Psychologists in leadership roles

The recent Health Education England report into wellbeing of NHS staff was welcomed by the British Psychological Society's Chief Executive, Sarb Bajwa, who noted, 'This report is an important step forward in recognising the psychological needs of people working in a high-stress, target-driven environment like the NHS… If the recommendations in this report are followed, they will change the lives of many thousands of employees, including more than 20,000 psychological practitioners providing vital services in the NHS'. Others have similarly commented on the need to address wellbeing in psychologists working in professional roles, whether it be for public bodies such as the NHS or in private healthcare settings. The recently published Recommendations of a task force set up by NHS Improvement will have direct and indirect implications for the wellbeing of such psychologists, and for psychologists in leadership roles. The work of that task force emanated from what happened to a nurse in 2016, working in a hospital in London.

A tragic journey

Amin Abdullah grew up in an orphanage in Malaysia. He fulfilled his dream of becoming a nurse in the NHS, and during his training he won an award from the hospital that later sacked him. On 9 February 2016, not long after he qualified and a few weeks after going through a harrowing disciplinary procedure that ended in his dismissal, he set himself on fire outside Kensington Palace. The resultant Independent Inquiry found Trust investigations to be biased and flawed, and in one case amounting to a 'whitewash', with an investigating officer showing a lack of integrity, and with weak evidence not properly challenged at Mr Abdullah's disciplinary hearing. A YouTube video of Amin Abdullah's story, A Nurse's Tragic Journey, is available here. 

In the light of the Inquiry findings, NHS Improvement (NHSI) set up an Advisory Group to consider the implications of the Inquiry Report for the wider NHS, as it had become clear from a number of high court, employment tribunal and coroners' judgments that flaws in HR and related management procedures were much more common in the NHS than had hitherto been realised. The case of Amin Abdullah was by no means an isolated occurrence, with whistleblowers and BME staff often taking the brunt of any management failings and bullying. Amin Abdullah's case resonates with more general concerns in the NHS about how staff, including psychologists, are treated (Kapur, 2018; Bourne et al., 2017). In his 2015 report on whistleblowing in the NHS (Francis, 2015), Sir Robert Francis commented: 'Repeatedly we hear of unaccountable managers protecting themselves and undertaking biased investigations, character assassination, lengthy suspensions, disciplinary hearings which resemble kangaroo courts, and ultimately dismissal of staff who previously had exemplary workrecords' (p.162). 

Towards fairness, excellence and compassion

In many of these cases, it is clinicians in management roles who play a decisive or major role in actions that impact on their professional colleagues (Powell & Davies, 2016). In order to ensure both excellence and accountability when healthcare professionals take on management roles, something that successive health secretaries have regarded as a high priority (Iacobucci, 2016; Rimmer, 2018), the NHSI Advisory Group has now produced a set of Recommendations for Trusts.

Psychologists in management roles should carefully consider these Recommendations, which aim to introduce fairness, excellence and compassion in how staff are managed, especially when they find themselves under investigation. Recommendation 4asks for regulatory and professional bodies to review relevant guidance and standards issued to registrants which relate to the conduct of local investigations and disciplinary procedures. The BPS and Health and Care Professions Council should consult on and produce such guidance, and this could fruitfully extend to other management roles, including recruitment, promotion, demotion, etc where bias or discrimination may creep in, consciously or unconsciously. Such guidance is essential if we are to reduce bullying, victimisation and discrimination of individuals, especially vulnerable groups such as whistleblowers and BME staff.

In order to ensure both excellence and accountability when psychologists take on management roles, especially those involving staff, key steps need to be taken. 

Firstly, we must ensure that psychologists have specific training, skills and experience in management issues for which they are being asked to provide input. This includes training in relation to the occurrence of conscious and unconscious bias. Clinical psychology training, as well as other forms of postgraduate professional psychology training, need to include management within course contents. The managerial practice of clinical psychologists should, like their clinical practice, be competency-based, peer reviewed and subject to the regulatory scrutiny. Psychologists who carry out investigations of issues and events must be properly trained in the science of carrying out fair and accurate investigations (Simon, 2012).

The Trust Executive Board, which occasionally includes psychologists in its membership, should sanction every case of dismissal or suspension of a healthcare professional. The HCPC should follow the standard set by the General Medical Council and have guidance similar to the GMC document Leadership and Management for all Doctorsto ensure that there is greater scrutiny and accountability when psychologists in management roles show failings that result in harm or distress to staff. The BPS should produce similar guidance. It is sometimes the case that it is one or two clinicians in management roles who are responsible for a culture which promotes unfairness (Mannion et al., 2019).

PIPE and PRIME

Since investigations and disciplinary procedures for healthcare professionals have particularly devastating effects on their mental wellbeing, including the risk of major depression and suicide (Horsfall, 2014), as well as their future professional competence, I propose the following PIPE and PRIME principles to ensure greater fairness in such processes. PIPE principles are:  

• Plurality (more than one decision maker) for any important decision such as suspension or dismissal.
• Independence (some members on the panel external to the employer, and free of any professional or personal conflict of interest).
• Panel training to prevent conscious and unconscious bias and training in principles of investigation.
• Expertise, as related to the specific professional, technical, race, cultural, language, whistleblower, etc attributes of the staff member in question.   

PIPE principles should also be applied to other significant decisions which impact on the employment status, wellbeing or morale of staff. This includes selection, promotion, demotion, etc. and the treatment of agency staff, who are sometimes treated as 'second-class citizens' in healthcare settings.

The outcome of disciplinary hearings should be subject to PRIME principles –    

• Ensuring that any sanction is Proportionate.
• Exploring how Remediation could help the individual.
• Carrying out an Impact assessment of any sanction.
• Ensuring that Mediation is fairly and thoroughly explored whenever it may be appropriate.
• External, expert assessment of these four principles being fairly and robustly implemented.

Healthier staff, healthier patients

Over the years, there has rightly been an emphasis on patient safety in the NHS, but it is now abundantly clear that staff wellbeing and staff morale are also important and are in fact closely linked to quality of patient care (Dixon-Woods et al., 2014). Ensuring excellence and accountability for psychologists in management roles will go some way towards improving morale and wellbeing in the NHS workforce in general, and in the applied psychology workforce in particular, including those who in the past have tended to be victimised, such as whistleblowers and BME staff.

Narinder Kapur is visiting Professor of Neuropsychology at University College London and honorary consultant neuropsychologist at Imperial College Healthcare NHS Trust. He is Past-President of the British Neuropsychological Society and received a Lifetime Achievement Award by the British Psychological Society. 

References 

Bourne, T., De Cock, B., Wynants, L. et al. (2017). Doctors' perception of support and the processes involved in complaints investigations and how these relate to welfare and defensive practice: a cross-sectional survey of UK physicians. BMJ Open, 7: 1-11.

Dixon-Woods, M., Baker, R., Charles, K. et al. (2014). Culture and behavior in the English National Health Service: overview of lessons from a large multimethod study. BMJ Qual Saf, 23: 106-115.

Francis, R. (2015). Freedom to Speak Up. Department of Health.

Health Education England (2019). NHS Staff and Learners' Mental Wellbeing Commission. Health Education England.

Horsfall, S. (2014). Doctors who commit suicide while under GMC fitness to practise investigation. GMC publication. 

Iacobucci, G. (2016). Hunt lures doctors into management roles with promise of training at Yale. BMJ, 355: 1.

Kapur, N. (2018). NHS disciplinary processes. The Psychologist, 31: 4.

Mannion, R, Davies, H., Powell, M. et al. (2019). Healthcare scandals and the failings of doctors. Journal of Health Organization and Management, 33: 221-40.

Powell, A. & Davies, H. (2016). Managing Doctors, Doctors Managing. Nuffield Trust.

Rimmer A. (2018). Hancock: support doctors to become senior managers and chief executives. BMJ, 363: 1.

Simon, D. (2012). In Doubt. Cambridge, Mass: Harvard University Press.  

Acknowledgements

I am grateful to Dr Veronica Bradley and Dr Christian Harkensee for their helpful comments.