Can you change culture from Whitehall?

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Important reports on the quality of care that are unofficially named after the men who led them are turning out to be quite a feature of 2013. Following Robert Francis in February and Bruce Keogh last month, the National Advisory Group on the Safety of Patients in England – chaired by Don Berwick – published its report into how we can improve patient safety on Tuesday. It's a fluent and passionate plea that the whole health system should shift towards a culture of constant learning and improvement; that supports and empowers staff to focus on quality, and that meaningfully works in partnership with patients at all levels.

All three reports are impressive works of expertise and insight. Like many, I was impressed by the breadth and rigour of Francis' analysis, by the clarity and focus of Keogh's ambitions, and by the absolute primacy given by Berwick to supporting and motivating staff. Most of us seem to agree with much of these reports' diagnoses of the problems and articulations of the goal we should be aiming for.

Where there is inevitably less agreement is over the actions required to get us there, and in particular, the role of central government and national agencies. Can you change culture from Whitehall?

The most obvious answer is no, of course not. Quality of care is first and foremost the responsibility of frontline staff, then of their leaders in trust boards and elsewhere, and only thirdly and finally the responsibility of national bodies.  We have argued this in our response to the Care Quality Commission’s current consultation on its new approach.

Yet, recognising these limitations, the centre nevertheless has a role to play. The planned full government response to Francis is the opportunity for it to articulate and commit to this role. I think there are six broad things that the Department of Health and NHS England can and should do as a priority.

First, they can set the tone. A just and fair culture that trusts and supports staff, that puts the needs of patients above all else, and that welcomes criticism with a spirit of openness and enquiry rather than defensiveness, is something the top echelons of the DH and NHS England need to enact in everything they say and do.

Second, they can provide resources and training. Spreading the skills to lead for quality, to carry out quality improvement work, to involve patients in service design, and to analyse and use quality data, all needs investment in support, training and development. National agencies responsible for quality improvement have come and gone as much as any other structure in our constantly reorganised system, and have rarely been afforded the status and political commitment of other initiatives, and this needs to change.

Third, they can deliver transparency. Great strides are already taking place here, and while I am yet to be convinced that transparency will deliver significant improvement by helping patients make choices, or that the benefits of summary composite ratings will outweigh the pitfalls, it is true that the greater availability of timely, accurate, comparable data on quality is crucial to encourage and enable clinicians and organisations to continuously strive to improve.

Fourth, they can take some direct actions to improve how patients are listened to and involved in decisions. The degree of involvement in quality and safety issues afforded foundation trust governors, for example, remains in general a long way from what it could be.

Fifth, they can do more to ensure safe staffing levels. Like any structure or process target, simplistic, nationally-mandated levels that take insufficient account of local context will not work, but NICE guidance combined with greater external scrutiny on how it is being applied could help.

And finally, they can ensure clear, co-ordinated and proportionate responsibilities in accountability, assurance and enforcement. All staff, and patients, should be able to understand in five minutes what commissioners, regulators and national agencies are each responsible for. And as Berwick stressed, the government must require full co-ordination and co-operation between regulators to clarify and minimise their demands on the system. But regulation is a necessary and important final line of defence, and so as the CQC implements its new monitoring and inspection systems, they must be tested, researched and evaluated so that we can continue to refine the regulatory model.

This list doesn't add up to the creation of a safety culture – that is up to leaders, staff and patients to work together to deliver – but if the DH and NHS England deliver on these six areas over the next year and beyond, they would be making a significant contribution.


Frances Russell

Healthwatch West Sussex
Comment date
15 August 2013
Put the patient at the centre of all decision making.
Trust the professional staff to direct and deliver excellent quality care
Management should guide and enable
Develop quality systems that are respected by the professionals and give regular feedback on achievement
Set targets that are clinically driven and demonstrate efficient use of funding
Stop criticising,start supporting and developing staff
Be open and honest
It worked for me!

Prof Rowan Harwood

consuitlant geriatrician,
Nottingham university hospitals
Comment date
09 August 2013
'Can you change culture from Whitehall? The most obvious answer is no, of course not.' Well, yes actually. Read Win Tadd's report Dignity in Practice (HSDR 2011). Staff behave the way they do (sometimes badly) because they are caught between the needs of patients, and organisations' need to manage risk. Organisations behave the way they do because of demands from above (starting in Whitehall). This is the target-driven performance management culture. On the ground this sounds like 'if you don't improve your dashboards we'll move you on'. Not a recipe for compassionate, flexible, innovative, risk-taking, person-centred, professional care. CQC previously said dignified care required leadership, attitudes and skills and resoures. Up to now leaders have prioritised targets not experience. The elephant in the room is resouces. Long live the Berwick review, lets implement it now.

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