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This is a guest blog.
Guest authors bring different perspectives and diverse voices to our blog. They do not always represent the views of The King’s Fund.


If it’s about NHS culture, it’s about leadership


There are plenty of issues to keep NHS leaders awake at night: financial concerns, the winter crisis, the junior doctors’ strikes and experiences of poor-quality care are all in the news. But what about some of the underlying issues behind the headlines?

NHS leaders are concerned about staff reporting high levels of bullying and harassment and are considering strategies to deal with this. They are also concerned with high levels of discrimination reported by some groups of staff and are considering strategies to deal with this.

And there need to be strategies to deal with high levels of staff stress and absenteeism. And then the ambition for the NHS to be the largest learning organisation in the world requires a strategy for ensuring continuous improvement. And there is a need to develop system leadership, which will require yet more strategies. Plus the need to address the shortage of leaders throughout the NHS, which requires a further strategy. So what we end up with is a patchwork of strategies, sewn more or less together in a diffuse set of responses to these important concerns.

If we want to deal effectively with all these issues, then, first and foremost, we need to develop organisations with cultures that deliver high-quality, continually improving and compassionate care. Research shows that such cultures are sustained by organisations that have:

  • an unwavering commitment to providing safe, high-quality care

  • a commitment to effective, efficient, high-quality performance

  • behaviours characterised by support, compassion and inclusion for all patients and staff

  • ways of working that focus on continuous learning, quality improvement and innovation

  • enthusiastic co-operation, teamworking and support within and across boundaries.

We see these values and behaviours in high-performing trusts such as Wrightington, Wigan and Leigh NHS Foundation Trust; Salford Royal NHS Foundation Trust; Northumbria NHS Trust; East London NHS Foundation Trust; and Frimley Health NHS Foundation Trust. These organisations have seen considerable improvements in patient outcomes and staff wellbeing as a result of their efforts.

If one can achieve it, all can achieve it. The question is, how? To find answers to this question, The King’s Fund and NHS Improvement are working on a two-year programme to help trusts to identify their cultural issues and to take appropriate action to develop a culture that enables and sustains safe, high-quality, compassionate care.

Research reveals that leadership is the most significant influence on culture. Every interaction by every leader, every day, shapes the culture of the organisation. So we need leadership that is focused on ensuring constant commitment to all the elements that contribute to a nurturing culture. And we need to ensure we have leaders, and a pipeline of leaders, in place to provide that focus. Not interim leads, vacant leadership posts and make-do-and-mend approaches to leadership that are now commonplace in parts of the NHS.

Ultimately we need one strategy – a leadership strategy. This must ensure we have the right number of leaders in each area of an organisation over the next five years to nurture and sustain caring cultures. We need to identify the qualities these leaders need in order to meet challenges and we need to recruit, develop and select accordingly.

We must develop and continually reinforce the right leadership values and behaviours – such as developing and empowering people, encouraging shared learning and continuous improvement, building trust and co-operation, supporting inclusive climates, and managing performance – needed to nurture these cultures.

This means a move away from command-and-control leadership – still the dominant style in the NHS – to collective leadership. Not because of ideology but because international research evidence demonstrates that collective leadership is associated with high-quality care. Collective leadership is where staff at all levels act to improve care – within and across organisations. It means ‘leadership of all, by all and for all’.

The two-year programme announced today will pilot new online tools to support trusts to diagnose their cultural issues, develop collective leadership strategies to address them and implement any changes. Culture change and leadership transformation must happen at all levels of the NHS, from national bodies through to all provider organisations if we are to achieve and sustain consistent cultures of high-quality, continually improving and compassionate care. We hope this work will play an important part in supporting this.