Need presented on multiple fronts: low staff engagement and retention scores; incidents of bullying and discrimination; some services deemed to be underperforming, under the feared label of ‘special measures’. Leaving aside the big questions of what culture is and how much it can ever be willed to change, research has shown strong links between culture, behaviour and care outcomes. I found myself wondering afresh, though, how large scale culture change can be encouraged among the fabric of local dynamics of a complex organisation. And, perhaps rather pessimistically, whether any sustainable change is possible amid the swirl of constant change in the NHS.
Method and improvisation among Covid-19
The established NHS England and NHS Improvement culture and leadership toolkit had been picked as the approach of choice before I began. Initially I had reservations – more with relying on any single approach in a large heterogeneous system, than with this approach specifically. As I learnt from the method’s creators, a participative philosophy lay beneath a structured presentation – combining the power of participative, appreciative methods, with a sufficiently structured approach to meet governance requirements of the NHS hierarchy. Idealism meeting pragmatism, perhaps.
I recruited volunteer ‘champions’ from across all staff groups to learn about and then undertake a discovery, design and delivery process, which created an informed network of change agents, able to support change in practice. This participative model matched my experiences of seeing the deepest change happen when led by those who can implement it locally, with support from those above. We were inundated with enthusiastic applicants – a reassuring indication of a system hungry for change. Twenty-five staff were selected and trained when, just as the seeds had been sown, Covid-19 rolled in.
Following the CEO and Board’s determination to continue with the work through Covid-19, the next six months was an improvisation of adaptive steps, helping a keen yet tentative and preoccupied group of staff to learn about the social and political nature of culture, modifying the toolkit approach as the context changed. Somehow, among intensive care unit expansions, patient surges, infection control, redeployment and exhaustion, the group used the toolkit to deliver a deep listening exercise in the trust and then presented findings to stakeholders.
As the findings began to sink in, leaders grasped the implications of leading cultural change. An action plan emerged, integrating new and existing initiatives in a flexible framework. But with more than 1,000 people engaged in the process of inquiry already and a network now of more than 40 champions, change had already begun. Many people were coming to understand culture better and to see ways that they and their colleagues might help to improve it. This work reminded me that, more than anything, culture, and the changing of it is largely about leaders – and collective leadership particularly, where anyone can be a leader. What people see, say and do, everywhere in the system can start to make a difference.
Crisis as a catalyst for change
As Covid-19 accentuated cultural patterns, this work became a space for staff to make sense of their experiences along the way. As the operational context simplified in response to Covid-19, collaboration flourished overnight; but the pressure also told on everyone. Stories of discrimination, abdication, heroism and brilliance all vied for currency. Adversity and the resulting solidarity seemed to help the team inquire into patterns of ‘bad’ behaviour as patterns of the system, rather than individuals letting the side down. Curiosity and a whole systems perspective largely supplanted blame and judgement – the group were able to see individual behaviour as patterns of the greater whole of the organisation. I’ve never been one for following a recipe too strictly, but having the clear, written down approach in the NHS England and NHS Improvement toolkit helped this group find its way in a turbulent environment. To continue a large-scale culture initiative through the turbulence of the Covid-19 pandemic was, I think, a courageous move on the part of the CEO and the board, and it set them apart from most other trusts that postponed similar work.
Which change matters?
The trust saw some of the largest annual increases in engagement scores in the annual staff survey for many years, despite Covid-19. Whether this increase can be attributed at all to this work (let alone exiting from special measures) misses a wider point. The network created represents new capability – a cultural change in its own right for this system. Hopefully this capability can now help staff understand and improvise in whatever comes next. As issues of recovery, wellbeing and resilience ride high on the agenda, perhaps change capability is as important as change itself.