Lord That’s A Damned Shame
There are undoubtedly issues to be worked through in the ever-growing ripples of the Letby case. But one that’s not being touched on is puzzling. Is this as much an HR failing as a medical duty of care one? In a world obsessed with propriety and governance, what not only went wrong here – but why does it keep going wrong so catastrophically?
The issue would not arise if the HR actions had not included compulsory mediation and apologies being instructed. HR inquiries became bullying accusations while inquiries into the medical facts proved that something serious was genuinely amiss, even if they were not in a position to say at that stage precisely why. It forces you to ask the uncomfortable questions of what conditions have to be in play before a mediation effectively chastises a whistleblower, cannot identify a serial killer, and perpetuates dangerous and lethal conditions of work?
There are certainly issues of culture in play, and even the Nursing Times led with calls to end a ‘defensive leadership culture’ in the NHS generally. ‘Defensive’? With 5.6% of the salary bill going on negligence disputes, you betcha.
But wait. The infants suffered.
The trope of ‘lessons learned’ simply won’t work here as the Allitt case (nurse, 13 cases) is just too close for comfort. Add to that Shipman (GP, c250 cases), Norris (nurse, 5 cases), Chua (nurse, 3 cases) and a timeline in living memory of 1991, 2000, 2008, and 2015 respectively and it’s clear lessons are not being learned. Arguably in that structure, they can’t be.
Structural power plays
The structural politics dominates. Power plays echo throughout cases such as these, and especially brand-threatening reputational risks cases involving whistleblowers. That the HR team in Letby’s case were misled by a top rank sociopathic narcissist is not an excuse either. It’s their job to know them when they see them, and statistically every large organisation must have some.
The only saving grace here, and in all of these NHS cases, is that statistics don’t lie, but even that’s not a simple issue. Letby’s cunning was that she used the special vulnerability of extreme perinatal cases as ‘cover’. Eventually, the body count was simply inescapable. The same happened with Allitt being the only person in place for each case and with access to the necessary tools. But it is also true that with several maternity units nationwide having been exposed with unacceptable track records in care, managers would be very keen to ensure they did not join the statistical list of those reputationally scarred. Arguably this was only caught because the stats highlighted it, but equally the issue lasted so long because avoidance of reputational damage was front and centre too.
The six types of power
The difficulties hinge on the function and balancing of ‘expert power’ in particular, and the NHS is not alone in this by any means. Take a minute to review the types of ‘power’ in play and the complexities of the Managers versus Medics dialectic becomes very clear. Managers will also be dealing with porters, facilities managers, carers, insurers, lawyers, politicians, and often nurses will be a useful foil to the power of senior medics and consultants especially. The political ‘soup’ whereby issues escalate to high profile plays is also toxic.
‘Positional power’, especially that of a ‘manager’, can mean very little when confronted by ‘expert power’, especially that of the consultants. Bear in mind that the most prolific serial killer still in the UK is a Volvo-driving GP, and things get muddy. The senior medics here were calling out behaviour, and they were met with strong weaponry from the managers’ arsenal. Former nurse Letby clearly had a lot of ‘referent power’. Any sociopath will meticulously build this over years, and Letby was clearly proficient at it. It’s the soft power of charisma, contacts, networking, and often ‘reflected’ adulation or references. In the public sector especially, a common weapon in the arsenal is recourse all too easily to stress, bullying, and a plethora of tactics that delay and complicate discipline and grievance wrangles. The managers here had ‘reward power’ in their remit (at CEO level especially), and they used ‘coercive power’ in the mediation options deployed, forcing a doctor to apologise to Letby against his better professional judgment. It was only the still small voice of ‘informational power’ (the 20+ questionable deaths and life event stats) that eventually enabled referring it to the police.
Experts
The context is clearly that leadership in a professional environment can be enormously complicated by ‘expert power’. Experts are often by their very nature lousy at managing anything other than their narrow field of expertise. They also have enormous clout in ‘negative power’ where their expertise is central to the core purpose of the organisation, ie simply refusing to abide by recommendations, instructions or procedures. It’s why professional managers are so often stymied from the outset in seeking change. This is not unique to the medical profession. Barristers are ‘managed’ by clerks who control the flow of work, while several tiers of amorphous senior power brokers oversee advancement and conduct. Very few would claim that, frankly, even any of the ‘true’ professions (medics, lawyers, and clerics) are models of management probity, even today after generations of exposure to mature management disciplines. That an NHS HR team deployed positional power, referent power, reward/coercive power and simply got it completely wrong on an informational basis to deal with their long-running arm wrestle with those with expert power speaks volumes here. Issues such as budgets and staffing levels were explicitly used to deflect from ulterior quite evil motives, and again, simply won’t carry the issue.
Every enterprise where the experts run the show needs to look at the balance here. The NHS especially needs to find a structure that rebalances this better. Suggestions that reference should be made to external teams and investigations are already coming forward. In a procurement environment like the NHS, and indeed within most expert power-driven businesses, external references are only ever made when the answer is already known. Bureaucracies don’t ask questions that they don’t already know the answer to. The Trust structure is still struggling to fill vacancies in Cheshire, for perhaps obvious reasons, but the very fact that there are 28 oversight roles in it (10 vacant) means they will be ineffectual in precisely situations like this. None of their seven non-execs have legal or HR backgrounds either which would enable them to know when to drill in and upset apple carts.
Armchair criticisms? Maybe. I was privileged to see three organisations grow from scratch to 800-1200 employees each. I saw a world-class HRD at close quarters (take a bow Mr G). But I also saw some of the worst, from a non-exec now in prison, to sacked FDs, bullies promoted, incompetents shipped upwards, and even gross misconduct cases weaponised by an HR team against the interests of the victims. It’s an imperfect world, but all organisations need some grit in the oyster. What’s lacking is the respect for and deployment of characters who can manage it. In the NHS that means zero tolerance of a £9m pa negligence legal bill while (£150m worth of) experts are trusted in their fields. It means the right to manage not being constrained by bureaucracy while productivity soars.
Speaking truth to power
The role of non-executives is a key place to start here, and the ability to scrutinise the efficacy of the HR team in particular is often overlooked (management accounting too, in my view). In the Letby case a CEO ended up batting for the HR team on a decision that mid-ranking police officers could see needed criminal investigation within minutes. A hated, but effective, system I worked under was a global HQ ‘swat team’ known for taking scalps on every (unannounced) audit/visit. A weaponised CQC, I wouldn’t recommend it, but it was after its removal that a rot set in. This is only solved by careful curation of spans of control, but in large bureaucracies these are Byzantine. That’s the self-cleaning part of system design that the private sector is simply better at. And not really due to a ‘profit motive’ but simply because it gets more opportunities to address it, adapt and improve it. It should never be just a matter of votes and numbers either, although that’s what the top heavy tiers of governance default to; there’s a time for dashboards, and there’s a time for drilling in too.
What you need is someone who’s dealt with a bent FD or non-exec, removed abusive board members, not just team leaders, and replaced whole teams or divisions when the old adage of ‘rotting from the head’ emerges yet again. That the head rots so depressingly frequently is why management boards need insight, not just oversight. It is needed especially in environments where organisational change is rare, unionised, and always contentious. This adds urgency where the implications are lethal too. It’s not a matter of money; the governance world is awash with it right now. It’s a matter of incisiveness and celebrating those able and willing to speak truth to power. When Letby was at her peak in ‘16/’17 Cheshire Trust was a £230m enterprise. It paid staff £152m and directors £1.3m. It paid £19.6m on drugs and pretty much half of that again (another £8.6m) on clinical negligence fees. That’s a staggering sum, the reddest of flags.
But it just keeps happening. On this trajectory, statistically the next Shipman/Letby is already grooming their colleagues and environment to start their campaign and the NHS structure is simply incapable of dealing with it. In the words of that new hit song, ‘I wish that wasn’t true, but it is, and Lord, That’s a Damn shame’.