This is the nineth part of the BMJ Leader blog series written anonymously by “Magical Meander”, a medical manager working in the NHS, to help align perspectives and build understanding of medical management across these two professions.

I went recently to see the Thomas Becket exhibition at the British Museum. I was touched, as I often am by the charm and yet the deeply sinister and honest nature of the carvings and paintings of the Medieval period. I have found myself thinking about St Thomas; in his life he went from humble beginnings to be an important aide to the King (and trusted confidante) and eventually becoming Archbishop of Canterbury. His loyalty to each of these two power bases: state and church, changed as his roles changed. One minute all his efforts were for the King, the next the church, even if it meant opposing his former friend and boss the King. Ultimately this transferral of loyalties led to his death. Even after his death this duality led to a schism; his reverence as a Saint by some and by others he was decried as a sinner. It lead to a king seeking public penance and another to try to eviscerate his memory.

Loyalty is a powerful and revered trait. Loyalty to organisations is often under recognised today. We recognise it in loyalty to organisations associated with sport – we see how much joy adoring a football club can bring. We have also seen in the past seen how this can get out of hand, the dreaded hooliganism. We like to believe particularly now having lived through COVID that ours and the public loyalty is clearly with the NHS. Yet surveys regularly show that patients hold the NHS more dear than the public, as a whole and this is because patients connect to their particular experiences of a particular part of the NHS. Staff are loyal to NHS collective but connect to their organisation – to their practice, to their hospital, to their ambulance crew. Loyalty to their team members trumps even organisational loyalty.

This allows miraculous change – as COVID demonstrates. Various governments have sought perhaps imperceptibly to leverage this. In the time of competition organisational loyalty – competition for results depended in part on this connection. But now as we move to an age of cooperation and collaboration beyond boundaries this is challenged in a different way. As we talk of intangible integrated care systems, as we work to redefine boundaries through creation of provider networks we now need to shift 180 degrees from the us vs you to the we are you.

It is hard enough to understand a different service within a hospital, never mind a different hospital and how it works and how the myriad of inefficient pathways can be realigned at a system level. We rarely manage it at an organisational level never mind a bigger regional level.

So the question I am left pondering on is how do we leverage loyalty? How do we focus loyalty on the NHS not on the local unit level / team level? If we don’t what hope have we of making regional structures work? Perhaps even more that this question though, is how do we ensure that the loyalties we aspire to create now are sustained. We cannot go from saint to sinner, otherwise like Thomas Becket there is a risk to organisations feeling headless…

Magical Meander

Magical meander is an anonymous blog written by a medical manager working in the NHS and published every six weeks on BMJ Leader Blog.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.