"If you want to change the culture, you will have to start by changing the organization." Mary Douglas (1921-2007)
OK I'm going to try out this blogging thing out, yah?
Marvelous. And the thing I want to talk about first is **CULTURE in the NHS**. Now clearly, there are few people better to talk about this than The Twunt having been both Secretary of State for Culture and now Health (don't be convinced otherwise by this bogus survey on the right suggesting I was a shit culture secretary). My supporters (well, Camoron) don't let a little thing like that undermine their (his) ROCK solid
belief in me. Yes, I'm talking about the culture of the NHS. If you don’t have the misfortune to live in
the unbearably tedious world of health policy then let me tell you why this is
important.
So…I can hear you thinking "What…the fuck…is hospital
culture?". Good question. I don’t bloody
know but it sounds like something useful to put the blame on for all the shithouse
problems in the good ship NHS. It's also a fantastic stick to beat managers, doctors, nurses and every other poor fucker who has to scrub the decks.
Let me give you an example of how people use the word when they talk about the NHS in a way that's relevant to Midstaffs. Last week, a clever SpAd (I had to sack him) sent me a recent article from the BMJ by some nobody called Brian Jarman entitled ‘When Managers Rule’. It's utterly tedious so let me use my genius comms skills to distill it down for you. Since the early 1980's there has been a change in the NHS to a situation where managers have developed more power than patients and clinicians. Now, the only reason I paid it any attention was because it cited three reports by private consultants (which obviously have much more weight given their origin) that contained statements like this
So, I need to work out what culture is. That clever SpAd once told me that the word "culture" has a classical origin based on a term used by Cicero. He wrote of a cultivation of the soul "cultura animi" using an agricultural metaphor to describe the development of a philosophical soul, the highest possible ideal for human development. You see why I HAD to sack that SpAd?…bloody useless! Try measuring the development of the philosophical soul of a Hospital CEO with a C-diff outbreak trailing him round the wards, mortality stats going north and an annual PFI bill the size of Gidiots offshore assets.
Let me give you an example of how people use the word when they talk about the NHS in a way that's relevant to Midstaffs. Last week, a clever SpAd (I had to sack him) sent me a recent article from the BMJ by some nobody called Brian Jarman entitled ‘When Managers Rule’. It's utterly tedious so let me use my genius comms skills to distill it down for you. Since the early 1980's there has been a change in the NHS to a situation where managers have developed more power than patients and clinicians. Now, the only reason I paid it any attention was because it cited three reports by private consultants (which obviously have much more weight given their origin) that contained statements like this
“The NHS has developed a widespread culture more of fear and compliance, than of learning, innovation and enthusiastic participation in improvement.” It also said “Virtually everyone in the system is looking up (to satisfy an inspector or manager) rather than looking out (to satisfy patients and families)” and “managers ‘look up, not out.’”
Now, this is exactly the kind of thing that people are saying was the root cause of what went on at Midstaffs. The kind of thing that I'm supposed to sort out for fucks sake! Imagine if you will, someone suggesting trying to change the culture of England? What makes anyone think changing the culture of the monolithic NHS would be more achievable?! Incidentally, the fact that these reports had to be wrung out of the DoH using Freedom of Information requests tells you something about what might be driving the 'culture' they mentioned.
Now, this is exactly the kind of thing that people are saying was the root cause of what went on at Midstaffs. The kind of thing that I'm supposed to sort out for fucks sake! Imagine if you will, someone suggesting trying to change the culture of England? What makes anyone think changing the culture of the monolithic NHS would be more achievable?! Incidentally, the fact that these reports had to be wrung out of the DoH using Freedom of Information requests tells you something about what might be driving the 'culture' they mentioned.
So, I need to work out what culture is. That clever SpAd once told me that the word "culture" has a classical origin based on a term used by Cicero. He wrote of a cultivation of the soul "cultura animi" using an agricultural metaphor to describe the development of a philosophical soul, the highest possible ideal for human development. You see why I HAD to sack that SpAd?…bloody useless! Try measuring the development of the philosophical soul of a Hospital CEO with a C-diff outbreak trailing him round the wards, mortality stats going north and an annual PFI bill the size of Gidiots offshore assets.
The Oxford English Dictionary has Culture down as “The
ideas, customs, and social behavior of a particular people or society.” Now
that might be a bit more useful, but can it really help us come up with something we
can assess? Try assessing that CEO's ideas or behavior directly where it matters. Its bloody difficult. Doing it for a WHOLE FUCKING HOSPITAL? Good fucking luck with that.
If culture is something to do with our ideas and social behavior, what is 'the culture of the NHS'? Well there's been a cottage industry in academia looking at this for the last 10-15 years. Its proponents seem to think culture in the NHS is either attributes the NHS has, which it might be possible to change, or something the NHS is in which case changing its culture (on purpose at least) is probably fucking impossible. Can the culture of the NHS be changed? It does change, apparently (see refs below) but it is not at all clear that it will do our bidding.
A brief Google search will find you a shitload of business gurus and commentators (or 'legends' as I like to call them) telling us how to change the culture of an organisation. But you will notice they rarely define it and (however much they bang on about values and behaviours) the things they describe are changes in the procedures or operations or structures of their organisations. I'm not knocking what they achieved, it just doesn't seem to me like they changed culture, just how their employees 'did stuff'. Look at this example from the World Bank. And really, I think that's what people mean when they talk about culture in the NHS. How we do stuff. As Paul Corrigan puts it; Culture - "The way we do things around here" Read like that, a culture of compliance means too many people are too compliant when they should speak up. A culture of fear means a lot of people are afraid of ...speaking out when they should, losing their jobs, being bullied etc. Are these things, in themselves, culture, or are they are single outcomes of the wider, deeper and richer thing that culture is: what we are as people? More directly, they are outcomes of how institutions like the NHS are organised and managed. And that is where we come to Mary Douglas (see top) She is exactly the kind of person I wont be consulting in the push to change the NHS 'culture' because she was an anthropologist who studied culture her whole life and understood it deeply (and admittedly, partly because she is dead now). Just look at that quote of hers at the top. I don't think I'm going to get away with telling people the NHS needs more (dis/re)organization after the Health & Social Care Act clusterfuck, do you? Much easier to bang on about changing the culture than the organisation, and then change the organisation anyway..
This is all pretty complicated stuff isn't it? Lets look at an example of the kind of thing that needs to get sorted out. Nurses now routinely accused of working in an uncompassionate culture in the NHS? Why? Is it because of
a) Their culture?
b) They have too much work to do in too little time because of chronic under staffing?
c) They know that complaining about staffing levels and organisation will get them blackballed? (That incidentally is exactly what happened to the one nurse whistleblower we know of at Midstaffs)
d) b+c ?
e) Something else e.g Hospital CEOs and boards have much harsher penalties for not meeting financial targets than for ensuring the quality of patient care that nurses give is good.
How could the Winterborne View horror show be allowed to happen? Because of the culture of the carers or as a natural outcome of the way care of this group has been neglected from the top down for years?
Take your pick. It really is complicated isn't it? The profession has launched its own preemptive moves to the Francis MIdstaffs report with the publication of 'Compassion in Practice' which outlines a three year plan for promoting a culture of compassion. At no point do its authors even attempt to define what culture is. That's the kind of deep thinking I'll be encouraging more of on my watch.
There's one final point I would like to make. Whether you call it culture or not, whatever you call it, I'll bet you my detachable bell-end that the way people behave and the values they abide by in institutions is largely set by the way the people at the top behave themselves, and organize that institution. The NHS is nothing if not a fine institution full of large numbers of institutionalized people. So now, you see my problem? If the behavior of NHS workers is set from the top do you think someone like me is going to improve it, or change it? You may have read previous accounts of my business leadership. And look at the BSkyB balls up. Did I take an iota of responsibility for my team's behavior, or behave in in open and accountable way myself? Oh yes, Adam Smith could tell you some stories about the culture I promoted. But of course, I forgot! I don't lead the NHS, do I!? Who is in charge? Step forward Sir David Nicholson! Unfortunately SuhDave stands accused of presiding over the instigation of the very 'culture' of bullying which has been fingered as part of the problem at Midstaffs. Take a step down to CEO level in the NHS...read this. You see! NHS 'culture' isn't so different from the rest of Britain, and like I said, no one is going to be changing that in a hurry. Much easier to label the problem as culture and use it as a big stick to whack the NHS with before I pimp it out to Branson and Serco et al.
So, workers of the NHS. Loyal subjects. Culture is probably something you are going to be hearing a lot more about over the next year or so. I urge you not to think about it too deeply. Just accept the word of The Twunt and your other over lords. We have the situation in hand. You need to change. We can help you do it.
My next blog will be about subcultures in the NHS. .................That's a joke by the way....
Further Reading
Scott et al. (2002) Implementing culture change in health care: theory and practice. Int J Quality HealthCare 15(2). 111-118
Abbasi (2009) Your hospital was a ‘clan’, now it’s ‘rational’ J Roy Soc Med 102. 307
Mannion et al (2009) From cultural cohesion to rules and competition: the trajectory of senior management culture in English NHS hospitals, 2001–2008. J Roy Soc Med vol 102 8332-336
