Now is the time to transform NHS cultures

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Over the course of the past four years, a dedicated team of researchers from six universities (Lancaster, Leicester, Aberdeen, Aston, Sheffield and Birmingham), along with the National Association for Patient Participation, has spent hundreds of hours observing the way things are done in wards, A&E units, primary care reception areas, and intensive care units across the English NHS.

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.

See the BMJ article "Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study."


Bruce Gray

Comment date
10 September 2013
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...

But the way we do things 'round here' is through regulation, direction, suoervision and punishment. Those are the behaviours, that is the culture.

I agree with everything else said, but this quoted section seemed to miss the point for me.

Ed Macalister-Smith

NHS Leadership Coach,
Comment date
12 September 2013
A good article, and a good and important challenge - not just that we should focus on the culture, but that we should do it now, and that Boards need to take responsibility for how their organisations work. Entirely consistent with Berwick diagnosis, and with Keogh actions.

And Boards and leaders in organisations, whatever the pressures put upon them from above, need to make sure that the right signals are given to their staff. If the Board gives out messages that suggest that they are in "victim" mode, then their staff will copy that. It is far, far too easy to become a victim, and that's not what we pay Boards to be, and it's not what their public would expect of them.

Front-line staff deserve nothing less than unequivocal support from their leaders locally as to the right things to do - and that needs to include also the unequivocal dealing with by management (clinical and non-) of unacceptable performance by staff. Changing culture is not just about describing the right things to do, but it is also about dealing assertively with the unacceptable.

Dr Malcolm Rigler

Partners in Health ( Midland ) Ltd.
Comment date
12 September 2013
The need for the NHS to take seriously the fact that cultural issues are at the heart of NHS dysfunction was long ago appreciated by Rev Dr Michael Wilson - his book "Health is for People" pub. Darton ,Longman and Todd remains as a key text for those interested in cultural change within health services. Within the Uk the "arts and health" community has been well aware of the issues raised by Michale West for some years. However, the divide between "the creative arts" and "medical science" is wide and deep . The medical world is dominated by science and pseudo-science so that the voice of the artist / cultural change agent is not heard. Maybe our "visiting fellow" can help to bridge the divide ?

Dr Robert G Ma…

Architect & Reader in Architecture,
Liverpool John Moores University
Comment date
12 September 2013
Ofcourse it all depends on what we understand by culture and cultured ? Can a psychiatric hospital be cultural or just clinical ? Why are medical buildings not full of classical music ? In " The Eyes of the Skin" Cultural experiences are viewed through our eyes, smell, touch and hearing. We need to define and discuss the meaning of culture in more detail.

Michael West

Comment date
13 September 2013
I agree Bruce. I think this is the key area to focus on changing culture in the NHS

Betty Njuguna

Qualty manager,
Comment date
04 March 2014
any one withexperience of measuring organisational culture? are there any recognised metrics to do so?

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