Why changing NHS culture must be at the heart of responding to Berwick

12 August 2013

Stephen Singleton

Politicians and the media love the idea of fixes for the NHS: 'there must be a minimum level of nursing cover for a ward!' 'It must be a criminal offence to hide things from patients!' 'Throw money at it!' 'Take money away!' 'Reorganise!' 'Regulate!' 'Tell them what to do!'

Three obvious problems arise with this approach:

  1. Technical solutions alone cannot fix complex problems.
  2. The real message (culture eats strategy for breakfast every day) is lost in the noise.
  3. If the approach was taken to its logical conclusion, the NHS would have to dismiss a lot of doctors, nurses and managers for unacceptable behaviour.

Let’s look at that last point again: why would staff have to go? What is this unacceptable behaviour? Aren’t we all against blaming individuals now?

Last week I was listening to chastening feedback from some junior doctors. They talked about well-known issues that should have been dealt with long ago. Why do some ward managers get away with years of bullying their team? Why is one ward delivering poor care when the ward across the corridor is a sea of calm and excellent care? Why is it scary to ring some consultants for advice and a pleasure to ring others?

In any other high aspiring, high quality service industry, the necessary technical solutions would be applied:

  • lots of induction and training of staff
  • regular and meaningful appraisal
  • proper development plans for individuals and teams
  • regular skilled and positive coaching for supervisors and managers
  • and, when necessary, systems to sack any staff who consistently abuse the organisation’s values, ignore agreed processes and standards for work and refuse offers of support when things go wrong.

But just as importantly for these high performing organisations, the non-technical 'adaptive challenge' solutions will be in play too. The values, purpose and objectives of the organisation would be transparent. Leaders would see signalling how to behave, how to live those values and deliver delight to their customers, as real work. Nurturing a culture to support excellence would be the business of every member of staff. Staff would be engaged in continuous improvement of their work. The customers would be a constant source of real-time, useful and acted upon feedback.

All of this is exactly what the best NHS organisations do too. Some try but fail, whilst others don't even try. This is one of the reasons that safety and patient experience varies across the NHS, why the is so important to the future of the NHS and why, if we tackle it, the NHS could be simply brilliant all of the time.

When supported properly, poor ward managers can be developed. Scary consultants can change. Struggling managers can be found the right work. Chaotic, fearful, poor quality healthcare environments can be made safe and kind. And yes, very occasionally, staff have to be sacked.

I asked the junior doctors if they had tried to give feedback or complain? Had they used their clinical supervision time to reflect on why it was so painful, even an experience of real fear and danger, to work on certain wards? Yes, obviously they had, but no-one listened. Their supervisors gave excuses ('he/she is good at some things'), poor advice ('keep your head down, it is only for 4 months') and unhelpful coaching ('yeah, people have complained about that ward before...'). The junior nurses were just as scared as they were. The HR team didn’t answer emails. It was just accepted that it was always like that...

Toxic leadership exists amongst some nurses, doctors and managers in the NHS. It matters because it harms patients and hurts colleagues. The solutions are theoretically both straightforward (follow good HR practice and policy) and complex (change the culture that permits bad behaviour) but both of these strategies are really very difficult to implement consistently. It takes Herculean will-power from right-minded leaders, constant coaching of the middle managers and it takes time. Setbacks have to be accepted with no loss of enthusiasm. It will not be easy but this is what the Berwick report asks the NHS to do - to change its culture and continuously improve patient safety.

However I would ask: Is it the sheer hardness of the challenge that allows us to tolerate doctors and nurses who are poor role models, incompetent managers and bullies? Or is it something else?

Stephen is a former NHS medical director and Chief Executive and was a member of the Don Berwick advisory group.

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