He told a tale of cultures within cultures. It wasn't just the organisation's culture – hierarchical, deferential, based on consensus – that was an issue. The wider societal culture and other factors, including the media, auditors and regulators, also contributed to a reluctance to deal with the issue – an organisational culture doesn't sit in isolation. The Francis Report highlights the need for NHS organisations to create and maintain the right culture to deliver high-quality care that is responsive to patients' needs and preferences. Michael's story highlights the significant challenge of achieving this; it bring into sharp focus the scale of the task of helping NHS leaders to influence and change the complex cultures and sub-cultures that exist, and to make their teams, organisations and systems more care-centred. It reinforces the importance of those in the most senior roles in the NHS paying attention to and significantly shifting the NHS culture to encourage new and healthier micro cultures to be cultivated and grown.
The message from Michael was clear – the operating environment is created from the very top. He spoke of the Japanese culture being one of consensus and harmony, with loyalty as the core value, and how this took precedence over everything else. Loyalty to the organisation and to the chairman got in the way of honesty and transparency. There are parallels here to Francis's diagnosis that NHS leaders placed the highest value on prioritising financial balance and achieving targets while overlooking patient safety and the fundamental standards of care. At Mid Staffordshire, delivery on targets was rewarded, whereas messages about failures in standards of care were discouraged and ignored. This happened to such an extent that those further down the line came to treat finance and targets as ends in themselves. Under such a regime, leaders become detached from those on the front line and from the consequences of their decisions.
Michael used one interesting phrase: 'a lot of management is about turning the stones'. That sense of challenge and continuous enquiry is vital, not just for improving performance but also for uncovering problems. This is so pertinent to the role of non-executive directors on NHS boards and their duty of oversight and scrutiny. Francis identified that there had been a woeful lack of 'stone-turning' by the board at Mid Staffs. In order to learn from mistakes and identify areas for improvement, boards must learn to listen to what they hear, seek to understand, ask the difficult questions and encourage clinical staff to feel comfortable bringing bad news to their attention.
During his lecture, Michael made the case for independent whistleblowing hotlines and a ban on gagging orders. No doubt there are concrete things that organisations can put in place to facilitate the exposure of wrongdoing. But surely whistleblowing as an intervention is too late when it comes to ensuring high standards of patient care? Effort needs to be put into watching, spotting early warning signs and aiming for prevention. The longer-term goal needs to be creating cultures of openness, candour and honesty. This will not happen quickly or by accident, but will rely on strong and stable leadership reinforced by training, personal engagement and commitment.
Whistleblowing is one way of exposing the problem, but this does not necessarily solve the underlying issue. Leaders at all levels and of all disciplines will need to step up and take responsibility for changing a defective and destructive culture. Changing culture is hard work that requires vision, courage, energy and stamina. It will be easy to get distracted by the delivery and operational consequences of the most significant reforms ever faced by the NHS, but leaders ignore the task of culture shift at their peril. Breaking habits is hard and developing new ones requires practice and effort. Leaders leading culture change across the NHS will need to dig deep, cherish their values, look after themselves and stay focused on why things need to change. If they are successful, whistleblowing will be rare, not as a result of gagging clauses, but because the NHS has a thriving culture of transparency and honesty where decision-making is care-centred, and problems are surfaced early and resolved quickly.
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