Joe’s View: Leadership, cultural revolution and health informatics

“Obviously a major malfunction.”

A chilling understatement which will take anyone who watched the Challenger Shuttle launch right back to that January morning in 1986. All seven members of the crew were killed that day, just 120 seconds after this photo was taken.

There was an excellent documentary on Radio 4 recently, The Reunion, which brought together the widow of Richard “Dick” Scobee – the commander of the space shuttle – and Allan McDonald, the director responsible for the manufacture of the rocket booster which failed and so caused the disaster.

McDonald tearfully recalled how, on the eve of the flight, he had convened a meeting to explain to NASA that the rocket boosters were not safe to use at a temperature of less than 56F. The weather forecast was for 18F.

He refused to sign the necessary release forms to approve the launch but, under financial and political pressure, his boss signed the paperwork to give the go-ahead. McDonald watched in horror as he was proved right.

Tear-stained lessons

The subsequent inquiry into the disaster criticised NASA’s organisational culture and management as overly hierarchical, saying any dissent was viewed as criticism.

McDonald said he was grateful he was subsequently allowed to take his tear-stained lessons into the design of new solid rocket boosters. They would successfully launch another 110 shuttle missions without failing.

It was with the intention of making my own measure of experience and painful failure come to bear on NHS IT that I applied for the job of chief executive of NHS Digital when it was advertised a few months ago. I knew that I wouldn’t be appointed because – unlike in the US and contrary even to what was recommended by Bob Wachter last year – the very top jobs in UK health IT don’t go to clinicians. A mistake in my opinion. But then I would say that, wouldn’t I?

The challenge of cultural change

I was interested to read Digital Health’s recent interview with Beverley Bryant in which she spelled out the need for a “cultural transformation” in NHS Digital. It was something she passionately reiterated at UK e-Health Week recently.

I have occasionally written about organisational culture and the need for NHS informatics to review its cultural baggage. I recall that digital health strategist Ewan Davis responded to that piece by saying there are three things that can happen when a new leader joins a new culture.

First – and most likely – the leader will be assimilated by the existing culture and get along with everyone who is already there. The organisation can then continue as before, and if it is well functioning and has a healthy culture, this is fine. Secondly, the new leader can decide to change the culture. But this is difficult and can result in organisational strife and the expulsion of the newcomer. The third and least likely outcome of a new leader dropping into a strong existing culture is that the new leader successfully changes the culture.

Now, NHS Digital has quite a lot of cultural baggage and is on its third rebranding in nearly as many years because of that baggage. The lovechild of a shotgun wedding between The Information Centre and Connecting for Health, they were for a time The Health & Social Care Information Centre and unloved stepchild of NHS England.

Around the time The Information Centre and Connecting for Health merged, I remember being in a lift in Leeds in which two CfH’ers were earnestly discussing “do they wear ties at the IC”. The importance of adopting the new culture plainly uppermost in their minds.

What’s in a name?

The merged organisation, The Health & Social Care Information Centre, betrayed itself with its name. It thought it was in the information business and – in its eagerness to profit from information and in its growing over-obsession with pleasing the boss – it blundered into care.data and became an untrusted brand. Realising, too late, that they were in the ‘trust’ business not the information business they decided, not unreasonably, to rebrand and this time include “NHS” in the title. Everyone trusts the NHS, right? Right.

Unfortunately public trust is a bit like your virginity: you only get one go at it and when it’s gone it’s gone. The NHS does enjoy a reputation for trustworthiness. It’s been hard won over the years by an unsung band of provider-based information governance professionals and Caldicott Guardians who, being from clinical backgrounds, understand entirely that they are in the trust business not the information business.

Consequently, when they are approached by the authorities for confidential patient information, as they often are, they will routinely ask the authorities to get the patient’s permission and if that’s not forthcoming they will politely tell the authorities to naff off.

The world’s least likely whistleblower

This was not the culture exposed by NHS Digital’s former chair Kingsley Manning who resigned and then gave press interviews about his concerns over the legality of the Home Office’s access to patient information in pursuit of illegal immigrants.

So the culture of over-eagerness to please the boss and being in the information business appears to remain dominant, turning Kingsley Manning into the world’s least likely whistleblower.

Changing this culture will be quite a challenge for the newly appointed chief executive, Sarah Wilkinson. Difficult but not impossible. Culture change begins with a willingness for leaders to take on some really uncomfortable conversations.

Enter the Zone of Uncomfortable Debate

As a psychiatrist I specialise in difficult conversations that people don’t usually want to have. First you must spend time building trust but ultimately you have to get to the heart of the matter and enter ZOUD – the Zone of Uncomfortable Debate. Discussing NHS Digital’s cultural baggage will be uncomfortable for many but Sarah Wilkinson will have to enter the ZOUD or NHS Digital’s culture is likely to remain unchanged.

Beverley Bryant’s recent acknowledgement of the need for culture change is a welcome beginning but it will require a sustained effort by the new leader, and maybe more than one new face. While we are not in the rocket science business, many more lives depend on us getting this right. If this latest change of leadership isn’t uncomfortable it probably isn’t working. Embrace the ZOUD!