David Oliver: Do bring me problems

david_oliver_2015In her book Smile or Die: How Positive Thinking Fooled America and the World, Barbara Ehrenreich brilliantly deconstructed this cult. Her starting point was her own diagnosis of breast cancer and the bullying attitude that if you don’t “fight” the cancer and stay “positive” in the face of distress and worry, then your demise is your own doing. She showed how these exhortations to think positively had permeated thinking in many aspects of policy, business, careers, and “self-actualisation.” Jenni Murray referred to this as seeing “the glass as half full even when it lies shattered on the floor.” On a recent day on call, I bonded with another physician over her irritation at this US business phenomenon entering UK healthcare, while also agreeing that some NHS staff have embraced the equally unhelpful cult of “negative thinking.”

Positive thinking “guru” Zig Ziglar—among many annoying quotes—said, “It’s your attitude, not your aptitude that will determine your altitude,” and pushed the message that to succeed companies should employ only people who were happy.

We’ve always known that it’s as much about how we react to what life throws at us—whether we see it as an opportunity or a threat—that can affect our own mental wellbeing or our chance of success. Abraham Lincoln, for instance, said: “We can complain because rose bushes have thorns, or rejoice because thorn bushes have roses.” Some cognitive behavioural therapy relies on this reframing of thoughts to “manage your mind.”

In the weekly profiles of successful clinical leaders in the BMJ Confidential series, subjects are asked to describe their personality in three words. “Energetic,” “enthusiastic,” “resilient,” “determined,” and “optimistic” feature highly among people who’ve made an impact. The literature on clinical leadership emphasises the importance of some of these traits. Then again, the literature and those profiles in The BMJ also show that caution, scrutiny, careful listening, realism, team building, and healthy scepticism also matter in many circumstances—traits less valued by positive thinking zealots and a societal bias towards extroversion, charisma, and the “heroic” individual. On occasion, more of such traits could have averted poorly planned, rushed through change and kept the focus more on patients and frontline staff.

Sadly, there is a group of change management enthusiasts who’ve got absinthe drunk on positive thinking potion—an absinthe that doesn’t make my heart grow fonder. They ping out dozens of tweets a week, extolling the virtues and latest zeitgeisty theories of clinical leadership and change management, often bigging up their own role or institution and showing “zero tolerance” for those who raise real concerns over resource, staffing, performance pressures, or morale.

There was a recent and well publicised Economist Intelligence Unit (EIU) report showing that the UK is close to the bottom of the European and OECD league for staffing, resource, equipment, and beds in its health services and already provides incredible value for money even if outcomes are middling. Just afterwards, one tweeter who ran his own for-profit “health knowledge exchange” was blithely telling us all that “we can all do more with less, and improvement’s not about resource.” Apart from his obvious commercial interest in pushing this angle, it was a prime example of what Barbara Ehrenreich described, with ostrich-type denial thrown in.

Such characters are what I’ll refer to as “zombie evangelists”—barrelling on with a fixed rictus, shining eyes within the blinkers, two fingers in their ears. Their credo reflects Zig Ziglar: “Be grateful for what you have and stop complaining; it bores everyone else, does you no good, and doesn’t solve any problems.”

There are problems with this worldview when applied to the NHS. Firstly, as the EIU’s report and many others have pointed out, there are very serious issues in terms of funding, system pressures, equipment, workforce recruitment and retention, endless reorganisation, and performance pressure. Glossing over the problems with a dose of positive thinking doesn’t make them go away. And staff who raise them don’t need to be patronised or fobbed off with “don’t bring me problems, bring me solutions,” or “I only want to hear good news” mantras. These issues are not just “excuses” for avoiding change or quality improvement. They are real impediments. They need to be openly discussed and addressed.

Last year’s annual leadership survey from the King’s Fund showed that executive level organisational leaders express a much rosier view of their organisations performance than frontline staff who are dealing daily with the operational problems. Perhaps it’s “wilful blindness” or too much of a threat to their own self-esteem to admit the problems. But it was precisely this failure to engage with operational issues that led to the problems at Mid Staffordshire hospitals. And even though the government’s response to the Francis report has placed a duty on staff to raise concerns openly and transparently, there doesn’t seem to be a reciprocal duty to listen and act. In the highest performing healthcare organisations, staff morale and engagement are highest, hierarchies are flatter, and people feel able to raise problems without being judged. There’d be no need for a “whistleblowers’ charter” if all organisations worked like that.

I never play computer games, but I’d love a “shoot-em-up” where I could take out health leadership zombie evangelists. Rather than having to shoot them myself, I’d get the programmer to create an arch enemy tribe—the “mood hoovers.” I first heard this term used with no trace of self-aware irony by the cricketer Kevin Pietersen in his joyless, colleague blaming autobiography. They have close cousins: the “saboteurs.” They’re essentially people who will suck the life blood out of any proposal to change anything with blocking arguments or lack of engagement. Another type of zombie—undead but unwilling to change a thing or express any enthusiasm or engagement. Talk about the “irresistible force against the immovable object.”

I realise that in many cases their behaviour stems from real problems with their own health or burnout, and that we should seek to understand the behaviour and support them. I also differentiate them from “quizzical sceptics,” who have seen so many cycles of attempts to alter services, unintended consequences, and so many failures that they need some convincing that “this time it will be different.” We need people like this—they’re a powerful corrective.

No, what I am talking about is people who will just wear you down, block every argument and every suggestion with a recitation of all the barriers or “no evidence” assertions. (“No evidence” tending to mean “No RCTs,” or “it’ll never work here, because”.) If you are trying to get anything done, you eventually lose the will to live. They have seen others off before, and they’ll sure as hell see you off. Sometimes we need to be bold and assertive in setting out what “good” would look like, deciding where we want to get to, starting with the “why nots?” instead of always starting with the “what ifs.”

Happily, there is a third way that allows change and improvement, but doesn’t marginalise or blame anyone who raises concerns. I’d call these folk the “constructive challengers.”

Lois Kelly compared “troublemakers” with “rebels.” The former are characterised by “complain,” “me focused,” “anger,” “pessimist,” “energy sapping,” “alienate,” “problems,” “alone.” The latter are certainly “challenging” (a favourite word in NHS management speak to describe anyone with independent thought prepared to challenge the corporate groupthink). They are certainly prepared to flag problems and tell it like it is. But Kelly ascribes these words to them: “create,” “mission focused,” “passion,” “optimist,” “energy generating,” “attract,” “possibilities,” “together.”

These are the people we need more of. They are unafraid to raise legitimate complaints and concerns. After all, to have meaningful realistic solutions we need to know what’s going wrong and why. We need to spell out all the barriers to change and see if they are surmountable. And if not (and in the current health and social care climate there are big, big barriers) ,we need a stark dose of realism and expectation management rather than ludicrous overpromising (such as the unrealisable 3.6% reductions in urgent activity in last year’s clinical commissioning group plans—delivered nowhere because they were never going to be delivered).

Having fearlessly set out the problems, “constructive challengers” aren’t against trying to do something in the face of them. My question is whether we do anywhere near enough to allow and encourage people to play that role. It’s easier for someone who’s been around as long as I have and got some armour. But for many staff, it feels a lot more secure to “keep calm, carry on, and keep your job.”

David Oliver is a consultant in geriatrics and general medicine at the Royal Berkshire NHS Foundation Trust, current president of the British Geriatrics Society, and a visiting fellow at the King’s Fund.

Competing interests: None declared.