Elephants, riders and the NHS

“Leadership is not even that interesting. It’s obvious why someone would want to lead, the real puzzle is why someone would want to follow.”. This line peaked my interest, as someone who is very much the reluctant leader I had never (and still don’t) relish being in a leadership role. Followership is much more appealing to me. I do recognise how lucky I am to be in my current position, it’s just a position that feels particularly ill-fitting. I have a preternatural preference for lone working, I love exercise but dislike team sports, I love cinema but only near empty showings, and my favourite place in the world is driving anywhere in my car alone with nothing but a podcast or the radio for company. As such, employment in the NHS is probably something I should’ve reappraised many years ago, except that I genuinely do enjoy achieving success with people. I just happen to find talking to people so mentally taxing that I sometimes wish I could perform all my communication entirely through the written word. Yet even I, someone who is such an introvert that I once willingly sat in my car for a whole hour waiting for a vague acquaintance to leave a building before going in (to avoid the inevitable awkward chat) still feel a sense of value, positivity and joy from group endeavour. And so perhaps this explains why a role in the NHS is not such a bad fit for me after all, as shared goals, failures, successes and efforts are all par for the course in the NHS. I had never really understood the internal conflict that I feel each day……. until now.

The Book

The last few weeks I have been reading a book titled “The Righteous Mind” by Jonathan Haidt, and it is a book that has radically altered my thinking about so much. The quote at the start of this blog is taken from the same book, it’s over a decade old now, but I do wish I had read it much sooner, and I would recommend everybody locate a copy and dive into it soon (especially if the recent Trump election win feels inexplicable to you).

I’ll attempt to summarise a few of the key findings but the blend of philosophy, politics, religion and leadership on offer in the book is a heady mix that certainly benefits from the longer form.

The two central dichotomies I now feel clearer on after reading the book are:

• I prefer being alone but still value shared effort,
• I find the decisions and reactions of others hard to predict or comprehend in most settings.#

Chimps and Bees

Taking the first bullet-point, the book explains that humans are ‘90% Chimp and 10% Bee’. And this is used to describe our tendency to be very individualistic the majority of the time (90% chimp) but with a strong sense of ‘hiveishness’ (or groupishness) the remaining 10% (the bee). This simple analogy provides a reassuring insight into my internal sense of struggle and neatly encapsulates why I mostly prefer being alone yet still feel a need for group identity. The book elaborates much more fully on the reasoning behind this natural human tendency towards both individualism and groupishness, and inevitably it has evolutionary roots. The groups that best adapted, worked together and supported each other were best able to survive and pass on their genes to the next generation.

Elephants and riders

The second bullet-point is one of struggling to understand the emotions and decisions of others, and again the book offers an animal based analogy that illustrates the reality of how a human mind works. The author describes a rider sitting atop an elephant. The elephant represents the ‘gut reaction’ or the instinctual choice we make when faced with a decision. And the rider represents the reasoning process. In this analogy you can envision how the elephant (our initial reaction) is what starts to turn first, and we then set upon a path without the rider (our reason) having had a chance to coldly and logically inform the decision. We might believe we use reason to inform our choices, but the reality is that our gut instincts and initial reactions are what drive our decision making whilst our reasoning processes (or rider) simply rationalise and justify our decisions post hoc. The sobering fact is that humans use reason for justification, not truth. And if you take a quick scan of social media, mainstream media, the political discourse, the religious discourse or any other form of discourse, you will quickly see examples of people seeking to justify, rather than be truthful. This explains why populist politicians have such an advantage, as they appeal more to our elephants and not our riders.

This is something that impacts us all, we each have our own instinctual reaction when presented with a choice and this reaction is informed by our development and experiences over the years. And when this occurs our elephant will instantly begin to ‘turn’, and this may be to the bemusement of others who’s elephant (their instinctual decision) would’ve turned a different way. We then face questions and challenges about our choice, and our rider (or sense of reason) will leap to our defence and justify our ‘chosen’ course of action, and yet the outside party looking in will only see irrationality where we see reason. This is where conflict so often arises. As arguing against belief rather than reason, is fruitless.

After reading this book I now realise that seeking to understand a person’s reasoning is a mistake on my part, instead I should be seeking to understand them as a person first, to then allow me to understand their beliefs.

How's this relevant to healthcare?

You might now be questioning what relevance this has to leadership, healthcare or anyone else who might be reading this.

Well, I believe that the NHS can better utilise our tendency towards both individualism and groupishness to foster a work environment where staff feel a tangible sense of belonging. And in doing so resolve the challenge of workforce retention and lower productivity. And if the NHS can apply learning from the elephant and rider analogy then we can change leadership behaviours enough to build greater staff engagement, trust and followership. All of which are crucial to the next 10yrs of the NHS.

Groupishness is endangered in the NHS

If we accept the premise that people need and actively seek group identity then the way the NHS is structured actively hampers this from establishing itself. The NHS has developed ever more collective nouns for both its organisational arrangements and its geographic catchments; collaboratives, partnerships, systems, neighbourhoods, places, groups, providers, directorates, regions, ICS’s, ICB’s etc etc. The fact that healthcare staff have access to ‘explainer’ videos describing this stuff should be all the evidence we need that it is a convoluted mess. Yet, not only does the current structure present a challenge for healthcare staff to know where they fit into the whole, it also prevents us from identifying or aligning with a meaningful group size. The scale of these new geographic and organisational structures are anathema to any sense of team being developed.

The group we should be encouraging our staff to identify with, to bond with and to grow a sense of family and trust with their immediate team. And by this I mean the colleagues, clinicians and administrative professionals that they work alongside to deliver their service. As soon as we ask staff to work as a ‘team’ across the more nebulous and far larger structures described above we are setting them up for failure. The author of the Righteous Mind suggests that anything larger than about 150 people is too large to allow a shared sense of ‘group’ identity to develop. And every faux structure I mentioned previously far exceeds this threshold. And of course smaller teams find this identity much easier to cultivate.

Not only is a system, a place, or a collaborative a poor structure in which to develop camaraderie and teamwork at scale, the NHS is actively dissolving whatever sense of groupishness a smaller, localised team may have by continually attempting to change and tweak these structures further. And often this is done in the name of……….. integration.

Integration has been an NHS buzzword for longer than I have been working in healthcare, and yet no one really knows what it looks like or when it is achieved. The definition of ‘integration’ is “the action of successfully joining or mixing different groups of people” (Cambridge Dictionary). From an NHS perspective this would mean the joining or mixing of healthcare providers, healthcare services or other structures into a unified whole. The idea being that this would align processes, reduce duplication, and allow for a more cohesive patient journey etc. Yet, what this normally means in reality is greater ‘collaboration’ (not integration) between separate and distinct healthcare services, providers and other structures. Rarely does real integration actually take place, mostly because commissioning and financial budgets dictate what services deliver what interventions. And as the NHS continues to create these additional borders and fracture lines this collaboration becomes more complex, ironically making true integration harder to achieve. Instead we often apply the phrase ‘integrated working’ instead, asking staff to work in an integrated fashion without actually integrating the structures and processes. Of course, this is not a viable solution and results in staff burnout, reduced productivity and ultimately staff attrition.

Integration is neither good nor bad, it is how it is delivered and achieved that ultimately dictates its utility. Integrating already large, suboptimal structures or organisations will simply create even larger, suboptimal structures and organisations, and this brings greater challenges around developing effective team identities. In the case of team working then size does matter. Integration could be beneficial if team dynamics and effectiveness were always factored into the planning and change process.

I propose that instead of blindly accepting ‘integration’ to be the panacea to the NHS’s ills, we should instead intensively focus on building effective service level teams, and be ambitious in supporting colleagues to develop a sense of group identity, trust and shared endeavour. This would provide a strong foundation for these newly bolstered teams to go forward and collaborate (not integrate) with other strong, trusting and enabled teams. This is the most important element, because if team members feel secure, trusted and anchored in what their team can deliver then they are much less likely to practise defensively, to deflect referrals or to hide their own errors. It is this sense of trust and security within teams that needs to be treasured, tended to and scaled. Where there is trust, there is productivity.

And if this sounds like woolly, imprecise and idealistic principles unlikely to ever work in the real world, then Google took the time to research effective team working during Project Aristotle. They found that the most impactful and productive teams had:

• Psychological safety
• Dependability
• Clarity of structure
• Meaning to their work
• Sight of their impact

Google obviously did this research to enhance their profits, not out of goodwill or a sense of wanting to pamper their staff. Which makes it all the more revealing to see the above principles for effective, productive teams. Now apply those principles to the structures we find in the NHS and ask where they might best be applied. I would suggest that a service level team is the optimal scale for developing these principles, and that trying to keep sight of your impact or maintain clarity of structure, for example, at a system or collaborative level is an impossible task for individual NHS healthcare workers.

How can the NHS harness its elephants?

As I have shared many times before, I believe NHS staff are our greatest resource. And I align strongly with the ‘safety II’ model of actively learning from ‘good’ care where staff are viewed as an adaptable asset, opposed to the ‘safety I’ approach whereby staff are viewed as a liability and where we learn from things going wrong (Safety I or safety II).

So often in the NHS policies and incident responses are written and instigated in a manner designed to prevent ‘bad’ behaviour or practise from being repeated. This approach does not work well, as often the behaviours and actions that lead to an error or omission are the very same actions that result in positive outcomes many more times over. We need staff to be able to adapt, deviate and flex as one would expect in a complex, adaptive and high stress industry such as healthcare. Yet sadly, the ‘safety I’ approach is still the most commonly adopted one.

This leads staff to feel distrusted, dictated to and lumbered with increasingly labyrinthine processes, tick boxes or IT systems to negotiate. Often these processes and tick boxes have arisen out of past safety incident responses and action plans, all created through good intention but all simply adding to the tasks of frontline clinicians. When humanity is stripped out of healthcare, when it is further mechanised, and when healthcare is increasingly taskified then clinicians and their decision making changes. Their elephant is more sensitive, more liable to seek comfort, to avoid risk, to avoid complication and to minimise effort. In short, when faced with a ‘difficult’ situation then they are more likely to turn away and take the ‘safer’ option which in healthcare may often be the less impactful one and/or be the more insidiously harmful option. Like delaying discharge that little bit longer, or requesting one more test, or prioritising the completion of risk assessments above sitting and conversing with a patient to really understand their needs. The NHS’s cultural and operational environment creates a herd of instinctual elephants to turn away from fewer but deeper meaningful interactions with patients. And instead staff are turned towards more frequent but shallower interactions that places value on activity over impact. And all the while their riders (or reasoning) have been trained to retrospectively justify this course of ‘chosen’ action with pernicious phrases such as “If it’s not written down it didn’t happen.”.

NHS staff need to be given the time and capacity to value the depth of their interaction with patients and service users again. And NHS structures need to find the courage to accept that on occasion harm will occur, and where staff maliciousness is a contributor then this must be dealt with swiftly and robustly, but the majority of cases will not be because of this. And where staff have made an honest error or caused unintended harm, due to a behaviour or action that would normally just be an adaptive feature of their work, then they should be given the time and support to work this through. It should not result in action plans or reactions seeking to limit all similar, future behaviours. If we can achieve this then we will grow and develop staff trust, and professionals and clinicians will feel able to practise more holistically whilst experiencing less moral conflict in the work they deliver.

If we begin to release the binding reins of patient safety that often hinders staff action more than helping it, and we create the conditions in which we can trust their elephants to turn the right way, then we won’t be so reliant on ill-informed and powerless riders to justify errant behaviours and outcomes.

Summary

I realise that I often sound critical of the NHS, but it is only because I value its potential so greatly. To have so many people working together to improve the health of a nation is truly precious. And yet I often feel that the people working in the NHS are not treated as its most valued asset. The Righteous Mind has taught me that group identity and a sense of ‘team’ is powerful and critical to human wellbeing. And I believe the NHS needs to harness this bee-like tendency instead of acting counter to it. I also now recognise that people/staff do not make their decisions based on reason, and instead see their elephant turn instinctually. It’s up to the NHS to create the environment whereby healthcare staff see their elephants instinctively turn towards the welfare of patients, rather than towards the preservation of their own sanity, registration and sense of moral conflict.

If we optimise team working, then we optimise decision making, and this will optimise patient care.

p.s.- The vague acquaintance I described in the first paragraph became my wife. And we’ve been together for 22 years.