Mike Chitty

Helping realise development since 1986

Leadership

The ‘Impossibility’ of Working in the Current NHS: Sacrifice to a Primitive God

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by Rachel Gibbons (2025)

Reviewed by Mike Chitty

Rachel Gibbons’ recent contribution to Psychodynamic Practice offers a lucid and unsettling diagnoses of NHS organisational culture. Moving beyond typical accounts of staff burnout, under-resourcing, and institutional inertia, Gibbons draws on psychoanalytic and symbolic frameworks to reveal the deeper currents that trap health professionals in a cycle of sacrifice and despair. Her core thesis is that working in the NHS today is not merely difficult, but psychically impossible, unless one submits to being ritually sacrificed to maintain the illusion of a benevolent, functional system.

The ‘Primitive God’ of Sacrificial Health Work

At the heart of Gibbons’ argument is the symbolic function of sacrifice. She contends that NHS workers, particularly those in caring roles, are not merely overworked, but sacrificed. Their wellbeing, values, and often sanity are consumed in service of an institutional mythology that cannot bear to confront its own incoherence. The “primitive god” in this case is the organisation itself, sustained not by functional governance but by ritual acts of devotion and denial.

Sacrifice is not a metaphor but a defence mechanism. It keeps the wider system stable, even if it means destroying those within it. The sacrificial offering is the emotional and moral integrity of frontline workers, those whose care is most authentic and whose suffering is most repressed.

Psychodynamics: Splitting, Projection, and Denial

Gibbons makes good use of psychoanalytic concepts to explain how this dynamic is sustained:

  • Splitting: Staff and systems alternate between being idealised (“heroes”, “angels”) and denigrated (“troublemakers”, “burnouts”), rather than being seen in their full humanity. This fragmentation protects the system from integrating contradictory truths.
  • Projective Identification: Organisational anxiety is offloaded onto individuals, who are then punished or marginalised for manifesting it. This is particularly visible in the treatment of whistleblowers and dissenters.
  • Denial: Leaders and institutions deny systemic trauma by overemphasising strategy, data, and performance management, mechanisms that conceal emotional and moral breakdowns beneath a veneer of rationality.

The result is an emotionally broken culture that expects moral performance without moral support, a theatre of virtue sustained by suffering.

Implications for Leadership and Organisational Culture

One of Gibbons’ most important contributions is her challenge to prevailing models of NHS leadership. Rather than calling for better metrics or resilience training, she calls for psychic and symbolic honesty. NHS leaders, she argues, must become aware of the unconscious dynamics that animate their institutions: the roles they play in sacrificial rituals, the stories they tell to justify harm, and the fear of confronting institutional grief.

She invites leaders to:

  • Develop emotional literacy, able to name and work with shame, guilt, and projection.
  • Hold spaces for collective reflection, not as a form of managerialism, but as a way of honouring moral experience.
  • Resist the myth of heroic individualism, which feeds the sacrificial logic, and instead embrace relational and collective leadership.

In doing so, she implicitly aligns with broader movements that seek to embed ethics of care and process-relational thinking into public service cultures.

The ‘Impossibility’ Reframed

To call working in the NHS “impossible” is not to suggest it cannot be done, it is to suggest that, under current conditions, it can only be done by engaging in forms of self-abandonment that ultimately dehumanise. Those of us who work with colleagues who have sustained NHS careers will recognise this phenomena. Gibbons reframes this impossibility not as a failure of individuals, but as a systemic indictment. She names the collective delusion: that we can continue to expect quality care, moral integrity, and emotional labour from professionals while denying them the psychic and structural support they need.

Her paper, then, is less a critique and more a call to consciousness, to notice what we have repressed, to question the gods we serve, and to remember that care cannot survive where sacrifice is demanded.

A Leadership Ethic for the Post-Sacrificial NHS

For those working in leadership development, Gibbons’ insights offer an urgent provocation: our leadership paradigms must evolve. The NHS cannot be reformed by better targets, slicker dashboards, or even more compassionate rhetoric if it continues to rely on unconscious rituals of self-sacrifice. Instead, what is needed is:

  • A shift toward collective responsibility, where care is not individualised but shared.
  • A refusal of martyrdom, cultivating leadership that names its limits and honours its own needs.
  • The development of psychodynamic fluency in leadership education, recognising that what is not spoken still shapes what is done.
  • The cultivation of process-relational awareness, where institutions are seen not as machines to optimise, but as evolving fields of relationship to be tended.

Such a shift would require leaders not only to learn new skills, but to undergo a kind of moral and emotional reckoning: a willingness to listen to the unspoken, to disrupt sacrificial norms, and to reimagine care as something grounded in shared vulnerability rather than heroic endurance.

Conclusion

Rachel Gibbons has written a rare thing: a paper that is both clinically astute and politically courageous. By drawing attention to the unconscious sacrifices demanded by NHS culture, she gives voice to what so many feel but dare not name. In doing so, she opens the door to a new conversation, one in which care is no longer confused with suffering, and leadership becomes an act of deep, relational responsibility.

Her paper deserves to be widely read, not only by clinicians and psychotherapists, but by health leaders, policymakers, and anyone seeking to restore soul and sanity to public service. For those of us working at the intersection of ethics, process, and leadership, her work is not only insightful, it is indispensable.

If you would like to explore this paper further and its implications for your leaders or leadership please do get in touch.

33 Ways (and counting) that ‘Whiteness’ Works

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White in a black frame
Whiteness

I started in anti racism when some of my favourite musicians starting playing gigs in the late 70s for the Anti Nazi League and Rock against Racism and I was ‘just seventeen’, if you know what I mean. It was not long after Bowie had declared that ‘Britain is ready for a Fascist leader’.

In the 80s I trained as a Teacher when the impacts of race, class and gender on educational attainment and child development were taught rather than the mechanics of the national curriculum. It was the time of the miners’ strike and the North/South divide in the UK was wide.

In the 90s I worked in black, village schools in rural West Africa in an old British colony before coming back to Leeds to raise a family and build a career. I had some theory as well as a little practice and experience under my belt.

But no-one had re-framed the challenges of anti-racist practice with the study of ‘whiteness’ and how it operates until Tracie Jolliff introduced it to me at the NHS Leadership Academy perhaps 5 years ago. It has shaped my practice and my observations and reflections ever since.

Now I will ask leadership teams and boards to have a good look at how ‘whiteness’ operates in their culture. Because until we can start to see ‘whiteness’ as an ‘operating system’ and start to re-write some of its code, it will keep being extractive. It will keep producing inequities.

More recently working with Pauline Mayers on ‘Lessons From Henrietta Lacks’ has helped me to see a bit more of how my own whiteness operates as part of the wider system. Heather Nelson at the Black Health Initiative in Leeds too has helped me to look in the mirror. And Whiteness has also had me in its sights. “If you are going to do ant-racist work you will have your baptism of fire”. You will have many baptisms…

By ‘whiteness’ I don’t mean all white people. As Professor Kehinde Andrews has said ‘whiteness is not just for whites’. I mean a system of cultural and historical assumptions about hierarchy, power, objectivity, logical positivism, duality (whiteness is happier with black and white rules not shades of grey, nuance, wisdom and judgement) and patriarchy that are so deeply enmeshed in many ‘white’ cultures that they pass invisibly as ‘how things are’.

I have started to look for clues about how whiteness works. Signs of whiteness at work. In myself. In the organisations I work with, and for. In the communities and societies that I am a part of. That are a part of me. They are clues, not laws, or rules or truths.

  1. Whiteness looks for and at what is wrong with colour
  2. Whiteness commissions or supports people of colour to sort out ‘what is wrong’ (provide special course for people of colour, set up networks, write reports)
  3. When Whiteness experiences dissent or challenge it frames it as a threat and defaults to power and hierarchy over compassion and listening
  4. Whiteness likes to be taught by colour (What should we do?)
  5. Whiteness finds reflecting on itself difficult – it often triggers guilt and shame rather than hope and opportunities to change
  6. Whiteness often blames victims (if we feed the children they will become dependent)
  7. Whiteness polices tone – ‘calm down…’
  8. Whiteness when it feels threatened punishes
  9. Whiteness invites people to learn and when the learning becomes powerful, painful and the Zone of Uncomfortable Debate is entered with accompanying emotion, they close it down or punish the ones expressing their pain
  10. Whiteness values compliance over dissent
  11. Whiteness ‘does to’ rather than stands alongside
  12. Whiteness rarely looks hard at itself
  13. Whiteness learns slowly because it already knows how to look after itself
  14. Whiteness values self development over self sacrifice
  15. Whiteness exercises ‘power over’ in preference to ‘power with’ or ‘power to’
  16. Whiteness holds on to its power
  17. Whiteness sees itself apart from the system rather than as a part of the system
  18. Whiteness prefers domination to collaboration; competition to cooperation
  19. Whiteness is used to ‘winning’; getting its way
  20. Whiteness is trapped in its own miserable, extractive, consumerist nightmare of progress
  21. Whiteness finds it hard to see its paradigm of privilege
  22. Whiteness manipulates through psychological safety and self supporting cliques
  23. Whiteness recognises as intelligence/wisdom the products of white normative educational and developmental processes. It tends not to recognise the product of other non-white developmental norms.
  24. Whiteness claims inclusion and compassion – while presiding over enormous inequalities and violence
  25. Whiteness shies away from complexity and nuance in favour of evidence
  26. Whiteness tends to divide the mind from the body
  27. Whiteness encourages us to privilege certain world views and to dismiss others as unscientific, or not evidenced
  28. whiteness upon learning of the pain/trauma of others will become the emotional ‘victim’ needing comfort thus derailing the conversation and focus back to themselves
  29. Whiteness upon learning of the pain/trauma it causes others will become the emotional ‘victim’ needing comfort and thus derailing the conversation and putting the focus back to themselves
  30. Whiteness starts with white as the default. It then uses categorisation and tick boxes to fragment people, shift them away from default and identify them in more and more ways as Not Normal. To hide intersectionality by counting variables that it can then treat as ‘independent’.
  31. Whiteness prizes ‘knowledge’, but is very clear about the forms that it finds acceptable – fetishising a narrow field of science and turning away from epistemological positions that doesn’t privilege it.
  32. Whiteness sees ‘BAME’ as a ‘background’. In the foreground it sees opportunity.
  33. Whiteness prefers to see racism as an individual, personal act, an event that can be condemned – rather than as a structure of its making for its own convenience and power.

What have I missed?

Love’s Leadership; Lost or Found?

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Leadership is a toxic word for many.

While for others it seems like the holy grail. The missing ingredient in failure. The magic that leads to success. A thing worth obsessing about and building a multi billion pound industry, and healthy livelihoods in.

What is Leadership?

Leadership has no widely agreed definition. It is a word that is used to describe and explain a wide range of phenomena in:

  • politics, culture, work and leisure from the global to local,
  • organisations of all sorts,
  • networks, communities, associations and ‘social movements’

Leadership is found in just about every aspect of human endeavour. But only because we look for it. Or its magical explanatory powers.

It comes in a bewildering choice of varieties:

  • Transactional
  • Transformational
  • Digital
  • Directive
  • Affiliative
  • Participative
  • Clinical
  • Patient
  • Citizen
  • Distributed
  • Distributive
  • Collective
  • Charismatic
  • Dictatorial
  • Evil
  • Benevolent
  • Adaptive…
  • I could go on, probably for ever

But perhaps, like Phlogiston, it doesn’t really exist?

Doers Leadership even Exist?

After all it is a word that allows us to label something that we can’t actually describe. A bit like love. And for me, leadership is an expression of togetherness and love. And no matter how hard we try our expression is imperfect. But we can reflect. Learn, change and get better.

Leadership, like love, is a gift that has to be given and received. Neither are straightforward. Plenty can go wrong. It probably will. But this is part of the process. It allows it to deepen and mature.

For me, leadership is a collective process that creates a future that is different to the present. Good leadership creates more sustainability and fairness. Not so good leadership leads to an insecure future and grave inequalities. It is heart-breaking that in our current narrative Leadership is too often judged in much narrower terms, and in fact inequality and environmental harm are things that can be created as long as the price is right.

Leadership and Leaders

We have a generation of gifted leaders working hard, being heroic, making great progress. Providing us with GOLD command. But it would seem we also have a generation of evil and malevolent leaders spreading division and oppression, shirking and profiteering.

See what I did there?

I shifted from LEADERSHIP – that social process that we are all engaged in to some extent, to LEADERS. The anointed few, with special powers of high office, high skill, high imagination or high finance who we can choose to love or loathe. This lets us escape from thinking about our role in this. It supplies us with heroes and villains and allows us to play the victim. The age old drama triangle plays out and nothing changes.

We must resist the temptation to act as if Leadership is a special set of behaviours that Leaders, those other people, do.

Leadership is not power. It is not authority. It is not what ‘the bosses’ do. It is the ultimate inclusive process. We are ALL more or less complicit in it. It is a social process that we all contribute to. Sometimes through our silence and compliance.

Human civilisation is fragile, brutal, powerful and hate filled. It is also beautiful and loving. In my home city of Leeds, in spite of a strong economy, inequalities have worsened. Life expectancies have stalled or are going backwards. Even before Covid hit. And if look at the global level thinks look even worse.

Has it all gone wrong?

Leadership has not been getting most of us to a better future. Even those that have made a lot of money from it aren’t any happier. And aren’t living any longer. And even if they were living longer and more happily, while the rest get left way behind, how long could that be sustained? Socially? Environmentally?

So perhaps we still have a lot to learn about the thing that we label ‘leadership’.

Where do I start?

We can start with a more committed, generous, imaginative and thorough attempt to describe what we think we are putting the label on, and what we think that thing is for. And a reaffirmation that we intend this thing called ‘leadership’ to take all of us to a more secure and fairer future.

And a recognition that we all have a part to play. Gifts to contribute and gifts to receive.

Are you ready to start your leadership journey?

Be A Better Leader – Ruby Ubhi

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If you prefer to watch your podcasts then this is for you!

I met Ruby at the NHS Leadership Academy in Leeds where we both work on various programmes. Ruby is a talent and leadership developer an executive coach, facilitator speaker and pracademic – practitioner and an academic!

We come from different generations, different backgrounds, different cultures, and different cities. In this podcast we explore what has shaped us and what continues to shape us in our leadership practice.

We talk about doing and being, collusion, Born to Run, race, gender and what growing up taught us. We also talk about social mobility, straddling two worlds and the pain that can involve…