NHS must rise to the cultural change challenge

Publication of the Francis report has been a watershed moment for the NHS. It publicly voiced the growing concern of patients and healthcare professionals, shining a spotlight on the significant gap between what the public expect of the caring professions and what some of us actually experience.

‘About 80 per cent of culture change projects fail to achieve their potential outcomes, mainly due to lack of clear leadership’

The report states “an unhealthy and dangerous culture pervaded not only the trust, but the system of oversight and regulation as a whole and at every level”. It asserts that the negative culture is not restricted to Stafford and can be found throughout the NHS system. This should sound the alarm in every boardroom and staff room.

My team of leadership coaches and consultants have spent a considerable amount of time working with leaders and managers in a wide variety of NHS organisations, including being invited in to Stafford Hospital when the original Healthcare Commission report was released. Our role was to try and identify why the communication system had failed to inform the leadership team of the frontline issues. It was a sobering experience that still guides our work in other trusts.

From the top

All of us in this business know that the first reaction to change is defensive and the second is to push back and resist at least some or all of the changes being introduced. We also know that in the longer term, about 80 per cent of culture change projects fail to achieve their potential outcomes, mainly due to lack of clear leadership, communication and commitment to see the changes through.

The NHS is a federal organisation with a myriad of reporting structures and complex rules about dealing with problem staff. No hospital chief executive has the powers of a CEO in the private sector; no HR manager has the tools or resources available to deal with issues as effectively as they would like.

It is little wonder that achieving uniform national standards of care quality and a patient-centric service culture across the whole NHS would appear to be a near impossibility.  

The Francis report states the need to have a culture of “caring, commitment and compassion.” It suggests that such a culture should start at the top. Those at the top, however, say it should start at the bottom. Of course, they are both right. It actually needs to be endemic across every NHS organisation and ingrained in every employee. But therein lies the challenge − how to achieve that.     

Coaching culture

As with all culture change programmes, the key is effective communication, from the top leadership down and from the frontline staff up.

‘Four years on, we are still reading about care quality and patient safety issues – why haven’t these been successfully dealt with?’

The leadership style needs to create a coaching culture that develops and reinforces positive improvements in every individual at every level, empowering them to take responsibility and encouraging them to act to correct issues, challenging every fellow member of the team as well as themselves to continuously improve, sharing the learning points and best practice.

That way the whole organisation will start acting like a team focused on improving themselves and their team’s performance. It is a culture and environment that has been at the heart of developing UK-based businesses such as Nissan and Toyota, allowing them to become world class.

When we were asked to investigate the role of communications in the failure of Stafford Hospital’s board to grasp the scale of the issues on the front-line, we gained real insight into the day-to-day workings of the communications team in a small district hospital.

Experience is vital

Communication is a two-way process and at cash-strapped Stafford, with little leadership experience from the first-time board directors, they failed to recognise the need to put an experienced communications team in a position to help them transmit, receive or monitor communications − let alone set up a proper system that could alert them of the issues and give them the authority to lay those issues on the desks of the directors responsible.

Priorities were elsewhere and the board’s faith in clinical leadership to deliver quality care, patient safety and deal with patients as individuals was, in much of this period, misinformed and misplaced. The resulting issues and results are well documented in both of Robert Francis’ reports.

Four years on, we are still reading about care quality and patient safety issues − so why haven’t these been successfully dealt with?

It is easy to blame individuals and overlook that, in an effective team, each individual takes responsibility for other team members and their actions, successes and shortcomings.

In a coaching culture that is designed to grow the performance of each member, you assess the issues, identify the performance gap and the reasons behind it, empower every individual to address the problem and monitor the improvement in performance.

Performance measurement

In the federal system the NHS runs, particularly as trusts move to foundation status, trust boards have been empowered. But they are using a compliance-based performance measurement system, so hospital managers have created recording systems that force frontline clinicians to spend too much time on computer records and too little time with patients. 

‘We need some leadership with the vision and will to make the changes that the public and Francis are demanding’

The huddle around the nurses’ station is a good example. In Stafford, I recall watching as patients’ buzzers were sounding asking for help but nurses and healthcare assistants were focused on their computer screens and treated the buzzer as an annoying distraction.  

We now hear that ministers have decreed that all patients shall be spoken to at least once an hour by a nurse or healthcare assistant. It is another tick-box measure to ensure compliance, but it doesn’t really address the problems.

What is actually needed is for every trust to refocus its staff on patients and their needs.

That is not easy when we have understaffed wards with overworked, under-pressure, tired clinicians who, to use Liam Donaldson’s phrase from the Francis report, can begin to see patients as a “diseased object to be processed”.

In such circumstances, the quote from Viscount Slim gives you the answer: “Managers are necessary, leaders are essential.” We now need some leadership with the vision and will to make the changes that the public and Francis are demanding. 

Leaders at all levels

In other industries where culture change has succeeded, the key has been to ensure that every leader at every level:

• constantly challenges themselves and their team to look for better ways to deliver the outcomes they have identified;
• creates a culture that says, “Good is never good enough.” It becomes a personal quest of every member of the team to look for and suggest improvements.
• They jointly take responsibility for each other and if issues do occur, address them quickly, focusing the whole team on how they can be resolved and lessons learned to prevent them happening again.

The key to delivering a change in culture post-Francis must be engaging all trust staff to adopt a coaching style of team building. They need to learn how to properly assess the systems, processes and behaviour they use when dealing with patients and each other for effectiveness and good patient experience.

They must challenge themselves and their team members to find ways to continually improve, ask the right questions in an open way and listen far more than talk, taking on board what they hear rather than defending the status quo.

Effective leaders need to learn how to provide positive, constructive, feedback and use a coaching style of leadership to help team members continuously develop their skills, practices and behaviours. Each person needs to accept responsibility and accountability for their own and other team members’ actions and behaviour, without being judgemental.

Team NHS

The ethos is that every member of staff is ultimately part of “Team NHS”.

‘Change won’t start by itself. Every leader in every NHS organisation needs to ignite the spark within their employees’

Everyone has a right to have an input and to respect each other within the team, as well as other teams. Each staff member should respect the patient, who is a key part of the team working to resolve the medical issue they have presented. You need the patient at the heart of the team − not as “the object to be processed”.

It is easy to say, far harder to do. Trusts that wish to change will, undoubtedly, need external help to create an effective change programme that will deliver what we, the public both want and expect − high-quality care and patient safety.

It won’t come from regulators but it can emerge from an informed, effective trust leadership that creates a positive, self-improving culture.

This change won’t start by itself. Every leader in every NHS organisation needs to ignite the spark within their employees, share their vision of what is expected and reinforce it again and again.

Trust chief executives need to take action now, empowering staff, patients and other stakeholders, communicating effectively to develop a powerful open culture focused on putting quality and patients at the heart of all their services.

Warwick Partington is managing director of MTM Communication Skills Training and has worked as a communications consultant for a variety of NHS organisations over 17 years, including Stafford Hospital