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Culture is such a difficult thing to pin down, isn’t it? Yet we can’t help but contribute to it in all that we do and don’t do – ‘what we walk by we tolerate’ as they say. But while we can’t help but contribute to culture, the act of changing it – creating it – is more difficult.
In our leadership development programmes at the Fund we are explicit in our view that one of the primary tasks of leaders – perhaps the single most important task – is to create the right culture. In a health care context this means creating the conditions in which high-quality, compassionate care can flourish – and it’s a collective responsibility. In my work with leaders I have never once had this view challenged.
Yet here we are, two years after Sir Robert Francis published his findings into the failings at Mid Staffordshire NHS Foundation Trust, getting to grips with his latest report on the need to support staff who speak out about poor-quality care. This is in the same week that the Ombudsman and Healthwatch have shone an uncomfortable light on how the NHS deals with patient complaints.
Secretary of State for Health Jeremy Hunt has made his response clear, emphasising the need for greater transparency, protection for staff who whistleblow and a renewed focus on changing the culture in the interests of patient safety.
Providing more training for medical students in raising concerns would definitely be a step in the right direction. Our own work with emerging leaders suggests that they frequently find themselves at a loss to know how to best escalate a concern or risk. Equally I can think of very experienced clinical leaders who have found themselves inexplicably silenced by the fact that they don’t know how to navigate the organisational bureaucracy when raising concerns over aspects of care within their own service, for which they are directly accountable. The experience seems to leave many feeling angry, anxious, powerless and professionally compromised.
This week’s reports have been accompanied by the usual statements about the actions that will need to be taken by organisations at a local and national level. But the emphasis from both Robert Francis and the Secretary of State on getting the underlying culture and expectations of behaviour right (not just the processes) is very positive. In Francis’s own words, his recommendations ‘are largely about doing better what should already be done’. My hope is that this time we don’t once again hit the target but miss the point. Culture change is about tackling something that is deeply ingrained.
I think fundamentally it is about power – how power might be used to enable rather than constrain and how it can be shared to ensure leadership and expertise are aligned at every level, as our approach to collective leadership describes. However, conversations about power aren’t easy.
Re-reading my colleague Nicola Hartley’s blog on whistleblowing shortly after the publication of the Francis report in 2013 got me thinking again about this issue. A glance at this week’s headlines on the banking sector reveals once again the extent to which whistleblowers can divide opinion – hero or villain? What do we give away to the whistleblower in terms of our own power and sense of collective responsibility? The health sector abounds with examples and careers lost or sacrificed in the name of patient safety. But, as Nicola writes in her blog, by the time it gets to whistleblowing isn’t it already too late? Surely there must be a better way?
On one level the act of whistleblowing could be seen as a last-ditch attempt to be heard. At a more existential level I see it more as a primitive, distressed cry for help. In this context the ability to hear that which might be difficult – sometimes even unbearable – seems to me to be a key leadership practice for leaders at all levels who are serious about culture change. It’s the very antithesis of the collusive avoidance of responsibility described by Isabel Menzies-Lyth and would mark a real shift to the genuine sharing of collective leadership responsibility for organisational success described by my colleague Michael West. Collective leadership is necessary to really listen and learn from the experiences of patients and service users, but applies equally and importantly to really hearing the experiences of staff.
How do we create cultures in which it becomes possible to hear and be heard and without resorting to a whistle. It’s that simple. Isn’t it?