The difficulties of creating culture change in the NHS

There is an enormous amount of interest in how culture can be changed in many aspects of public services and particularly in the NHS. At various times, everyone from policy analysts to politicians, professional associations to patients has highlighted problems in the culture of the NHS and set out an alternative vision of what that culture should be. Despite all this interest over many decades, there has been very few examples of where large-scale culture change has been introduced in the NHS.

I believe that there are 5 factors which explain this failure and some of the problems of introducing culture change in the NHS.

1) The mosquito vs the elephant

Outsiders to the NHS often look at organisational charts of the NHS and assume that the Board and Senior Management Team have all the power in the NHS and that they can issue instructions and policies is a “command and control” style. This fails to recognize one of the major weaknesses in Senior Management Teams highlighted by Sir David Nicholson (NHS Chief Executive) in the HSJ (January 2007) that the average NHS Chief Executive is in post for less than 700 days and a specific Executive Team of 5 Executive Directors is likely to be stable for less than a year. 

In comparison, most medical and surgical consultants stay in the same post in the same organization for an average of 30 years and General Practitioners tend to stay in the same practice in the same area for a similar time. What this means is that the senior medical staff in both primary and secondary care will have a dozen different Chief Executives and even more Boards throughout their career and so can simply outwait any new top-down initiative or new management program that they do not support, particularly if they use their extensive local networks to slow it down.

The Elephant can always outwait the Mosquito no matter how much noise or irritation the Mosquito produces.

2) Manchester United vs Chelsea

The larger the organization, the more consistent the senior leadership focus needs to be for longer to enable genuine culture change. As shown previously, many frontline staff are on their third or fourth logo on their name badge and their sixth or seventh manager and if each manager had a different philosophy or management approach, then these will be ineffective and any change will be short-lived. 

3) The reality of bath times

There is often a great deal of rhetoric about how services are designed around the needs of the patient or the wishes of the client. There needs to be recognition of the reality of the relationship between professional and patient and services are often organised around needs of professional or the organization. Two relatively trivial examples are as follows:

• most adults choose to have baths in the evening at the end of the day whereas almost all patients are bathed in the morning to suit the professional workload
• most working adults never pass an open GP practice near where they live as they open after the commute begins and close before the commute ends

4) Dealing with middle management dementors

Most of the literature around innovation shows that ideas about service improvements are often generated by the front-line staff in most contact with the users of a service. In the NHS, innovation tends to be driven from the top and the bottom of an organisation and is slowed/blocked by the middle of an organization. On the Nurse First programme, we spent considerable time trying to reconnect the top and bottom by enabling clinical staff to deal with layers of middle management who spend considerable time and energy stifling any innovation. Like the dementors in Harry Potter, the effect of this layer can be to suck the happiness, the enthusiasm and the hope from front-line staff. This is not because NHS middle managers are inherently bad or against innovation, but their primary focus is often on cost-containment and achieving service targets.

5) The delusion of NHS culture change

There is almost no empirical evidence of intentional NHS culture change. There are many NHS leaders will claim a policy change without any robust “before” and “after” measurement. This can be demonstrated by looking at the NHS Staff Survey which is commissioned every year. Over the last few years, most organizations would claim that they are improving the culture in the organizations and improving their management culture. The 2011 NHS staff survey showed:

• The percentage of staff who would recommend their organisation as a place to work in fell from 55% in 2009 to 53% in 2010 to 51% in 2011
• Only 26% said that communication between senior managers and staff is effective and less than a third (30%) reported that senior managers act on feedback from staff.
• Less than half of all staff across the NHS (46%, unchanged from 2010) felt that healthcare professionals and managers worked well together. 
• Only 26% of staff (27% in 2010) felt that their managers involve staff in important decisions. 
• Just over one third of staff felt that managers encourage them to suggest new ideas.

If there is going to be genuine culture shift that can be learned from then there needs to be a level of transparency in what the culture was before and how it has subsequently changed.