The NHS blame culture came as a shock to me’
Sorting the health and care system is a more fiendish task than ex-army chief ever faced in the military
General Sir Gordon Messenger has served in Kosovo, Lebanon and Afghanistan. Twenty years ago, he led the Royal Marines’ invasion of Iraq. Yet he suggests Britain’s health and social care system, and how best to manage it, is in some ways a more fiendish challenge.
The military man was asked by Downing Street to launch the most far-reaching review of health and social care leadership in 40 years.
“I think there is an assumption – wrongly held, in certain quarters – that if you want to get something done, you get a general in,” says Sir Gordon. “It misses the point that generals can get things done because they’ve got lots of people who do things for them; because they have a system in place.”
The former general had already been brought in by ministers to assist in the pandemic, introducing community testing and hotel quarantine. Repeatedly, he found himself “pulling levers” only to find “there was nothing at the end of them”.
“I have learnt more about leadership in the three years since I left the military than in the 38 years I served in it,” says Sir Gordon, 60. “Essentially military leadership has got a lot going for it. It’s got a good hand of cards because you’ve got a culture of leaders and being led, well understood structures, relationships and very clear hierarchies.
“The reason why the military can ‘do’ crises is because they’ve got a doctrine established in peacetime to fall back on; a set of handrails if you like. I don’t think that’s necessarily true of other organisations, such as the NHS,” says Sir Gordon.
Since his review of leadership in health and social care reported last summer, the Government’s own leadership has been on its own rollercoaster, including three changes of Health Secretary. Meanwhile, the NHS has careered into the worst winter crisis in its history, with record A&E and ambulance waits and seven million on waiting lists.
Rishi Sunak last week launched an urgent and emergency care plan, promising “the largest and fastest-ever improvement in emergency waiting times in the NHS’S history”.
But Sir Gordon suggests it is a mistake for the NHS to keep bouncing from one crisis to the next, without making fundamental changes, to bolster the service for the long term. An “inadequate” focus on such matters is letting staff – and the public – down.
“Unless you get the right culture, better leadership, it’s almost like painting the bedrooms without fixing the roof, in terms of throwing money at A&E waiting times,” he says.
“Unless you have that well-led, well-motivated, valued, resilient workforce, the sand is slipping through your fingers, however much you keep topping it up.” In particular, he was perturbed by the lack of team spirit he encountered in many parts of the health and social care system, with wrongdoing unchecked.
“The things that I found most surprising were the blame culture, the fingerpointing and the responsibility avoidance,” he says. “If you feel alone, you don’t feel brave enough. If you see something that’s going wrong, what should happen is a team response – let’s rally around, let’s get this sorted.”
Instead too often he encountered staff who feared that raising issues meant “putting my head above the parapet, to be criticised or shut down or accused”. He encountered such a response at all levels, including senior medicine and management.
“The idea that you have a collective instinct, that ‘we’re in it together’ doesn’t seem to exist and I think at the heart of it, that is a leadership issue,” he says. Among his recommendations are competence standards for NHS managers, at key points in their career, and consistent systems of appraisals, training and development. The absence of such systems means that despite being Britain’s largest employer, the NHS does little to attract or develop the best leaders, he says, instead swapping around the most senior figures, and giving far too little help to those coming up the ranks.
“Talent management is almost non-existent,” he says, suggesting that boards with good senior executives “hoard” them and those in a comfortable job have no incentive to move.
It is hard to persuade senior managers to take on the toughest and most high-risk jobs, turning around organisations with the worst performance. “I would describe the senior leadership in the health sector as a transfer market,” he says.
“It’s just headhunters that are paid ridiculous amounts of money phoning up the names that are already known and asking if they want to do jobs as the head of trusts. It’s unbelievable.”
While the findings were welcomed by Government and the NHS, there has been little outward sign of changes, though Sir Gordon believes plans to roll out such changes are still “alive” within the health service.
Before his report was issued last June, newspapers – including this one – were briefed by Government that it was part of a war on “waste and wokery” with the NHS ordered to cut “diversity and inclusion jobs”.
Today Sir Gordon describes those messages as “a total distortion of the findings”. The report itself was rather more nuanced, suggesting that in time the numbers in such posts, should naturally reduce, if the health service made progress tackling inequality
“It was a single issue plucked and magnified to turn it into a whole ‘woke thing’ which I have no time for at all,” he says. “There is inequality in the way that people are dealt with in all systems and you need to recognise the experience and understand it.”
Sir Gordon has now moved on to a task that may prove yet more thankless – as a non-executive director of the UK Health Security Agency (UKHSA), the body which replaced Public Health England. Auditors have just refused to sign off its first set of accounts, accusing it of having “no clear oversight structure in place” for its first six months, until belatedly appointing a non-executive team.
A fitting challenge for a military man, perhaps, who has also taken on a more celebrated role as Constable of the Tower of London, taking possession of the fortress keys, in a role once filled by Thomas Becket.
Asked what lessons the NHS can learn from the military, for Sir Gordon, one stands out: the need for a clear vision, rather than a blizzard of dictats.
“Mission command: giving a clear direction, rather than setting out all the detail of how you want it done. I think there is a lot to be said for that.”
‘Without a well-led workforce, the sand is slipping through your fingers’