They have interviewed hundreds of key stakeholders and surveyed hundreds of clinical teams; pored over thousands of pages of board meeting minutes and analysed existing national data sets for significant trends. The research, published today in the BMJ Quality and Safety, has provided a comprehensive assessment of the extent to which there are cultures that prioritise quality and safety across the NHS in England and revealed, as would be expected, considerable variation. There are many bright spots and some dark spots.
Virtually all those we interviewed were firmly committed to the ideal of a safe, high-quality health service for patients and to good patient experience. Many identified the values of compassion and care as the heart of the mission for their organisations, and as their most deeply felt personal professional commitment. For organisations to succeed in delivering high-quality, safe care, our research suggested that they needed to have a clearly articulated vision, including explicit goals for quality and safety and a strategy for achieving them.
But dark spots were found where staff were challenged to provide quality care, were harried or distracted or were preoccupied with bureaucracy. Interviews and surveys with patient and carer groups suggested that patients and their carers were often concerned about quality and safety. Inconsistent care, care that was task-focused rather than person-centred, and a low level of staff engagement were features of many of these settings. This in turn left patients variously ill-informed, distressed, and disappointed. We also found that there was evidence of wide variation in the ability of NHS organisations to gather, identify, sort, understand, monitor, and act appropriately upon information about their performance in relation to quality and safety.
While this research has been going on, the NHS has been buffeted by huge change and subject to many painful pressures. The largest structural change in its history; the Francis report; the Berwick review; the Keogh review; a sustained and hostile press barrage; and the resignation of the Chief Executive of NHS England are just some examples. What all this turbulence has created is a rare opportunity – right now – to transform NHS cultures at every level of the sector. There is an opportunity to change top-down hierarchies into engaged, participative, learning organisations; to change from punitive inspection regimes to cultures of appreciative inquiry which focus on diffusing and absorbing good practice; to encourage innovation at every level; to move to a system where problems are dealt with effectively and compassionately in the interests of patient care and staff wellbeing.
That means leaders at all levels need to develop an understanding of culture and recognise that culture – not regulation, direction, supervision and punishment – is what determines behaviour in NHS trusts. Culture is the way we do things around here; it is the current in the river; the hidden determinant of organisational direction; the manifestation of values. Leaders must then work together to nurture healthy, positive cultures and that will require them to embrace the concept of collective leadership.
This is a rare opportunity to build on the forces for change released by Francis, Keogh and Berwick to nurture cultures where quality and safety are the top priority; where there are clear goals for improvement at every level from board to ward; where patient engagement and voice are truly enabled; where staff are engaged in developing their organisations; where staff are supported, respected, valued and developed; where team-working is not undermined by status and professional subcultures; and where there is integrity of purpose across the organisation.
Culture change will require all involved in the health service to change their minds and their behaviours and to challenge taken-for-granted assumptions in their trusts, teams, wards and departments. It requires regulatory bodies to speak with one voice, challenge their own assumptions and change their own cultures. It will require boards to take responsibility for nurturing learning cultures that emphasise quality, safety, compassion, engagement and transparency in practice, not just in words. And it will require politicians to honestly address what they can do in the long term to help nurture such cultures to ensure that the NHS continues to fulfil its inspirational founding values.
The findings of our research suggest a need for a renewed and more co-ordinated emphasis on quality and safety to ensure that recent progress is not lost. We must all take responsibility and seize the moment to bring about transformational change in NHS cultures that the service now requires and our communities deserve.