This is a transcript of a conversation with Professor Domhnall MacAuley for BMJ Leader. You can read it here or watch the full interview.
Hello, I’m Domhnall MacAuley and welcome to this BMJ Leader conversation. Today I’m talking to Roger Kline.
There’s something you say on your website that caught my imagination – that you are a disruptive innovator. So, my question is, can you be a disruptive innovator and a leader at the same time?
Roger Kline: Yes, but it’s hard work and it carries risks with it. And, over the years, I’ve slowly learned how to how to duck and dive, when to step back and step sideways, but never lose your principles. And sometimes, there is a time to hold fire.
When I was a young firebrand in my twenties, a young ‘Trot’, I used to work on the basis that if you weren’t with me, you were against me. And I’ve slowly worked out that there is a better way of working – if you’re not against me, you might be with me. And I’ve tried to apply that all the time. I have three or four mantras that I try of keep to.
When I was a trade union official in eight different unions, at senior level in most of them, as well as watching the employers, I had to watch my back. I was seen as a slightly risky person to deal with, but I managed to develop a sort of persona, which I think is me, which was based on a saying my dad had, which was- “speak softly, carry big stick”. (Often attributed to American President Theodore Roosevelt). Don’t go around threatening people, but always try to get people to think that- if you’re speaking quietly like that, I’d better be careful. And it has stood me in good stead. I always keep reminding myself of those things. And I’m an optimist.
So, going back to your question, yes, you can be a disruptive leader, but you really have to learn how to do it and how to work with people who you might not completely agree with. But, never step back from your ethics.
DMacA: That concept of working with people who you may not necessarily agree with, that’s really important in the NHS and in trying making things happen. Your experience of trade unions must have honed that skill. What other lessons do you bring from the trade unions to medicine?
RK: I spent eight years working as a forklift driver in a factory. I went there as a summer job. I really liked it. It was the biggest tractor factory in the world, very well unionized. And I learned more in that job, which I still use than I have done in any other job. And, one of the things I learned is about the potential people have, even though they don’t show it. Everybody has huge potential.
Also, there’s never a good reason to be rude to 99.9% of the population even to people who do deserve it.
Always be curious. Don’t go looking for safety. Mary Dixon-Woods, who writes for BMJ has this lovely saying, which I now constantly refer to, is that – organizations need to stop comfort seeking and be problem sensing. https://blog.thisinstitute.cam.ac.uk/organisational-culture-problem-sensing-and-comfort-seeking
And that’s about curiosity.
I learned to survive. I was very young when I took that summer job. I was very left wing, so I had to learn to survive in a very tough working class environment, but not step back from your principles. I had to work out which issues to raise, when, who to work with, to be curious, to understand people, what motivated people, and recognize that, actually, you could work with people that you didn’t really want to spend a night in a pub with, because you actually had some shared interests. There were other things I had to learn afterwards. It was an overwhelmingly male environment. It was an overwhelmingly white environment, and I’ve had to learn lots of things. I’m still learning. But, I did learn a lot of things in that environment that I don’t think I would have learned anywhere else.
DMacA: You talked about an overwhelmingly white male environment, which sounds very like what medicine used to be like, but you’ve done quite a bit of work on racism in the NHS, and particularly your work with the GMC. How can we change that?
RK: I was lucky. I had two parents who were Jewish communists in the days when lots of Jews became communist in the thirties because they were the anti-fascists. So that gave me a sort of a grounding. I got a moral compass and a confidence in dealing with those issues.
In terms of changing how the NHS approaches racism, I’ve had to learn about that. I didn’t understand that. When I wrote “ The Snowy White Peaks of the NHS” (https://repository.mdx.ac.uk/item/84qy7 I was against racism, but I didn’t really know what to do about it. And I think I’ve slowly learned what works and what doesn’t. You have to get into the hearts and heads of people. You have to really make people think.
Lots of people come to grips with racism through personal experiences. They have friends, things happen to them, things happen to friends, their children marry, etc. But you also need to be able to say what works. And I think a real problem for the health service at the moment is that there’s a lot of talk about being anti-racist. But, that requires leaders to make themselves uncomfortable and understand their own privilege. I mean, I’ve never, ever been for a job interview that didn’t have a majority of white men on the board.
The other thing is we have to stop being performative. We do lots and lots of things with good intentions. We celebrate this, we celebrate that, we have diverse interview panels, we have positive action to give people confidence for interviews. But we don’t address the institutional barriers. I have written about this and BMJ Leader was good enough to publish a piece with a slightly dodgy title of “Paradigm Lost. Reflections on the effectiveness of NHS approaches to improving employment relations”(https://bmjleader.bmj.com/content/7/4/314) It was basically a critique, or actually it’s a denunciation, of the HR approach to culture and employment relations, which said – stop relying on individuals who are brave enough or foolish enough to stick their head above the parapet and say, this isn’t fair, this isn’t right. There is no evidence base that, if you put in place policies, procedures and training, that’s the model, that’s the paradigm, and that will enable individuals to safely and effectively raise concerns because the panels are trained, etc. There’s no evidence base that, in isolation, this will work.
There is an evidence base that says different things work. De-biasing processes rather than primarily de-biasing people; Inserting accountability, because people who are watched change their behaviours, and; having leaders who are allies and who are willing to put themselves in other people’s shoes. This is with intention and, not leave the standing up to detriment to those who are suffering. In other words, you step in in the moment.
It’s taken me a long time to get to those principles. If you look at what I was writing ten years ago, it now feels very naïve but now I think I have some confidence that what I write about works. And I think I’ve managed to work it out because I try to spend at least two days a week on pro-bono work, just listening to people, giving advice to people, and I can’t tell you how much I learned from them
DMacA: I was very interested in what you said about the individual calling out the system, about putting your head above the parapet, and challenging the orthodoxies. One of the things that concerns me a lot is that- no matter how good the cause, the whistle blower is always damaged.
RK: There’s been some really interesting research on this. So the work for Jill Maben and colleagues recently on whistleblowing, and the writing by Mary Dixon Woods, Graeme Martin and Meghan Wright’s in BMJ are all saying that – making having better processes for people to raise concerns is the wrong problem. The real issue is- will leaders listen when they hear it – and largely they don’t.
Jill Maben et al https://openresearch.surrey.ac.uk/esploro/outputs/report/A-mixed-methods-evaluation-of-the/99587023202346
Wu, Dixon Woods et al https://pubmed.ncbi.nlm.nih.gov/34051553/
We have so many policies and procedures, so much training, freedom to speak up guardians etc. (https://nationalguardian.org.uk ) I’m not against freedom to speak up guardians. But, in my view, they only work really effectively in organizations that really want them to work which, of course, are the organizations where they’re least needed. So, I think that the focus has to shift to- how do leaders listen and how do we make sure they act on what they hear, and what do we do to incentivize or require them to do that? Because, without that, we will have more people losing their jobs or suffering detriment as a result of raising concerns. Most of the major crises we’ve had in the health service could have been averted by raising concerns. There were people saying things were going wrong and we didn’t listen to them.
DMacA: Related to that topic, you’ve written on bullying as well. What are your thoughts on that and how we put it right?
RK: I think bullying is one of the hardest issues to address. The research base is probably thinner than it is on improving discipline., Disciplinary data in the health service has improved fantastically, largely as a result of stuff that myself and others have been writing. I think we’re making progress. But bullying, less so…There is some evidence in the approach I might summarize as follows. Stop exhorting people to create zero tolerance for bullying when leaders don’t apply this to themselves.. You need to set out really clear expectations of behaviour and you start softly. So, if I am deliberately or universally rude or bully somebody, you want a situation where other people will step in as bystanders and say, Roger, you realize that’s the third time you’ve done that, or do you realize what the impact that has on people?
And the Vanderbilt Medical School in the States is the place that pioneered this approach, and they were quite taken aback with the outcomes. A very large majority of doctors who were spoken to in that way took it on board. But, you need preparation because otherwise you have moral injury to people if, for example, people were to say, “Hey, Roger, why are you behaving like this?” and I say “Sod off” , and there is no one standing behind them.
So you have to create a culture in which that’s the expectation. Most doctors who were approached in that way ceased their behaviour.
And then we have to recognize that some groups of staff are disproportionately impacted. Black and minority ethnic staff are more likely to be bullied, especially by staff and by managers, more so than by the public.
A hidden element of bullying and harassment that’s finally surfacing is that of sexual harassment. There are some parallels in terms of the reluctance of people to speak out because they’re worried about the consequences.
That’s probably the more productive direction to go because most of what we do at the moment, the policies, procedures and training, all they do, frankly, is to give the employer a defence when they go to a tribunal, and that doesn’t really address the issues of bullying.
Organizations are trying to think through how we might address that. But I think it’s fair to say that the evidence base, until very recently, has been fairly thin. And, for example, Jill Maben found that when she looked at bullying, there was almost nothing about sexual harassment, and almost nothing about bullying of Black and Minority Ethnic staff. So, I think we are still in the foothills of that one.
On the other issues like recruitment, career progression, discipline, I think we know what needs to be done. The question is will people do it?
DMacA: You’ve talked about the internal mechanisms and the internal changes that we need to do in the NHS. But what I admire about you is that you’re not afraid to speak out. Tell us about the importance of using all forms of media to get the message across.
RK: When I was Joint Director of the Workforce Race Equality Standard between 2015 and 2017, there had been an incident with a Conservative Party election van with a slogan on the other side where it toppled over due strong winds on the M6. I had tweeted that this feels very symbolic and appropriate. I then got a phone call from somebody very senior at the Department of Health during the general election who said, “I’m not telling you shouldn’t tweet, but you’ve just tweeted…”
He said, “You have to remember, you’re a very senior director in the NHS and you can’t do things like that.”
So I said, “Well, I’m not sure what to say now.”
He said, “Why not?”
I said, “Well, I’ve just taped this conversation and I’m not sure what to do about it now. I mean, you don’t want to put this tape on social media. I’ll tell you what, why don’t you go back and say you’ve spoken to me? And that I listened carefully to what you said”
I never heard any more. I hadn’t, incidentally, taped the conversation. That was when I was inside the system but you have to be quite good at what you do, otherwise you get picked up on stuff. But I have one foot in the system, the rest outside.
I’ve worked with some really great leaders in the NHS. There are some pretty awful ones too. I’ve publicly attacked what they’ve done. But, always remember what you’re trying to do here. If I don’t like somebody that’s not necessarily a reason for me to personally attack them
I use humour a lot and I find humour very effective. I have occasionally, very rarely, directly attacked individuals. There are one or two chief executives who I know have behaved like corporate psychopaths and I’ll be prepared to call for their resignation. But on the whole, I use humour a lot. But, mainly I try to be accurate and try to rest on the evidence.
DMacA: Are you optimistic about the future of the NHS?
RK: You have to be. I was born one month before the NHS was formed. My parents described to me what it was like as working class people not to have the NHS. I spend a lot of time with our grandson who lives with us, who inspires me every day. I want it to be there for him. It might change, but we have to have a system where accessing health care doesn’t depend on your wealth, or your standing, or your status, and is available at least as easily publicly as it would be privately. its so important. It is part of what I think now makes us a country, a nation.
So, I am an optimist and much of what I do is about campaigning to keep it there both by criticizing what is bad about the people who run it and their expectations, but also praising what is good.
My wife is a nurse in the health service, still working. One of my daughters works for a national NHS organization, I shan’t name. And my other daughter is a teacher. And you know, it’s for them as much as for me.
DMacA: Roger It’s been fun chatting to you. Thank you very much, as always for your refreshing view of health care, of the organization, the future, and what we can do. Thank you very much indeed.
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