'The gap - often a tribal or cultural one - between doctors and managers seems to be widening again, not helped by the current, and inevitable, obsession with finance.'

Picture of Hilary Thomas

An anthropologist who has been studying healthcare for some time recently described hospital as 'a place where tribes interact. Each tribe having its own values and behaviours'. He should know. I would extend the observation wider than that - there are tribes throughout the NHS.

I have been back at the coalface of medical management for just over a month now and am not encouraged by what I see. The vast majority of staff working in the service, from all backgrounds, are passionate about the business they are in - the essence of what we do - caring for patients. This is a time of huge change and pressure, nevertheless I find that an awareness of the importance of culture in the NHS and its relevance to the implementation of change is patently missing.

Those of you lucky enough to have seen Tom Stoppard's play Rock 'n' Rollthis year may, like me, have been reflecting on the metaphors. The plot explores two very different journeys. Jan, the pragmatic young Czech exile, returns to Prague in the spring of 1968 and, with the gradual withdrawal of his freedom, becomes a dissident by the time of the Velvet Revolution in 1989.

Meanwhile Max, the Cambridge Don born at the time of the October revolution, remains an idealistic, fervent communist from the comfort of his ivory tower, unchallenged by the realities on the ground. Jan, desperately trying to cling to the spirit of what it means to be Czechoslovakian. Max, pontificating on communist ideology from afar. Does that resonate?

A tribal gap

I'm not making a political point here, the metaphor can be seen across the NHS and between many different 'actors'. The dysfunction at the heart of Max and Jan's relationship is visible in many places and at many levels: between doctors and managers, GPs and consultants, primary care and acute trusts, health departments and the frontline. Even, at times, between staff and patients. We all see it. I see numerous Jans populating the service at the moment - at different stages in the development of their dissidence - identifying other players as Max, unable to feel their pain.

After a while, like Jan, you realise the detail of what is happening does not matter. The gap - often a tribal or cultural one - between doctors and managers seems to be widening again, not helped by the current, and inevitable, obsession with finance. The original largesse of the consultant contract is now being reined in and in many places study leave expenses are not being paid. It is naive to think that a service that accounts for nearly one fifth of gross domestic product could sit outside the sphere of political control. But complex systems like healthcare always default to transactional, structural solutions when things go wrong.

This is where an awareness, and better still, an understanding, of culture is so vital. Relationships are key. Apologies for using a cricketing analogy at this difficult time but without an understanding of the culture and the impact it has on relationships - within and between organisations - you will be bowled out. The grit in the oyster is the means of corralling the tribes and ensuring a better dialogue; a more functional interaction.

There are some fundamental management principles here. Treat people well - staff, patients and carers. Value them. Nurture them. Try to stand in their shoes. If we do not invest in relationships we will find implementation lacking. If we do not understand the importance of culture in delivering sustainable change we will drown in policy but the service will not move forward. The cost is time, some space and kindness; the prize a real chance to reform the system.

Hilary Thomas is medical director of the Royal Surrey County Hospital and professor of oncology at the University of Surrey.