Why “Send in the Army” might not be the best way to ‘fix’ the NHS

Published on: 23 April 2019
Written by: Ben Tipney

Many of you may have read the recent article citing Matt Hancock’s proposals to bring in the army to boost leadership skills.

Does any of this sound familiar? Until recently the rhetoric was very much that healthcare should see civil aviation as the exemplar for safety - certainly the previous Health Secretary Jeremy Hunt was keen to promote that idea, and to some extent it still abounds.

Is bringing in the army Mr Hancock’s way of putting his own stamp on Patient Safety? He also suggests bringing in experts from the retail & service sectors to train NHS managers in motivation and team management. This is nothing new, with books like Fred Lee’s “If Disney Ran Your Hospital” and numerous articles suggesting that the NHS should learn lessons about leadership & customer experience from corporate retailers.

Before we consider the validity of any of these comparisons or initiatives, we have to first put a stop to this notion of "the NHS" being cited as an entity that must learn, or do anything for that matter.

The NHS is a concept, a vehicle through which public funding is channelled to a multitude of provider organisations (CCGs, Trusts etc) and regulatory/advisory/support bodies (NHS England, NHS Improvement, CQC etc).

Our healthcare is provided by such a vast array of organisations who provide hugely different services. Just consider for a moment the difference between providing community mental health in a low density and geographically dispersed part of the country to working in an Emergency Department in an acute hospital in a major city centre.

Whilst some of the underlying knowledge carried by some of the professionals is consistent across the health service (e.g., Doctors’ Foundation Training), the jobs themselves, the environments and the contextual challenges are hugely varied. I would go as far as to say that comparing operating theatres to a GP practice is like comparing football to tennis.

The model of safety/performance is contextual — whilst many of the components of performance (e.g., system design, rules & processes, attitudes & behaviours, cultural norms) may be common, the relative contribution of each component will vary depending on where you are. This is eloquently described in Charles Vincent and Rene Amalberti’s book, Safer Healthcare — Strategies for the Real World (free online).

In it they describe the trade-off between standardised processes that protect operators through layers of redundancy on the system (Safety I) and building flexibility into the system/allowing space for professional judgement (Safety II/Resilience Engineering). This balance very much depends on the environment — to what extent does the level of potential control/predictability/resources allow you to design error out of the system.

Healthcare is very unusual in that the various domains of the industry sit at different points on the scale, and this means that no one model of performance/safety is appropriate for all of healthcare — whether it comes from the Army, Civil Aviation, Tesco or Disney World — or indeed from another part of healthcare. Interestingly much of the research and expertise in the field of human performance under pressure and team dynamics comes from high performance sport, yet this is hugely under-utilised.

As humans we have a habit of slipping into either protectionist thinking (we’re different so what they do doesn’t apply to us) or trying to cut & paste from one environment to another — neither is helpful and one tends to breed the other. There is no doubt that there is much that can be learnt between all risk industries (e.g., healthcare, aviation, rail, fire service), the retail & service sectors, the various branches of the military and the world of elite sport.

The problem comes when we look to bring in individuals who have extensive experience in one of those domains, as they tend to see issues/challenges through the (relatively) narrow lens of their experience and their model of performance. In order to develop contextually appropriate solutions, we need to look at performance with a wide-angle lens and this can only happen using a team approach, bringing together professionals and leaders from multiple fields/industries with experts in Human Factors/Performance Science to establish common factors of high performance, and then working closely with front line professionals in each domain of healthcare to build a model of performance that fits their environment.

Any training or education that is delivered also needs to consider the specialist skills required to deliver that effectively. Education is a performance discipline in its own right — too often training is ineffective, not because of content, but because of a lack of educational skills and/or pedagogical rigour.

Coming back to the original article ;

Do NHS Managers need more support than many currently get to develop leadership and management skills?

I’m sure few would disagree.

Is it possible that leaders from the armed forces or retail/service sectors have value to add in healthcare?

Absolutely.

But does their style of leadership/model of performance fit any/all healthcare domains? How much variability exists within military leadership itself for example, and importantly - how much does Mr Hancock actually understand about any of this? "NHS Managers will be trained by the Army" makes a nice soundbite, but we should exercise a tremendous amount of caution before attempting any form of wide scale initiative that focuses exclusively or predominantly on seeing one industry as the exemplar for another.

I don’t consider myself to be an expert in any particular field, but I am fortunate to have had a diverse experience of working with and developing high performing teams across a diverse range of domains including sport, secondary/tertiary education, various aspects of the corporate world and healthcare. I am always excited to meet, work with and learn from those with particular specialist knowledge/skills and with different experiences to my own, and the MedLed team come from a diverse range of backgrounds, enabling us to provide that wide lens — which will continue to develop as our team grows.