Why do parts of the NHS have a bullying culture, and how can it be changed, asks Andy Cowper

Cowper’s Cut is a new weekly column from HSJ’s comment editor Andy Cowper. It will be published every Monday and seeks to serve as an informative and entertaining stimulant for HSJ’s subscribers at the start of the working week.

A quote attributed to Henry Ford, and reportedly written on the Ford boardroom wall – that “culture eats strategy for breakfast” – often features in discussions about the culture of the NHS.

Oddly, those discussions often avoid taking on one of the biggest issues in NHS management: why do parts of the service have a bullying culture, and how can it be changed?

Let’s be clear: not every allegation of bullying in the NHS is well founded, just as not every self styled NHS whistleblower is in reality a whistleblower. Settling of scores and personal retaliation for real or perceived wrongs can be present in both areas.

There can also be legitimate differences of personal style; there can be thoughtlessness; and there can be tactlessness. These are not necessarily tantamount to bullying: they are much closer to an unmet training need in better people skills.

Hydra’s heads

Let’s be equally clear: the NHS has a problem with bullying, and this problem is not rare.

Why does this problem arise in a public service whose basic ethos is about helping people? Several factors are pertinent. One is that a universal public service comes under existential pressure to deliver the “right answers” to the challenges or standards (AKA targets) it is set by The Centre.

The Centre is not always the Department of Health or the health secretary: it varies, and has multiplied like Hydra’s heads in response to the new public management reforms; the burgeoning regulation industry; and in particular the decentralised aspirations of the 2012 Act.

The Centre circa 2017 may be a multipolar centre, but it probably weighs more heavily on leaders than at any point in the NHS’s history. The promise of meaningful local accountability, central to the creation of foundation trust status and of clinical commissioning groups has never seemed more remote. The “right answer” – just now, a financial balance “right answer” – is king.

There is also persistent and significant failure to root out the worst practices and the worst culprits, at local organisation level and at system leading level. It’s not as if the identities of the people who consistently and deliberately do this are a mystery. The annual NHS staff survey points to where the problems are.

Indeed, sometimes they are tolerated with the weakest of all excuses: “they get results”. This may be true, if the results you’re looking for are significantly unhappy organisations with high turnover of those staff able and qualified to move somewhere less toxic. That ought not to be the goal, however.

There have also been real problems of self styled “alpha” leaders who are in fact bullies recruiting and promoting in their own images: a significant failure for the service’s HR and governance.

‘There’s a nice line used by some of the best NHS leaders: ”culture is the way we do things round here when nobody’s looking”’

Likewise, another ugly piece of this jigsaw is the experience of black and minority ethnic staff (and their woeful underrepresentation at director level), ably captured by the work of Roger Kline, Yvonne Coghill and colleagues.

Good NHS leaders sometimes use another quote: ”the soft stuff is the hard stuff”. If you take that absolutely literally, however, it’s misleading.

Culture is not soft: far from it. It may be hard to measure, but you know an organisation’s culture when you meet it. There’s a nice line used by some of the best NHS leaders: ”culture is the way we do things round here when nobody’s looking”.

Culture shapes all

Culture is what you do, incentivise, promote and reward. Culture is not what organisations or leaders say about themselves: that’s PR. Culture is the way they consistently behave towards colleagues at all levels, particularly when under pressure.

The NHS’s instinctive reaction to being under pressure is too often to firefight to the target – the “right answer” that The Centre(s) demand. That’s the wrong approach.

The right approach is to realise that your culture shapes everything that your organisation does and means. This is why I’ve long argued that the NHS needs a chief anthropologist more than it needs any chief inspector.

Culture can change, too: preferably for the better and the more open. Feel free to start today.

Andy Cowper is comment editor of HSJ