Open to improvement

“I’m a product of the civil service’s commitment to diversity,” Paul Gray says with a smile. “I left school at the age of sixteen, having sat my Highers, and went to work on a farm as a cattleman. I milked a herd of a hundred cattle. It’s a good way to start out in working life,” he says.

Now, of course, Gray has one of the biggest jobs in the Scottish Government. The Director General of Health and Social Care incorporates the role of Chief Executive of NHS Scotland. With responsibility over the largest budget and public sector workforce of the Scottish Government, Paul Gray only has the Permanent Secretary above him on the pay scale.

In 1979, however, his ambitions were modest. University wasn’t an option “for various personal reasons and family circumstances”, and Gray was encouraged by friends to enter the civil service as a clerical officer in central pay. “At that stage my motivation was not one of public service, but certainly of having steady employment,” he says.

As he progressed, he moved into IT, and grew in influence. He drafted Standard grade questions on computing and robotics for what was then Her Majesty’s Inspectors of Schools before being seconded to the Home Office in the Criminal Injuries Compensation Board (CICB), which was “exposure to some new experiences” for the young Gray.

After a period leading Scottish negotiation on fishing quotas, he returned to IT to design the systems for the newly formed Scottish Parliament. Hansard, the Westminster official report, was to be replicated in Scotland, but Gray refused. “They said we would have to use that system and I said no. We needed a newer and more modern one, and indeed we got one,” he remembers.

Gray had reached the top of the IT sphere, and was attracted to the idea of a broader policy role. “Social justice was one of the directorates on offer at the time. The government of the day was taking forward the policy of closing the opportunity gap, and I felt it was a good opportunity to take on a broader policy role. That was the point, I think, where the value of what government does and what public service does to deliver social good became most obvious to me.”

His work for the CICB had shown Gray the impact of what government did “on members of society who suffered considerably from disadvantage and deprivation,” he says, but the social justice role was where he began to see the value of working in public service.

“I was working very closely with the voluntary sector, and with issues connected with poverty, with discrimination and inequality, and all of these things came together to give a real sense of the enormous value properly managed public service can provide,” he says.

This carried on into health, where he was appointed Director of Primary and Community Care, and Director of E-health. At this point, he also oversaw the transition from the old departmental structure to the new system of directorates as Director of Transition in 2007. To the disbelief of consultants, the process took just three months.

“It wasn’t easy. It was a massive change but the benefit of it was the opportunities it presented were very visible. The departmental structure had got us a long way in the delivery of services, but what it didn’t really facilitate was a joined-up approach to the delivery of outcomes.”

The new structure allows a greater focus on outcomes, according to Gray. “I’m indebted to Kevin Woods, one of my predecessors in this role, for the phrase ‘if you always do what you’ve always done, you will always get what you have always got’. You know? We knew we couldn’t carry on just getting what we had always got.”

Engaging with other parts of the public and voluntary sectors has been made easier and more productive, Gray says, because government is working less in silos. A whole of government approach fits nicely into health, with former Chief Medical Officer Sir Harry Burns championing the idea.

After a stint as Director General of  Rural Affairs and Environment, which showed him “the importance of understanding the potentially differential impact of policies, depending on where you live and the communities that you serve”, and then Governance and Communities, Gray came into his current role in November last year.

“I’ve described it as the best job in the world. I believe it is. There will be other people who think they’ve got the best job in the world, and I’m sure they’ll be right about that – for them it will be. But for me, this is the best job in the world. Why? Because I can make a difference in the lives of everybody in Scotland, and of people who come to Scotland, and I have the opportunity to lead a National Health Service that is world-renowned for its approach to patient safety, recognised for its innovation, and recognised for the quality and standard of care that we provide.”

Gray believes engaging with communities is the answer. “The Scottish Government’s approach, founded on assets and co-production, and underpinned by a real commitment to a properly implemented improvement methodology, is fundamental to making progress with the big issues we face. We’ve been trying to tackle health inequalities for years, and Harry Burns has been really an internationally recognised figure in bringing to public attention some of the deep rooted problems we’ve got and the causes.”

He hails the research of the Glasgow Centre for Population Health, whose director Carol Tannahill has been brought into government as a chief social policy adviser.

“For me, one of the really clear issues about tackling health inequalities is actually, it’s not about health inequalities on their own, it’s about inequalities as a whole. It really requires every part of public service to work together in order to get to the root of the issues that frankly besets some communities, and has for many years,” says Gray. The third sector and corporate social responsibility are needed too, he adds.

“The solutions which are most likely to work are those which are co-produced with individuals and communities. To use the improvement science terminology – they need to have a name and they need to have a method. However good your intentions are, if you don’t have a name and you don’t have a method you’re much less likely to succeed.”

He was inspired by a presentation at a recent Scottish Leaders Forum from the Poverty Truth Commission. “What we saw there were people from communities who had suffered real and long-term disadvantage expressing for themselves how they had brought about change in their lives. In a sense, the best thing the public sector could do is to listen, not to tell; to listen and to learn,” he says.

It is clear tackling inequality is a passion of Gray’s, and a deciding reason for him accepting his current job. “Inequality is something I believe sits at the heart of what most public servants do. I have never met a public servant, or I will say this, a politician, who had a motivation to make things worse.

“There’ll be different views about how you should make it better, but what I see all around is people – both elected representatives and public servants – who have a joint commitment to improving the lives of the people of Scotland, to improving Scotland’s economy, to improving Scotland’s environment, to improving Scotland’s wellbeing. That’s what I see, and that’s what I capitalise on.”

The answers lie in improvement methodology, he says. “You need three things: you need will. I think the will is there. You need ideas, the propositions that say this is what we will do. But then you need execution. Execution is the hard bit, and that’s where I’m saying you need a name and you need a method. It’s all very well to have the will, it’s all very well to have the ideas, but unless you’ve got the ability to deliver, then the will and ideas simply stay as these things.”

An active member and former chair of the Public Service Reform Board, Gray believes public service can drive and develop new ways to tackle inequalities. Making better use of evidence is the way forward, he says, using the success of the smoking ban as an example. “Overloading communities” with possible solutions can create barriers between the intention and the community, he suggests.

The public sector workforce can hold the key to improvement, he says. “It’s really important to be honest about the fact that unless we are better and more agile at helping our workforce engage with communities, and to engage with the people we serve, we won’t make the progress we need to see.”

If people are used to top-down solutions, however, considerable cultural change is needed. “There is a huge reservoir of potential in Scotland’s public sector workforce. In health I see, every time I go out, real evidence there are people at the frontline who understand the problems, who know how the communities they serve work, who have great connections into these communities, and who are just waiting to be released. One of the things I try to do is to ensure people feel they have permission to do things that are good. They don’t need to wait for some kind of formal mandate.”

Engaging with communities in the health sphere means person-centred care, and listening to patients. “I have said to colleagues in the NHS at all levels, and in public, patient experience is a defining feature of the reputation of the National Health Service in Scotland, and I’m committed to getting better at hearing patient and family and carer experience, and to accepting where that experience is not positive, we learn from it and we learn quickly.”

Gray speaks to NHS staff on leadership development programmes often, he says, about core values. He also says he has been discussing values-based recruitment with NHS Education Scotland, so that leadership capacity is at all levels of the NHS.

“You don’t change culture by saying you want to change the culture. And you don’t really change culture by having a culture change programme either. The way you change culture, I think, the powerful way, is to say what you value. Now I value openness and transparency,” he says.

Part of this is empowering staff to be able to say sorry, he says, using tools like the Patient Opinion website. “When we do something that isn’t up to the standard it should be, we should say we are sorry. We absolutely should. We should not catch ourselves in the bureaucratic tangle of wondering whether an issue might lead to some kind of legal action against us, or whether it might damage our reputation. We should be immediate and upfront, and apologise when things don’t go as they should. That’s my absolute stance on this.”

He also believes areas with the greatest need should be prioritised. “You can see that there is really good impact of things like free prescriptions in areas that are deprived, because there’s a removal of a barrier to uptake and so on, but the prioritisation then has to be within the communities we serve, finding out what’s important to them. There’s a theme running through good clinical practice of asking people ‘what matters to you?’

“So instead of the model that says ‘what’s the matter with you’, we say, ‘what matters to you?’ Now I think that applies to both individuals and communities, because if we don’t ask communities what matters to them then we simply have my opinion about what should matter, and not theirs. It’s their opinion that counts.”

The well-publicised pressure the NHS is put under has led to some uncomfortable headlines. Gray insists he welcomes the level of scrutiny. “I welcome the challenge that comes through public scrutiny and the press. Of course at times it’s uncomfortable, and of course at times I don’t necessarily agree with everything said, but that element of scrutiny, I believe, keeps us mindful of how the public perceive what we’re doing, and it also helps us to really think carefully about not becoming complacent about what we’re delivering. I think we need to get better at listening to challenge and at reacting positively to it.”

Run charts on the walls of most hospital wards in the country show a commitment to transparency, he says, but the service needs to be better at telling “the many thousands” of positive stories too. Negative stories arising from missed targets and pressures on the system can also lead to heavy criticism from opposition politicians as well, but Gray’s experience gives him perspective.

“We live in a democracy, and I therefore completely accept politicians have a right to do what they do. They were elected. And I also accept under any government – and I’ve worked for Conservative, Labour, Labour/Lib Dem and SNP, so I’ve worked in many political environments, I’ve worked in reserved administration and devolved administration, and strong government is helped by strong opposition, holding to account, scrutiny, the parliament scrutinising the executive, all of these things are part of a strong democracy, and I work within that.

“I made the choice to work within that, and therefore I don’t resent the fact politicians are political. There’s a clue in the name. Politicians are political, that’s what they do. In a sense they have earned the right to do that by being elected. I’m happy to work in that environment. As I’ve said, sometimes it’s uncomfortable, sometimes I think some of the things said are unfair, but a core part of my job is to ensure the NHS is seen to be an organisation that is world class and delivers high value.”

With all the pressures and responsibilities, doesn’t he get misty-eyed about a simple life of milking cattle? It’s all part of the journey, he insists. “When you’re milking a herd of cattle, you can be kicked very suddenly at any time, and unpleasant things can drop on your head without warning, so actually, working in public service could be seen to have certain similarities. It was great training.”