Courageous challenge versus conformist control

This morning I was up early (for a Saturday), scrolling through twitter, wondering how to kick start my weekend. Last weekend wasn’t my best one and I was hopeful for something to set a different path. Jodi Brown and friends didn’t disappoint:

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Genuinely killer question. I don’t know Jodi at all well, we’ve exchanged tweets occasionally but no more than that, Annie C had shared this and so I thought about replying and decided to jump in. The first point of reflection is that I did think about whether to join in, a couple of years ago I’d not have engaged in any thought, I’d have just jumped into the mix and saw what came from it, but these days I tend to be a bit more cautious about engaging in #NHS chat online.

A truly fantastic conversation followed, Jodi, Annie and I were joined by about ten others, including @Ermintrude2 @JaneStreetPPAD @mikechitty @RichardatKF @alisonleary1 @JennytheM @elinlowri @gleefulkaz @carollread @NHS_rants. Not surprisingly we didn’t agree with each other on everything, in fact there were some of us who probably didn’t agree with much that others were saying, but it was respectful, challenging and for me personally a reassurance that it was still possible to have a non-scheduled, chat on twitter and have your mind stretched with multiple perspectives. Here’s an excerpt from this discussion where Jodi and I were disagreeing over what/who counts as ‘radical’:

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Our chat continued, others joined in, think we were at it for about an hour in total. Really made me think and question, what I consider radical and what it must be like to work in a system (the NHS) that was repeatedly described as, without putting too fine a point on it, toxic. Lots of talk about cultures of repression, fear and hierarchy. We all went about our ways, Jodi had to take her kids swimming, Richard was off to a food festival and I hit the gym.

I left the gym an hour or so later, grabbed my phone and was bouncing home to the weekend and was hit with this tweet:

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Booooooooom, smack, bang. Sorry, what just happened? I looked around for further discussion, NHS_Rants had questioned this but there had been no response. I checked the sender’s stream, they hadn’t joined in on any of the rest of our hour of conversation, just singled in on my one comment about NHS Change Day and decided that I was wrong. Not just wrong, but obviously wrong *and* stupid or deaf – I need to be told that BOTH of the previous change days had been groundbreaking.

I lost my cool, didn’t ignore this (which I probably should have) and questioned how they could be so rude. Thing is I think social media is a conversation, and when there are ten people talking, I imagine in my head it’s a bit like we’re all sat around in a room trying to understand each other, the reality could be far from that, some were travelling, others juggling family commitments, no doubt there were PJs and gym gear worn alike – so, unconventional, but still we’d had a great conversation. How I experienced this tweet was that the sender listened into our conversation, picked one bit that they had an issue (or pride about), walked into our room, shouted their opinion (literally in those capitals), in no uncertain terms and then walked out again.

This was the exact sort of conversation I’d been nervous about getting involved with first thing. You see there are loads more NHS people on social media these days, and that’s a great thing. It also means it’s much harder to hear balance, and to truly discuss things without being shouted down by the party line. In the context of our conversation about cultures of control and challenge this was a perfect example. The sender’s biog is clearly claiming expertise in this area, they’re a ‘Social Media Innovator – NHS Change Day 2014 Social Media Lead. NHS Leadership Academy SoMe tutor. Passionate SoMe practitioner’. Their response perfectly embodied what I’d been querying in the first place. Whether all of these NHS initiatives are now seeking to use #socmed and indeed the initiatives themselves to control and centralise the messages. Ironic that the very strength of social media could be lost in so many ways. As ever I wasn’t claiming this to be an absolute truth, or even a truth at all, hence my delight at the genuinely open conversation earlier in the morning.

When I got this tweet though, it’s safe to say I didn’t feel I’d been listened to. The sender hadn’t engaged in our conversation and didn’t seek to understand where I was coming from. They just let me know that I was wrong. I don’t want to make this about the tweet though, and the lovely Anne Marie pulled me up on ‘public shaming’, which wasn’t my intention at all, hence no identifying features on this blog post. I could have exercised more tact, but I also (strongly) feel that the tweeter was incredibly selective in what they picked on, and incredibly blinkered in their engagement. This was exactly the type of conversation that is all too familiar on social media these days, and precisely what I wanted to avoid.

The NHS seems obsessed with Cs at the moment, but rather than the #6Cs that are admirable yet seemingly a distant ambition in these cultures of ‘repression, fear and hierarchy’, I’d like to reflect on a few Cs of my own – I’m not offering an opinion, just a few (deliberately loaded) questions. I’d love to hear your thoughts:

Control: Are leadership programmes/away days/initiatives provided to help sustain and support weary folk in (toxic) cultures to really bring about change, or are they used to control and pacify?

Construction: Social movements are by their nature fluid, open and dynamic, has the new obsession with initiatives killed the very essence of these strengths through overly constructing them with approved hashtags, conversation times, and self-appointed experts?

Centralisation: Is it possible to develop and improve practice in one area, then try to roll it out centrally, without losing why it worked in the first place?

Challenge: When was the last time someone challenged you? Outwardly, openly and in public? Are the social media conversations of today vanilla in colour, weak in strength and just affirming our own biases?

Conformity: How many dissenting voices feed back into your viewpoint each day? How many patients or citizens are involved and attending the many leadership courses, initiatives and awards ceremonies that you frequent?

Candour: I’ve been elbow deep in redacted documents of late through JusticeforLB, I’ve seen the inner workings of the NHS Spin Machine at its worst, I honestly think there is a long way to go before candour becomes meaningful within the NHS; that said I’ll be eternally grateful to those medical professionals (especially our GP) who showed an extraordinary level of candour (and compassion) when Dad was ill. I’ve spent years praising the NHS and all it stands for, but if we can’t criticise openly we’re never going to improve anything.

Courage: It’s hard to be a lone voice, it’s even harder to be a lone voice when your voice can be taken out of context or one thing you say can be pounced on for someone else’s agenda. I’ve learnt so much in the last 9 months about courage from Sara Ryan. I’ve also experienced first hand how utterly exhausting (and pointless) it is to be a lone voice in the face of the NHS spin machine.

I understand why people are proud of the NHS, it’s care and it’s staff. I am too. That said, if people like me need to psych themselves up to engage in conversations, something is very, very wrong. I think it’s time we had some courageous challenge, I think it’s the only way the NHS will survive and people will retain their confidence in it. I remain grateful for the chat first thing this morning, and would love people’s views on my deliberately loaded questions, because I’m genuinely open to challenge and want to learn. Thank you.

PS Thought it was worth adding a note on here that I should have included when it was first published. I know it may take courage to disagree with me (not sure why but guess we’re programmed to avoid conflict or challenge), and I know sometimes adding a blog comment feels more finite than a tweet or an email or a DM, but I really *really* would like to develop this conversation further. Since I’ve been involved with JusticeforLB I’ve had more DM/email traffic of support, and less public agreement although not necessarily less challenge. Given the actions of the Trust where Connor was ‘cared for’ before his preventable death, I feel I have had to criticise the NHS, and I’ve been exposed to the worst of spin and poor manipulative communications; but I am not for a minute ‘tarring everyone with the same brush’, nor do I doubt the good intentions of most people (even some of those who seemingly lack competence or skill or support), so please, please do disagree or agree or comment or whatever, or don’t if you’d rather not, but please don’t feel afraid to do what’s right for you.

0 comments on “Courageous challenge versus conformist control”

Thanks for this. I am aware I can come across as a bit petulant on Twitter sometimes and I think a lot of my concerns about what seems to be a groupthink of ‘leadership/change agents/radicals’ which I lump together are reflected in this post.
I have, until a couple of years ago, worked extensively in the NHS as a seconded LA social worker in a MH trust. I also worked in a LA for many more years. For all their faults (and they have many) I would have run back to the LA with open arms after experiencing the groupthink/hierarchy and intransigence of the NHS.

I worry that we aren’t challenging enough if we have to find safe places from which to challenge that need people to be taught how to ‘be radical’. As for ‘change agent’ as a I said this morning, noone should be able to give themselves that label. It should only be used by those who witness the change made and apply it to those responsible for the change.

Change Day is a nice idea but has become corporate with a lot of peer pressure about taking part and when you see people pledging ‘to smile at patients on my ward more’ then you wonder, genuinely what the value is. But I’m cynical. What worries me more is the way that people are led on these leadership programmes and innovation sessions and schools for radicals by people who are paid a great deal of money from public funds.

Telling people they are change agents and teaching them to be ‘radical’ in the right way – all nice if it’s a hobby blog but when it becomes too cliquey with people believing their own press – with money being spent in large amounts, it makes me wonder if it is to benefit people using NHS services or just another pat on the back for those at the top without welcoming real challenge.

One of the most damaging things in/about/around the NHS are those who believe in it as if it were a religion and who will accept no criticism of it. And there are a lot around. Don’t get me wrong. I am passionate about healthcare free at the point of delivery for all. I know excellent people work very hard in health services and brilliant stuff happens but not accepting any criticism is as dangerous as constant criticism and a lot of these initiatives don’t challenge enough.

Thanks for this.

jesslinworld says:

I don’t think my feelings about the modern NHS will fit into 140 characters. I came back to the NHS a few years ago about after 20 years elsewhere and found it unrecognisably difficult. Instead of people doing their job well because they were glad to work in a public service, that tried to help people, there were a profusion of policies and mission statements telling people how things should be done. The second shock was that people found it annoying and rather weird that I believed what I read. Apparently they didn’t.

Eg:” We should constantly strive to improve our services”. But make a suggestion which might do just that and you got batted away. I was even told, “You’re not paid to think”.

There was now a profusion of directorates and managers all fighting for their little slice of budget, not necessary before the internal market.

Managers were hastily promoted, frequently moved between jobs, and often had little idea about how to manage people. We had to smile patiently as we heard yet again the words ” I’m on a steep learning curve here”.

Initiatives would suddenly become flavour of the day with management, passed down the line to those at the bottom, then be silently dropped. A couple of years someone would say “You’re not still doing that are you?!”

I couldn’t understand this world where people said things they didn’t mean. Why do they bother in the first place? Why do they say we are being consulted when it is just a sham? Why do they say “Just phone if you have a problem” then not respond when you do? Why do they train you in a certain way then tell you you don’t have time to do a job in the way you have been trained.

One of the reasons I like being involved with #justiceforLB is that it is full of people who say what they think. Long may it stay like that.

anniecoops says:

Hello George

I found the discourse yesterday interesting and thought provoking. I think, tho, it is tricky to have a challenging, complex debate without risk of misunderstanding in 140 characters, at pace and without the use of body language, tone of voice etc. Some people are skilled at it, others less so, is my observation. I try hard not to get too fired up based on the position that I hold that most people I communicate with and are part of my network are here for good. It saddens me when things go a bit wrong but I think its inevitable if we are to have useful debates that move past #xfactor etc. So forgiveness is important.

So what do I think about radicals and change day and all that stuff?

It’s hard isn’t it? People endeavour to do good, make things better and to use what we know to create a better world – or at least that’s what I believe.

NHS Change day is a wonderful concept but I also think corporatization (is that a word?), where less skilled people who may not really understand (or take the time to understand) its underlying philosophies, take it and ‘do it’ to people, is a real risk. But do I think that makes it wrong? No – I do not. I think that it is still likely that this type of corporate approach to what change day is, is probably in the margins of it all, and in the balance there is more good than that. So, as is probably my way, I take the view that there is more good than bad and I am supportive and helpful. We will see how it pans out over time and see whether it continues to harness the imagination of people. Sometimes these things run their course. In the meanwhile I will continue to support and be a part of it.

Radicals? I don’t think the intention was ever to ‘create’ radicals at all. I think it was to expose a different way of being and to value some of the challenging things people take on and do. I tried to join in the school but I couldn’t and I was impressed by the work they did and the approach they took. I do not believe that they are part of a big corporate group think drive to create radicals.

I also accept that times are difficult. Cultures need to change. We need some new ways of being to cope with the challenges we face. This is one thing/approach that people think will help. Its based on theory, not corporate PR and if you ever get the chance, listen to Helen talk about it, or even see if you can have coffee with her. The theories are engaging and useful if we can harness the power.

At the end of the day I have an irritation that everyone thinks that one thing will fix everything, that there is a silver bullet that will make everything OK. I’m not in that camp, I think its naïve based on my longish career and my understanding of complexity. But I do think initiatives like this have a place, alongside people like you and lovely Sara, who lobby for change and challenge the system. Its a complex world – we need to continue to have complex conversations and I am always grateful for your challenge, debate and transparency.


Very interesting blog and twitter discussion George – as a service user of almost 20 years my thought would be that Jodi might want to distinguish between corporate edge and professional/compassionate edge – I have met many practitioners who have put themselves on the edge for their clients and service users and I have no doubt that in doing so they are putting themselves at risk professionally. In my opinion there is an emotional edge to compassionate practice that is integral to being an effective practitioner but it is something that can be incredibly demanding for the practitioner concerned.

I guess that is also why there are a great number of practitioners who don’t do it and who prefer to remain in the sanctity of the corporate centre/consensus. If these change initiatives go some way to making it safe for practitioners to make decisions that challenge corporate/consensus then great – if it doesn’t then its just rhetoric.

mikey3982 says:

Again a thoughtful blog and I wanted to ruminate on some of the questions you raised so apologies for my tardy response. My reflections are not from an NHS perspective but and outsiders. I have worked in the Pharma industry for most of my life in both Global and UK centric posts. That said interacting with various health organisations gives you a wonderful insight into their culture and operations. So my intent here is to be helpful to the many people helping to care for people.

You asked about CONTROL. I have worked in many cultures – many characterised by professional encouragement and growth. However some with fear and scarcity. The device of an awayday has many benefits, however is a great tool to get people away, listen to their voices and not do anything about it. The good leaders do work with it or at least I have seen their conversations of working exactly what context the dissenter is working to. I am concerned that so many rebels behave oppositionally not because they want destroy things but rather to make things better. In fact many are so passionate that maybe this gets in the way?

CONSTRUCTION. I do have a worry that social media is being industrialised. Clearly professional relations people are very proud of their job but so much is now reciped. To see your debate was refreshing and as always human The Recipe idea is what Centralisation looks like for me. Organisations do need therapeutic support sometimes to change the habits and the culture they have, however these organisations are not fixed with a 2 day seminar or a presentation a book the CEO has just received.

I wanted to congratulate you on this media of having courage to stand out. You together with Sara have shown everything in your dialogue about JusticeforLB. Sara is indeed an inspiration and her tweets resonate all the time with a desire for change to be made in LBs name. Systems are not easy to change and navigate and hope they do.

Lastly we do need to challenge to make sure that we collaborate more effectively. Maybe its more about how you embrace the challengers and understand / listen where they are coming from. I know that often even with my profile there is a reluctance to engage presumably because I am not part of a particular tribe? Wonder if this is what we learnt in the playground?

RichardatKF says:

You’ve summarised the issues that came out of this Twitter discussion with your customary incisive vim George. It all needs saying. It’s a shame that we can’t have open and honest conversations about the value of change initiatives without anyone getting defensive or trying to close it down. I may have said this before but I feel that Twitter demands a level of emotional intelligence that is not always evident in some contributions. 140 characters makes it really hard to avoid binary agree/disagree, right/wrong positions. Which is why your post is so helpful.

I do confess a certain cynicism about the NHS change day initiative but it is hard to deny that it has created an energy about service improvement that is usually absent from top-down initaitives so we need to avoid throwing the baby out with the bath water. It is the quasi evangelical tone of some of it that I find off-putting – and the immediate dismissal by some of any contrary view – as demonstrated in the tweet you quoted. We should keep talking and listening – especially to different views and voices.

Courageous challenge is a great term. Having the ability to “courageously” challenge, is in my opinion, less polarising than being a ‘radical’ but more meaningful than engaging as a ‘change agent’.

As a founder of change day I am clearly biased about the scope and outcomes of what ultimately remains an engagement initiative in its early stages. But I hope that change day doesn’t become a distraction as I think there is a more important focus of this piece. Nor I think is the issue on what constitutes good etiquette. At the end of the day twitter is SOCIAL media – and although conversations in content are no different than those you would have in a room with someone – they are global. While we would certainly feel uncomfortable or affronted by a person jumping into a conversation in a public space this is part of the twitter process. It may not be good practice but I think it is a risk that balances many of the benefits.

What draws my attention (especially as I am an avid fan of alliteration) is the revised 6Cs. As a newly qualified consultant I have had my head really turned by the challenges facing health care at the moment. As a trainee I was drawn into the ‘leadership’ lurgee, a virus that spread very quickly and infected you with the belief that change within the NHS was a thing that could delivered by some lectures, workshops and a quasi-successful quality improvement project. Delivering change is a much greater challenge than that and you identify a number of issues that are very real but often ignored.

We are all part of a process – and the conversations that occur in hospital corridors, GP surgeries, care homes and even on twitter shape our attitudes and intrinsic motivations. These conversations must be real and honest but also sensitive to the fact that not everyone will be at the same place, or even on the same journey. I hope I demonstrate courageous challenge but at the same time considerate to those who are were in a place I once was or in a place I might well go.

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