there is so much poor nursing. If nurses were managed properly, maybe they would be different. But so many simply don't think about their patients. A dear friend of mine was dying the year before last, and I went to the hospital to be with him. Because I'm very accident-prone and have been in hospitals a lot, and because of this report, I knew that night nurses don't do very much for you, so I was determined to be with him at night. He was barely conscious but howling and obviously in great pain. The nurses' station was right by him, but none of the nurses even looked at him. I asked if he could have his morphine, and they said, "Well, none of us is his nurse. His nurse is over there, giving a patient a bath, and she can't be disturbed. "That sort of behaviour is cruel.
TYRRELL: It is cruel. It's a kind of sanctioned torture of the vulnerable. In Handle with Care, your report about the care system for young people, you describe similar sorts of cruelty that come about through social workers moving young people around seemingly arbitrarily, so the youngsters don't have any stability. Even when they are well placed and getting on well, they are suddenly torn away. It is heartbreaking.
SERGEANT: What makes 'caring' people capable of acting like that? I think it is quite a lot to do with the training - both the nurse training and the social worker training. In nurse training, there is very little emphasis on making the patient comfortable and doing for the patient what they can't do for themselves - feeding, them, washing them, and so on, which was the emphasis 50 years ago. I talked to one nurse who was amazed that, during her three-year training, a whole day had been spent studying poverty in Russia but bedsores weren't mentioned once. Nurses emerge from their courses very sure they know what is right and yet they haven't learned to put the patient at the centre of everything they do.
One wonderful old Irish sister I interviewed said, "These modern girls, they just think they are going to sit all day at the computer. I tell them, if my patients are dying and you have to give them a bedpan 20 times a day, you do it. You don't complain."
TYRRELL: But they do!
SERGEANT: Yes. And with social workers it is something else. They aren't trained to plan. When I did the report on children in care, a social services director explained to me that an emergency in the family forces them to find an instant alternative. A child may have to be moved right out of the area to be kept safe, and this is what often leads to 'multiple place syndrome'. But one retired social worker put it down to poorly trained social workers, unable to plan ahead. "No child should be left on the town hall steps at 5pm on a Friday. We know the families. We know the kids at risk. Why don't we plan in advance?" she said.
I think the social work attitude is also a consequence of lack of money. The cost of the care system is borne by local authorities and it is expensive. They are desperate to cut back services and make savings. If one family of five is suddenly taken into care, this throws out the whole budget.
TYRRELL: Yes, you put that succinctly and shockingly in your report: "The system dictates that the earlier a young person fails, the sooner they cease to be a cost to their local authority. It is better for the local authority's budget to have a young person go to prison, for example, rather than to university. Prison is paid for by the Home Office, university by the local authority. In the topsy-turvy world of care, failure is cheap, success a financial burden."
A week's stay in a children's home, which is where children end up if their foster placements break down, can cost the local authority over £6000. As Polly Toynbee observed, and you quote her, that's enough to buy a place at Eton with a full-time personal mentor and intensive psychotherapy - which might surely do them a lot more good. And it is a problem that is going to grow, rather than one that can be shrunk, because more and more young people are growing up in dysfunctional families.
SERGEANT: Young people who end up in children's homes nowadays have gone through several placements and are very disturbed. By that time, not only have they been separated from family or from foster parents they may have cared for but they have probably been thrown out of several schools. One social service manager insisted to me that, although price comes into it, it is not the deciding factor. The young people have disrupted so many places that it is more a case of who will take them. For many young people in care, children's homes are their last chance before secure accommodation. These, together with secure units, accounted for 11 per cent of children in care in 2004. But lots of the larger homes have been closed now, because of paedophile scandals.
Whereas the children used to be a broad mix in the old care homes, now the average number of children is six, extremely challenging ones.
TYRRELL: There is a wonderful residential school in Cumbria, Fellside, working from the human givens approach, which is turning that around. The children, who were all previously highly disturbed, even get to interview potential staff at the school. If the candidates don't match up to the agreed person specification, which the children helped draw up, they are not hired. This makes each child feel valued and secure. Also, elsewhere in this issue of the journal, there is a heartening article about what can be achieved in a secure unit. But it all comes so late, when so much damage has been done.
You have been saturated in all this over the last four or five years. What has this research made you think has to happen?
SERGEANT: Well, certainly with the NHS, what has to happen is that you must be able to hire the people you want and pay them properly for good work, and be able to fire the people who don't do their job properly.
TYRRELL: And is that likely to happen?
SERGEANT: I don't want to sound political about this - that's the last thing I want to do - but at the moment it takes a year to fire a nurse, unless she is doing something like killing off her patients. I think the whole thing has to be turned around so that the patients are at the centre of everything, and what matters most is what is best for them. Instead of having power at the top, I think you should give the power to the patient. NHS patients were starting to get a bit more choice in where they go for elective surgery, but this is now being reversed. When I rang up local hospitals to try to find out their MRSA rates, they wouldn't tell me. Surely that's relevant in where you might, as a patient, choose to go. A private hospital will tell you. If all patients have a right to such information and refuse to go to particular hospitals on the basis of it, this will force hospitals to do something. They won't do it otherwise.
TYRRELL: I think that's right.
SERGEANT: I came across incredible people at the NHS but they are all doing their jobs in spite of what's going on, or else have to fight the system to do so. After the report on the NHS carne out, the nurses' union got upset and sent me off to see various modern matrons who they considered highly effective. There was an exceptional woman, who looks after patients with brain tumours. Most of her patients are dying and, if you were dying, you would want that matron by your side. But she spent most of her time not dealing with her patients with brain tumours but dealing with the lifts. These brand-new lifts in her brand-new hospital took the patients down three or four floors to the operating theatre but they were always breaking down; so either the patients couldn't get to have their operation or they couldn't get back up to the ward again afterwards. She spent her whole time fighting the maintenance people to get the lifts to work.
TYRRELL: Wasn't there a maintenance manager to do that?
SERGEANT: She could never get hold of him! In a private hospital, the maintenance manager is answerable to the chief executive. In this NHS hospital, he had no one kicking him along, because higher management were too busy looking at targets.
TYRRELL: So, the nurses' union sent you to see people who they thought were special and doing great work and even those people were being prevented from doing their jobs.
TYRRELL: It's an autistic system, isn't it?
SERGEANT: 'Autistic' is a good word for it.
TYRRELL: The kind of people who are attracted to designing and running systems are those with Asperger traits. They can be highly intelligent in particular ways but their condition makes them obsess about control, and so, with the best of intentions, they put in control systems and targets, but consistently they can't see the wider context. They can't see that, if you do this, it is going to affect that. When you get people right at the top of government with Asperger traits, that kind of straight-line thinking is going to permeate all the way through. Such people won't understand what you are complaining about because they think they are doing all the right things.
SERGEANT: Yes. Whereas, if you had a matron who was in charge just of her own three or four wards and could take total responsibility – and get a bonus at the end of the year for good work - it would transform everything. And it would be easy, through the sophisticated customer and staff surveys that can be done nowadays, to judge her performance. But a big problem militating against positive change in the NHS is that there are too many people chasing the same resources. I interviewed one woman who was running an accident and emergency department; she had created a marvellous children's section within it, with pretty, colourful pictures and nice furnishings and so on. Suddenly, far more parents started bringing their children to that department, because it was so welcoming. So her budget went rocketing through its limit and everyone was furious with her! She was in a terrible state. In any other business …
TYRRELL: … it would have been a success!
SERGEANT: Exactly. This is why the NHS is always cutting beds when it is in a state. They don't want to attract more people: they want to stop people coming in. That makes it much harder to improve quality. I think it is much simpler in the case of schooling: it is simpler to put pupils and parents at the heart of schools. I spent a lot of time in inner city areas, such as Brixton in South London, for the report on children in care. Parents there are desperate for their children to go to better schools because, particularly for single parent mothers of sons - and I'm not being overdramatic about this – it may be a matter of life and death. If their son comes through primary school, as many now do, without being able to read or write, starts dropping out of classes in secondary school because he is getting laughed at or doesn't want to be made to feel an idiot, then drops out altogether, joins a gang, starts stealing, taking drugs, gets a gun, there is a high risk that he will end up killed or as an addict and/or in prison. The parents in these areas complain that their sons are not being effectively disciplined.
TYRRELL: Which they are not. And boys need completely different input from girls.
SERGEANT: Absolutely! Boys and girls are different species! I visited some of the newly set up charter schools in New York. Anyone can set up a school there and, if you attract state pupils, you get funded - i.e. the money follows the pupil. I went to the Bronx and Harlem, where these charter schools have mostly black teachers and black headmasters, providing what the black and Hispanic parents in the area want for their children - which is discipline! The schools are very strict! The students are there from eight till five and there's a Saturday school, and they are getting amazing results. Compared to the virtual anarchy in state schools here, I was very impressed. One of the key things to look at, again, is the training how teachers are being taught to teach.
TYRRELL: Two head teachers who have done the human givens diploma are converting their schools to trust status - Worle Community School, a state Comprehensive, and Westhaven Community Special School, both in Weston. The Human Givens Institute is a Trust member and will be providing a trustee. People involved with the schools, including the local authority and the primary care trust, are totally committed to the idea that children have to get their innate needs met above all else, if they are to learn and flourish. Wherever possible, instead of referring emotionally disturbed children to the local child and adolescent mental health services, the teachers and school counsellors themselves help the children get out of depression, cope with anxiety or recover from trauma – we've taught them how. And they are also forging strong links with the parents, involving them in what is going on.
SERGEANT: Oh, I'd love to see those schools! The charter schools I saw trained their own teachers and they also talk to the parents. I spoke to one young black man, not highly literate, who had been in prison for six or seven years but was now settled down with his girlfriend and their 18month- old daughter. I said to him, "Are you reading to her every night?" and he said, ''What do you mean?" I said, "You should read her a bedtime story" and gave him a few books, and he was absolutely enchanted by this idea. No one had ever suggested it to him. He told me after, "My little girl loves those books. She goes and gets them every evening." It always annoys me if teachers say, ''You just don't know the parents we are dealing with!" Well, they may not be great parents but I think 90 per cent probably do want the best for their children.
TYRRELL: Of course they do. Interestingly, just introducing more exercise into schools at primary school level would do a lot to improve behaviour and get children learning. Most hyperactive children can concentrate well after they have had enough exercise. Children in hunter-gatherer societies don't suffer from ADHD because they are so active. The government has set as one of its targets for schools two hours of exercise a week, which means that most children must be doing less than that. That is particularly catastrophic for boys. I don't know how anyone can control boys or get them to do anything, if they are getting only around an hour of exercise a week. The way state schools, in particular, are geared up to educate boys now doesn't fit with how boys' brains develop. Exercise - rough and tumble, running, climbing, leaping, play-fighting and competition – is necessary for boys' development, and, when parents and schools don't understand and accommodate these innate needs, problems always arise. So many management systems are like this. They don't meet human needs and, consequently, end up creating more problems than they solve. That is partly why, I think, it is such an uphill struggle to make a difference in education and the NHS. After all, many people know what should be done. It's just that they're prevented from doing it.
SERGEANT: And a big problem is that those with the power just don't talk to the people doing the jobs, who very often are the ones who know exactly how to make a difference. People such as nurses and porters often have extremely good ideas about how things can be done better, but there is no mechanism for people to give ideas. Harry Selfridge, the founder of Selfridges, used to spend an hour walking around his store every morning, which meant he talked to thousands of customers and staff every year. No chief executive walks around the hospital like that, noticing what's important. They have no idea how much of a porter's time is spent wandering around the hospital, trying to find a wheelchair. They don't go up to patients and ask, "What has it been like?" They don't go up to nurses and ask, "How long have you been on duty? What's happened to you today? Are you absolutely shattered?" This is just good management. Instead, they hide away at their desks, filling in bits of paper. Hospital trusts have to produce more than 600 pieces of information for the Department of Health every month! And they don't even get any feedback from it.
But, here's one good story to end on. One bright, young manager was told by her chief executive that she must do something about the two-week wait for scans. She looked into it and found that nurses, doctors, even the man doing the scanning, were turning up late, so she made them all start on time. Then she noticed that the patients were often having difficulty getting undressed and the man doing the scan would have to stop and help them. This would make him cross because it slowed him up and so the atmosphere was unpleasant. All she did, for very little money, was get people to come along and help the patients prepare and get partially undressed. And, as that was all they did, they could chat with the patients and make them feel more at ease, and everything was speeded up. With just those simple changes, she brought the waiting time down from two weeks to just a day. Her intention was to get it down to a walk-in service.
TYRRELL: That is how things should operate with local knowledge. That's where individuals can make so much of a difference.
SERGEANT: Yes, if you make the patient – or the parent and child – important. If your bonus as a chief executive depends on customer satisfaction, then you are going to make sure that the staff looking after the patient are happy and right for the job and working properly, and everything else falls into place. Then the chief executive would be walking round, because, if his £20,000 bonus depends on the patient, he had better go and see what is happening to the patient.
But one useful thing this government has done is spend so much money on education and health that it is clear now that resolving the problems is not a question of money. That's a big step forward because it means that now everyone knows that we need to try something else.
TYRRELL: It is, we must hope, a useful learning curve, if an expensive one.
Harrient Sergeant is a journalist, author and Research Fellow of the Centre for Policy Studies, an independent Think Tank. Her new book 'Among The Hoods. My years with a teenage gang' is out in July. Find out more on her website.
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