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Thursday 27 April 2023

Empathy for the Devil

By Jon Restell

We need to challenge the widely-held belief that all-powerful managers are blocking change in the NHS. It's a lack of empathy for the difficult choices and hard realities that managers face which is holding us back.

Jon Restell portrait 2021

NHS leaders are expected to show empathy in their work and interactions. Empathy is at the heart of compassionate leadership and only a handful of dinosaurs struggle with the idea. Yet policymakers, system managers and regulators are little short of Jurassic when it comes to showing empathy for leaders themselves. I want to explain why this gets in the way of making the NHS better.

Let’s be clear about what empathy means. It’s not the same as sympathy, kindness or liking – although it can result in all three. Some of the most empathetic people I've known have been cold fish; there are cod patrolling Arctic waters with warmer blood. For me, empathy means understanding. It means seeing the world as someone else sees it, without overlaying your own prejudices and preconceptions.

At the start of my career, I was struck by talking to a chief executive turned troubleshooter, who was definitely in the cold fish category. I don't think she liked people much – she much preferred animals – but she understood them. And she particularly understood hospital doctors who weren't performing well. She could describe the knot in their stomach as they tried to assert their authority, their fear of being wrong, of being challenged, and their self-loathing. At first, doctors would do anything to avoid being in a room with her. But once she deployed her bewitching empathy, they felt understood for the first time, and she earned a hearing and their trust. Then they could engage in the dull business of improvement together. It was quite moving to see how, years later, senior doctors would thank her for saving their careers – or even their lives.

In healthcare, empathy should be seen as an essential pre-condition for effective change. But where’s the empathy for senior managers in our discussions about regulating board directors, system reform, manager numbers, the Covid 19 Inquiry or executive pay? This lack of empathy will lead to the wrong answers and to plans for change that will be dead on arrival.

If you believe senior leaders matter greatly in healthcare, finding empathy for them is a high priority. The starting point is to lose the belief that it’s all-powerful managers who are blocking change in the NHS. There are three reasons why this myth about management power needs correcting.

First, NHS managers are massively constrained by the sheer volume of regulation, micromanagement by system bodies and the political control inevitable in a centrally-funded public service. Independent studies have found that NHS chief executives have far less room for manoeuvre than counterparts in the private sector – so much so that few industry bosses would touch the NHS with a barge pole.

Secondly, professional power is a major counterweight to management power. Royal Colleges and in-demand doctors have considerable say over what gets done and how, and many expect – and receive – the power of veto. I've supported more than one member facing a grievance the essence of which is objections by clinical colleagues to a change in accountability and direction.

Thirdly, despite twittering from the Daily Telegraph, senior NHS managers are not awash with management resources and tools to do the job. Indeed, we bang on about our low management spending, compared to private industry and better-performing healthcare systems, as though it’s a major achievement. The Hewitt review will undoubtedly conclude again that the NHS is under-managed and over-regulated.

Of course, NHS managers are not Wizards of Oz – powerless beings haplessly projecting the appearance of authority – but their powers are far more limited than most policymakers think. It’s what managers achieve every day despite the constraints that invariably earns grudging respect from former critics.

But the lack of hard-nosed empathy for the realities managers face is blocking important change. Demanding more and more, regulating harder and harder, and thinking ever more wishfully will change little. And we’re making it harder than ever to keep the right kind of leader in the NHS. As one thoughtful member noted, the elixir of the executive suite will always attract people to the top jobs. The problem is keeping them there and letting them make the difference they have dedicated their careers to making.

  • Jon Restell is chief executive of Managers in Partnership.

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