After what feels like ten years of the NHS and those with an interest in the NHS obsessing about structures and systems, culture is starting to get the profile it deserves. In fact, it is hard to read anything about the NHS these days without culture getting a mention. This is how it should be. But to say this is the real challenge facing the NHS is to grossly underestimate its importance.
There is ample academic and other literature on the nature of culture, indeed “culture eats strategy for breakfast” is often quoted. In NHS terms, however, culture is particularly complex. The NHS is a mixture of cultures all operating and interacting together. Professional cultures – some of which have developed over a hundred years – combined with performance and political cultures develop a heady mix. Indeed, as anyone who has experience of the NHS can tell you, wards literally side-by-side can have very different cultures.
So how do you promote a more positive, transparent culture going forward?
Firstly, you have to ‘name it’, i.e. set out what the positive culture you want to create looks like. That is what we did in 2007/08 with the development of the NHS Constitution, where we set out the principles, values, behaviours and environment for patients, staff and the public to work together for improvement.
Secondly, you need to promote and value the culture. This takes time, effort and, most importantly, consistency of purpose. This is something that we have not always focussed on. You can see some evidence of progress in the staff and patient surveys, but not everywhere.
Thirdly, you need to see the culture lived by the leadership community, hence the development of new ways of encouraging more clinicians to take up leadership positions and redefine what success looks like, i.e. the NHS leadership framework and the development of NHS Leadership Academy.
Fourthly, the promotion of team-based working. The culture of the heroic individual in the NHS is very strong, whether it is the ‘maverick surgeon’ or the turnaround hero (seldom heroine), and yet most of our successes for patients are based on teamwork. The Michael West work shows that the greatest predictor of low mortality in hospitals is the quality of teamwork. Indeed, further research recently published in the BMJ shows that the greatest cause of premature deaths is wrong diagnosis, which reinforces the need for teamwork.
Fifthly, openness and transparency is essential, although incredibly hard. Robert Francis himself said that often what appears to be a lack of openness is the NHS attempting to put things right before they become public. This is often not because they want it to be hidden –these days, post FOI and the like, that’s almost impossible –but they want to be able to set out the solutions before being put under public glare. They are wrong. Many of these potential patient safety issues are difficult to resolve, typically involving multiple agencies and professions. The first priority has to be ensuring the issue is not repeated and that patients and their loved ones are informed and kept up to date. This is a hard lesson, but essential.
Sixthly, whatever the organisation you work for, make the changes there. It is too easy to point the finger at other organisations and say they have to change. They may need to, but that’s not the point. That’s why in setting up NHS England, we live-stream our board meetings, publish our risk register, the executive team has set out team-based objectives and published consultant level data.
Finally, cultural change has to start with yourself. It is the responsibility of every NHS leader to be the best they can be. By setting ambitious goals, by measuring your success, being open to failure and encouraging and supporting others to live the culture.
Sir David Nicholson is chief executive of NHS England. Follow NHS England on Twitter @NHSEngland