Begin with culture; the rest will follow

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Part of A programme with NHS Improvement to support culture change through collective leadership

What drives high performance in the NHS? Is it the promise of reward and recognition? Or is it the fear of impending punishment and blame? The answer is neither.

It’s said that motivation is all about rewarding good behaviour and punishing bad behaviour. Simple. Except that humans are not so simple. And research shows that while this formulaic approach might work with rats and dogs, it doesn’t bring about lasting changes in attitudes, values or mindsets in humans. When incentives and threats are taken away or made less explicit, their influence diminishes and, over time, their effects can disappear completely. So this quick and dirty approach to employee motivation can only go so far in bringing about and sustaining the highest quality of patient care that we all want to see throughout the NHS.

Quite simply, the top-down, ‘command and control’ leadership style that so often nurtures fear and blame in NHS organisations has got to go. For quality improvement and innovation efforts to truly work, they have to take place in a culture of compassion. Compassionate cultures are those in which employees feel understood, listened to, empathised with and well supported.

The first step for organisations hoping to create a culture of compassion is to really understand their current culture – this means taking the time to uncover and embrace areas of challenge and conflict, as well as highlighting and celebrating each unique success and strength. This process requires the input of all leaders in the organisation, both formal and informal, to ensure a holistic and inclusive assessment. The next step is for this understanding to inform the development of intelligent strategies that address key issues and build on areas of best practice. All areas and levels of the organisation should be invited to contribute to the design and implementation of these strategies and their feedback listened to intently.

To support trusts in adopting this approach to culture change, NHS Improvement, The King’s Fund and Center for Creative Leadership are working together on a two-year programme to provide: diagnostic tools to help trusts to understand their culture; guidance to help them design leadership strategies; and support for them to deliver specifically tailored interventions in their organisations.

And in the spirit of true co-design, we have also been working with three organisations – Central Manchester University Hospital, Northumbria Healthcare and East London NHS foundation trusts – who have been testing the diagnostic tools in their own organisations and evaluating their effectiveness and value. I am fortunate enough to have witnessed this collaboration first-hand, and have watched both the relationships and the work evolve and flourish over the past eight months. I have drawn three particular lessons from this.

  • First, this work couldn’t have been the success that it is without the humility and transparency that has been demonstrated by all members of the inter-organisational team. This has led to the creation of a positive, supportive and compassionate working environment.
  • Second, the reality is that if we want to see patients treated with the respect, dignity and compassion they deserve, then we should expect to see NHS staff being treated in the same way. Culture is the backdrop to all these interactions, so when leaders are deciding how to address difficulties in their organisation – whether it’s using these tools or others – they should start with a focus on culture and the rest will naturally follow.
  • Finally, and perhaps most importantly, creating cultures of compassion has to be the priority for all who work in the system and demonstrated in their interactions with one another: from frontline staff to senior leadership teams; national bodies to political leaders. Encouragingly, NHS Improvement’s leadership of this work has already set the wheels in motion.

The first phase of our programme has now come to an end; the learning from the three pilot trusts has been incorporated into the next version of the tools. The diagnostic tools from this first phase are to be launched at NHS England’s Health and Care Innovation Expo tomorrow, giving all NHS trusts the opportunity to take advantage of them. However, these tools are only an aid. Achieving cultural change throughout the system will require compassionate leaders in all areas and at all levels to go beyond the basic and ineffective reward and punishment framework.


Umesh Prabhu

Comment date
08 November 2016
There is lot of confusion around word culture, values and value based leadership. It took me 10 years to understand value based leadership. This is what I understand by these words in simple terms.

Culture - How we behave or provide care when no one is watching us. In an organisation with 4500 staff, it is how all 4500 staff provide care or behave when no one is watching them! To have all 4500 staff to be kind, caring, compassionate 365 days and 24 hours a day does take lot of effort to do and this is why staff must own it, they must decide it, they must define it and they must agree to stick by it and when they don't there must be leaders who act and deal with it! This is why culture is so variable in our NHS and in any organisation.

Values - Values is what we hold very dear to our heart. Or how we treat each other as human beings. Or our purpose of doing any job in our life. Why do I want to be a doctor or a nurse or a Clinical or a Medical Director? Most of us do not think about these things and just do a job and end up doing a bad job or poor job because we simply follow what our seniors did or what someone else did or does in our organisation!

Sad reality is NHS appoints non-clinical managers in to leadership positions and expect them to behave like leaders and many can not and struggle to be leaders. Many are good people and try their best to do a good job. Leadership is all about inspiring, motivating, caring and looking after all staff and creating a culture of staff happiness and putting systems and processes in place so that patients get the best care. Most important culture we need is a culture of staff happiness and then only staff will enjoy their job and are able to provide the safe and the best care. Good leaders focus more on staff engagement, staff involvement and staff well-being. Managers focus on targets and finance. They put pressure on staff to achieve targets and in such a culture staff suffer and when staff suffer patients also suffer.

NHS is still doing very well because it has core 80 to 90% value based staff who would always do the right thing for their patients the fellow human beings.

Rekha R Elaswarapu

The Good Governance institute
Comment date
12 September 2016
A few years ago I attended a seminar at the King's Fund. I can't remember the name of the chair who was from the the King's Fund. He banned us from using the word 'culture' instead we had to use 'behaviours'.
Culture is a rhetoric that is used so often and it somehow gives the impression that someone else is responsible for changing it. If we talk about behaviours there is much more ownership and the change in culture will follow. This is why most NHS organisations do not agree that they have certain types of culture e.g. bullying but are happy to say there are some bullying behaviours. How many instances of such behaviours will make it a culture.
Adopting compassionate behaviours are a pre-cursor to creating such cultures.

Tim Dalmau

Dalmau Consulting
Comment date
09 September 2016
Whilst much in this blog os material with which I would agree, it is based on a false premise - that culture is an input rather than an output and that it can be engineered. Pity.

Vincent Docherty

Direcor of Patient and Family Services,
St Christopher's
Comment date
07 September 2016
I work as the social work, bereavement service, welfare and Candle project lead at St Christopher's hospice south London.

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