Leadership in the NHS - who is responsible?

I heard a story last week that made me reel.

A loyal clinician was given a token as recognition of service over fifteen years. A group of colleagues gathered and a manager presented a pen, in a box. The recipient opened the box, took  the pen and tried to write with it, to find it contained no ink.

“Typical!” was the response. “They give me a pen, but there’s no ink in it. What good is a pen without any ink? Typical NHS. Scrimping and saving, undervaluing us. I am not even worth the ink to go in my pen.”

Within ten minutes, the gathered group had dispersed to carry on with their work. As each of the group met another colleague they repeated the story of the pen until the latest urban myth was established.

I say 'urban myth' because after the comment about the lack of ink, the manager picked up the discarded pen, opened the box, lifted the false bottom to the box and found the ink refill. Looking up to find an empty room, it was already too late to run after everyone and shout, “There is ink! They did give ink. We are worth the ink in the pen!”

There is so much to say about this story. The dismissive attitude of  the recognition of loyal service. The institutional cynicism. The externalisation of motivation which leads to transactional rather than transformational working. But it is from a leadership perspective I wish to look at this tale more closely.

A week after I heard this story I read an article on “hittability.” The author is a healthcare leadership expert in the USA who teaches and writes extensively on the topic. His thesis in this article is that hittability relates to whether we see a leadership challenge as solvable. He says that hittability is a  “function of our framing lenses – a person’s beliefs, values and worldviews” (Souba, 2016:1) that frames the way we see a leadership challenge and that this is in turn influenced by the way we perceive the future. I would add to this the level of personal responsibility we feel for such challenges, our sense of self efficacy and our desire to act to change the future.

The first thing that Souba highlights is the difference between technical expertise – our fund of knowledge and skills, and what I call transformational expertise – the ability to “see” beyond the restrictions of the challenge. Souba says that what marks out exceptional leaders is that they “see, understand and deal with leadership challenges differently” (ibid) to most people. They are able to separate the facts of the challenge from the various narratives that are constructed by the stakeholders.

Souba identifies a ‘Prevailing paradigm’ which emphasises what is known, and focuses on skills, know-how, competence and expertise and an ‘Emerging paradigm’ which emphasises what is seen. This paradigm suggests that leadership is largely a function of the  hittability of leadership challenges and that effective leaders reframe situations so they can see them as hittable.

If we return to the pen story, we can see that the prevailing narrative, which was quickly adopted, was that the NHS as an employer did not value its workers. This narrative ignores the fact that the clinician was given a pen in the first place and focuses on the perceived lack of ink (which was also factually wrong) to perpetuate the prevailing narrative. That the narrative was further and immediately amplified by those who had been in the room, and those who had been told the tale, suggests that not only was the narrative  a familiar one but also very popular with the majority of the group who spread it. With such a strong and pervasive narrative, one wonders how a leader can re frame this?

If we look at the prevailing paradigm, we can see that narratives about the lack of ink and its representative lack of value of the clinician betray an attitude  of helplessness. The recipient framed himself as worthless, and powerless in the face of a huge, faceless power called “They.”

However the manager, who looked under the false bottom of the pen box adopted an attitude of curiosity, assuming that there might be some ink, not dismissing a solution out of hand before a period of investigation. This reframed the situation, placing the employer in a more positive light and more importantly placing herself as an active, enquiring agent.

An alternative interpretation might have been that the recipient, on finding no ink, accepted the situation and resolved to buy some ink on the way home, thus reframing the employer in a neutral context and himself as a responsible agent of his own destiny.

So, in order to be able to face leadership challenges with autonomy and self respect, we need to learn to reframe the challenges we face. Seeing challenges   as “hittable” depends on us and our ability to reframe the lenses through which we view such challenges.

“Great leaders don't just listen carefully; they also recognise that their framing lenses and their listening are inseparable…..Listening from the place of ‘this person has something important to say’ and listening for the future she or he is committed to constitutes a very different framing lens than listening from a place of ‘this conversation is a waste of my time’ and listening for the first chance to end it” (Souba, 2016:2).

How often do we listen with a mindset that has already decided there is nothing worth hearing? Who crafts our lenses? With what are they smeared? Because we look through our lenses rather than at them, they are often imperceptible to us, says Souba. But what would happen if we took some time to look at our lenses, to ask whether  they are the lenses we chose for ourselves, those we most need, for our own benefit and that of the work we do? How often do we just accept without scrutiny the lenses we have had thrust upon us by the prevailing culture in which we work?

Souba suggests that by not making a conscious choice about our lenses, we are being schooled to accept the lenses of others around us. Our view of the future is in itself a lens which frames the present for us. But if we could make a choice about the future, would we really choose the one we have been enculturated into? Ask any clinician if they are happy with the current situation and they will say no; ask what they think the future holds and they will shudder in despair. But Souba says “having a clear picture of the future you want to create is critical because it acts as an inspiration that alters your ways of being and acting right now” (Ibid), which in turn brings the desired future into the present. Committing to a positive future makes challenges more hittable.

The act of reframing is not just about the challenges we face, it is also about us and the people we are. This is what makes it essential if we are to continue. Souba’s key question is twofold: how do we reframe our healthcare challenges so they show up as hittable, and how do we reframe ourselves so we show up for ourselves as able and confident?

If we are not interested in doing it for the greater good, we should be motivated to do it for our own good. Clinicians are asking for resilience  training, not realising that only they hold the power to develop what they need. Giving up at the first hurdle (“there’s no ink in my pen”) and blaming it on the organisation is self sabotage. Saying to oneself, “I am honoured to be recognised beyond my pay packet, and here is a token of that - a pen, in a box, with even some ink in there,” reveals a happier, more resilient professional, who has a stake in his or her own future, and the agency to create it.

Souba, W. Hittability: The Leader's Edge. Academic Medicine. Nov 2016

doi: 10.1097/ACM.0000000000001498

Early Adopter, Early Cynic, Blind Complier or Blind Rebel? How do you react to training courses?

Surgeons' reactions to training, assessment and management courses is understandably at a low ebb. With the PMETB trainer requirements deadline earlier this year, many consultants found themselves mandated to attend a range of courses in Educational Supervision; Clinical supervision; Training the Trainers; WBA tools; Assessment and Appraisal; Equality and Diversity; Trainees in Difficulty; or 'Manual Fire Bucket Assessment Handling' as one surgeon referred to the homogenised mass of courses he had to take.

Disparity in content, delivery and quality of these courses has led to a lowest common denominator perception among participant groups. Think of the worst course you have ever attended, multiply it by ten and you have the level of underwhelming expectation with which most groups greet their latest day out of clinical practice.

In little over three years there have been well over a thousand participants (estimates at time of press number over 1200) through the Royal College of Surgeons of England Training & Assessment in Practice (TAiP) course. Such numbers enable perception analysis to be carried out regarding the differing reactions from participants, to the course. Four predominant types emerged:

• Early Adopter
• Early Cynic
• Blind Complier
• Blind Rebel

TAiP was developed by an educator and a group of surgeons to support consultants in the use of the ISCP, a new training and assessment programme developed by the Intercollegiate Surgical body in response to MMC (modernising Medical Careers) and the advent of the EWTD (European Working Time Directive.) Although TAiP contains strategies to support consultants in using the new WBA (Workplace Based Assessment) tools, many participants see the course as an imposition.

The aim of the TAiP course is to give everyone the information they need to use the ISCP system in accordance with good training practices. This requires understanding of the system and a willingness to use it.

In analysing the different responses to the course, it became clear that these two predominant factors are central to a person's response. The first of these concerns capability; that is whether the surgeon comes to the course with either an understanding of ISCP or the capability to develop an understanding within the day. The second factor relates to attitude; does the surgeon have the willingness to work with the system? Some participants have an attitude of open mindedness, or compliance with suggested new approaches. Others have greater resistance to any suggestion of change and are determined not to comply with whatever is suggested. This attitude is very often pre determined by factors outside the area of responsibility of the group facilitators.

Understanding these patterns of behaviour can assist the facilitators to relate appropriately to each participant and to manage the course in slightly different ways, according to the group make up. By examining the four permutations of the aforementioned factors we can see that each response type presents its own challenges to the facilitators.

• Early Adopter - high capability, high compliance
• Early Cynic - high capability, low compliance
• Blind Complier - low capability, high compliance
• Blind Rebel - low capability, low compliance


The Early Adopters in a group have both high levels of compliance and capability. They are often keen to make sense of a new system and to find ways to implement change. They are not afraid to be seen to be different and for this reason often occupy positions of leadership. Early adopters do bring their own challenges to the group facilitators. Whilst their open mindedness means they are willing to look at new perspectives, their high levels of capability require the facilitators to have a sophisticated grasp of the issues and perspectives, the knowledge frameworks and the medical settings within which the participants work. If facilitators demonstrate credibility, considerable levels of knowledge and understanding, and harness the inventiveness of the group to a common goal, even making them think they have developed original ideas, the early adopters will react overwhelmingly positively to the course.

The second group are called Early Cynics because their lack of compliance means that they often announce their cynicism at the start of the course. They can initially appear to be very challenging to the facilitators but by asking about their cynicism it is easy to tell whether it is informed or not. Early Cynics can be the most rewarding of all participants due to their high levels of capability. If their cynicism is ill informed, they are not Early Cynics at all, but fall into the fourth category, Blind Rebels. There are some Early Cynics who have high capability but who are so fearful of change that their high level of non compliance reduces them to the fourth category too. But real Early Cynics have high levels of capability; their ideas are often persuasive and they are quick to grasp new information. It is their intelligence that will triumph over their non compliance and result in a positive response to the course at the end. For course facilitators Early Cynics present two challenges. Their aggression at the start of the course can be disruptive and hold up progress. If they are given a limited space to air their views, this will “park” their scepticism. And then, in a similar way to the early adopters, the Early Cynics require facilitators who are knowledgeable and who also demonstrate persuasive, informed argument. (Cynicism with poor levels of understanding is not cynicism but rebellion. For this reason the only true cynics are those who know what it is they do not believe in.)

The third group of respondents appear to be relatively easy members of the group initially. Called Blind Compliers they are characterized by their apparently high levels of compliance and low levels of understanding. They ask few questions and appear to be absorbing what is being said. However, without careful handling this group can easily leave with little more than they came. Their compliance means they are not likely to question the frameworks being presented, but unless all the details of the course, including acronyms, roles, responsibilities and relationships are spelled out to them, they let much of the new perspectives wash over their heads. Whilst they may present little by way of attitudinal challenge to the facilitators, the faculty must check that Blind Compliers are following, understanding and integrating what they are exposed to on the course into clinical practice. A course can become a one way didactic session never really getting beyond the basics of the course content, if there are lots of Blind Compliers in a group, so facilitators must ensure that these learners are made to think for themselves too. If the overall group has a mixture of Blind Compliers, Early Adopters and Early Cynics, it challenges the facilitators to cover the basics in a simple way but also to extend the complexity of the arguments for those with higher capability and understanding, as already discussed.

The final group is probably the most challenging but they often have the greatest need for the course. With Blind Rebels both their compliance and their capability are low. Most often they have attended the course because they have been forced to do so, either as a result of an appraisal action or because there have been threats associated with non attendance. This group have developed a stance of non compliance as a result of their lack of understanding or willingness to engage in new ideas, and see courses as threats to their professional standing. They will argue fiercely against any proposed change, finding a range of people to blame for the changes they see as having been externally imposed. The difference between this group and the Early Cynics is that the Blind Rebels do not have the capability to argue with any degree of information or logical reasoning. Indeed, the more vociferous they become the more the rest of the group begin to disengage with them. This group of participants can be very disruptive as they can raise a comment or an objection to every point made. The challenge for the faculty is to maintain composure in the face of often rather offensive behavior and to remember that this group need as careful instruction as the Blind Compliers. It would be encouraging to think that information would assist the Blind Rebels to overcome their non compliance but for many in this group it is often not enough. For those who are determined to destroy the course, it may be necessary to respond to their ill informed arguments somewhat aggressively, highlighting where they are misinformed and emphasizing that both information and a change in attitude would indeed help them to overcome their grievances. Often it is only their self instigated isolation from the rest of the group that finally reduces them to silence. Frequently they have to be allowed to hang themselves with their own petards, necessitating a group attack on their disruptive behaviour.

In an unrelated field but one which may be interesting to compare, we can see that similar findings have been discussed with regard to the responses of people to new technology. The Everett Rogers Diffusion of innovations theory - for any given product category, shows five categories of product adopters:

o Innovators – venturesome, educated, multiple info sources;
o Early adopters – social leaders, popular, educated;
o Early majority – deliberate, many informal social contacts;
o Late majority – sceptical, traditional, lower socio-economic status;
o Laggards – neighbours and friends are main info sources, fear of debt.

However this pattern is a linear one, describing types of people within a range of demographic factors, including social background, psychological make up, educational history, personality and popularity, economic situation, social influences and fears. In the paradigm used with surgeon responders to courses I look simply at the responses relating to two factors – those of compliance and capability.

For those of us involved in education and training, this paradigm provides us with an interesting perspective on the challenges facing us in any group of participants in a course group. A surgeon cohort group should not usually be perceived as a mixed ability group in the usual definition of the term. All consultant groups must surely share a similar level of intelligence and motivation to have achieved the position of consultant. But new initiatives coupled with the disenchantment surrounding the many changes we have seen in the last five years, mean that attitude to change as well as engagement with it result in a mixed ability reaction to training courses.

For course facilitators, such groups can be very challenging for a variety of reasons. Understanding the factors behind the behaviours of surgeons attending such courses can help faculty to respond appropriately to each type of participant, ensuring maximum success and minimum disruption for each course group.