Eric Berne spent his career watching how people talk to each other – the dynamics at play rather than the words themselves. He was looking for the interplay between those who hold the power, those who need the help, and those who takes responsibility.
He called his framework Transactional Analysis. And once you know it, you see it everywhere in the NHS.
THE FRAMEWORK
Parent | Adult | Child.
The basic idea is simple. In any interaction, we are operating from one of three ego states.
The Parent — the part of us that has absorbed the rules, the judgements, the authority of those who came before us. It speaks in two voices: the Nurturing Parent, which supports and encourages, and the Critical Parent, which controls, judges, and finds wanting.
The Adult — the part that responds to what is in front of us with curiosity rather than assumption. It is rational, present and grounded.
The Child — the part shaped by how we learned, early in life, to survive in the presence of authority. The Adapted Child complies or rebels whereas the Free Child creates.
The functional state, the one where things get done and problems get solved, is Adult-to-Adult. This happens when two people, or two organisations, meet each other as equals. It encourages clear thinking and requires a shared recognition of the truth.
How much of the NHS operates Adult-to-Adult?
I spent fifteen years at Chief Executive level in the NHS. What I watched, repeatedly, was a system that structurally generates Parent-Child dynamics. Indeed, I was part of that dynamic. It was almost impossible not to be, and it resulted in all of us no longer behaving like adults.
My leadership roles have almost always been in organisations subject to some kind of regulatory action. If I am honest, I have always been drawn to organisations that are in difficulty and would like to think that I did some good in rebuilding them. But now that I am on the outside and have a cooler eyed perspective, I have had time to think about what the regulatory architecture says to an organisation in difficulty.
You are not performing; We are coming in; We will oversee you; We will mandate support; We will tell you what to do until you do well enough to be trusted
That is not Adult-to-Adult, that is Critical Parent to Adapted Child and Adapted Children, in Berne’s framework, do one of two things. They comply passively, resentfully whilst waiting to be told the next thing. Or they rebel which in an NHS context looks like disengagement, cynicism, the slow withdrawal of the discretionary effort that is key to enabling a health system to work.
The escalation framework is not wrong. There are times when an organisation genuinely needs intensive support, and I have been in those organisations. But the way support is too often delivered — from above, to the organisation rather than with it, as something done to the leadership rather than alongside them — reproduces the very dynamic that probably contributed to the problem in the first place.
I’m Only Trying To Help You.
Berne described the sort of game this engenders in organisational dynamics. He called it “I’m Only Trying To Help You” – interactions that look productive on the surface but often are not.
The Rescuer arrives with solutions the Victim cannot quite use and so the Victim inevitably fails to improve. The Rescuer feels frustrated and superior and nothing fundamentally changes. Everyone can say, with their hand on their heart, that they tried and so the game continues. In the context of what I have seen, describing it as a game feels flippant and unserious because the consequences can be serious. I have witnessed careers ended, people’s reputations traduced and leadership wisdom lost too many times as a result of these cycles.
And this has been playing out across the NHS for decades. Not because the people involved are bad but because the system architecture has it baked into its design and, perhaps we have should now ask why this is the case and whether there are better ways to improve organisations.
Which ego state are you operating from right now?
I believe we need to start looking for alternatives because the cumulative cost of Parent – Child interactions is becoming hard to ignore. Finding the alternative starts with a question a leader must be honest enough to ask themselves.
Am I a Critical Parent — issuing instructions, closing down dissent, reinforcing compliance rather than building capability?
Am I a Adapted Child — waiting for the regulator to tell me what to do next, performing assurance rather than exercising it?
Or am I an Adult — facing what is true about my organisation, trusting the people around me enough to invite the real conversation rather than the managed one?
The organisations that are generally the more successful in the NHS are not the ones with the best strategies, although it helps to have a clear sense of strategic direction. The are the ones where the leadership has created the conditions for Adult-to-Adult interaction throughout the system. Where a ward manager will tell the Chief Executive what is not working and expect to be heard. Where the Board receives uncomfortable intelligence and responds with curiosity rather than defence or blame. Where the people who deliver care are treated, consistently and genuinely, as the adults who hold the answers.
This is not soft – I think it is the hardest thing a leader does because you cannot command Adult-to-Adult. You can only model it, protect it, and rebuild it when the inevitable pressure pushes everyone back into less helpful dynamics.
Berne’s insight, at its root, was an optimistic one. He believed that underneath the games, the scripts, the accumulated defensive patterns of a lifetime, people are fundamentally OK.
I believe the same is true of NHS organisations.
The answers are already in the organisation but the people who have them have stopped being asked.
People, not problems.
Steve Moore · Founder & Principal, Moore & Company