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Begin with culture; the rest will follow

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    Julia Fernando

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.