Will prescriptions for cultural change improve the NHS?

Abstract

It is hard to escape the conclusion from the Francis report into care at Mid Staffordshire NHS Foundation Trust that the primary culprit at the heart of this latest NHS scandal is "the culture" of our healthcare organisations.1 Francis suggests that "a fundamental culture change is needed" and is clear that he is seeking a move to something overarching and comprehensive for the whole NHS.The Francis inquiry, like the Kennedy inquiry into paediatric cardiac surgery at Bristol more than a decade earlier, 2 has gone to considerable trouble to try to understand the meaning of culture in a healthcare context. Yet the subtlety of some of the supporting evidence to the inquiry has not been matched by the same degree of nuance in the inquiry's recommendations about culture, which are somewhat aspirational and broad brush (box 1). This is a pity, since the research literature has much to say about the nature of culture and the possibilities for shaping cultural change to produce benefits. 3-5 Unpacking cultureBy finding fault with culture and providing prescriptions for change, Francis is making several assumptions that require examination. Firstly, he presupposes that we can identify and assess common aspects of culture, 6 as well as identify which aspects are supportive of or inimical to high quality care. Secondly, he assumes that these aspects of culture can be purposely changed, that any changes will lead to improvements, and that the costs and dysfunctions from such prescriptive changes will be outweighed by the benefits.4 7 Finally, while acknowledging that culture may vary "from organisation to organisation and from department to department," Francis emphasises the need for "a positive and common culture throughout." This presumes that common cultures are possible and desirable, even in systems as large and distributed as the NHS. However, research shows more complex and nuanced relations between cultures, practices, and outcomes than Francis implies.

Cultures of Silence and Cultures of Voice: The Role of Whistleblowing in Healthcare Organisations

“…12 A number of personal, social, and organisational factors have been identified which conspire to shape and sustain 'organisational deafness' in the face of poor and unsafe care. 13 Central to these are entrenched hierarchical status and power differences between different professional and occupational groups (eg, between nurses and doctors, or between frontline staff and managers) serving to limit or attenuate the development of open reporting cultures. 8,14 It is not immediately clear how whistleblowing ameliorates rather than exacerbates the 'deaf effect' in organisations.…”

Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews

“…186 That cultural change is as unproblematic as such pronouncements seem to suppose has, however, received some considerable challenge. 313 The Francis public inquiry, 11 like the Kennedy inquiry at Bristol more than a decade earlier, went to considerable trouble to try to understand the meaning of culture in a health-care context. Yet the subtlety of some of the supporting evidence to the inquiry was not matched by the same degree of nuance in the inquiry's recommendations about culture, which are somewhat aspirational and broad brush.…”

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

“…5,[87][88][89] Unfortunately, as noted by Professor Jon Glasby, 81 'The trouble with culture is everyone blames it when things go wrong but no-one really knows what it is or how to change it'. This issue is compounded when viewing (as we do) health-care organisations as comprising multiple cultures/cultural frames, rather than as a single culture of care.…”