Cowper’s Cut: The alpha and omega of NHS culture

This is the fifth in my series of ‘Five Easy Pieces’ about the biggest problems I see facing the NHS today. The others touched on workforce, wages, Brexit and planning.

I’d addressed the bullying culture of the NHS in a previous column, but NHS culture problems are broader than the bullying culture (although that is its worst manifestation). 

One school of thought suggests that all the problems in NHS culture are caused by evil managers hell-bent on denying clinicians resources and patients care. Not only is this reductive nonsense, it’s hog-whimperingly stupid reductive nonsense.

NHS management is simple: it’s about seeing that the taxpayer’s healthcare pound is spent in the most equitable and clinically effective and cost-effective way possible to get the maximum health gain for the most people. You can call it planning, or rationing: you can call it Shirley if you want. What you can’t do is run a cost-limited system without it.

‘Dear old Lord Lansley was forever hymning his proposed version of the NHS run by “doctors, not bureaucrats”, so it’s a good thing that bureaucracy was completely removed from the NHS by his reforms… just kidding!’

It is depressingly instructive of the opulent stupidity of too much of the national media and the public that NHS manager-bashing has become A Thing. Dear old Lord Lansley was forever hymning his proposed version of the NHS run by “doctors, not bureaucrats”, so it’s a good thing that bureaucracy was completely removed from the NHS by his reforms… just kidding! Instead they just sacked or downgraded the jobs of people who did important work.

Only when the last NHS staff member whose role is administration, co-ordination or organisation of healthcare has been ‘right-sized’ in the fevered dreams of buffoons and right-wing ideologues will we notice that clinics do not book themselves, diagnostic test results do not transmit themselves and cause the right follow-up and the public cannot navigate complex medical systems without support.

Dark side

Trying to run the NHS without competent, motivated and valued leaders of administration and organisation is like trying to get an orchestra to perform a piece without a conductor or a cast to do a play without a director or designer. In extremely rare cases, it’ll sort of come off, but by and large it’s going to be a self-indulgent mess led by the biggest egos and voices.

The clinical professions have to take a share of the blame here, unfortunately. Firstly, for the still ongoing use of the phase “going over to the dark side”, to refer to management and to denigrate clinicians who roll up their bare-below-the-elbows sleeves and get involved. By seeking to demean those described, users this phrase out themselves as members of the hard-of-thought community, so I suppose it may have diagnostic use value.

But the clinical professions are also at times responsible for the very silo-isation that critics of the NHS system so deplore. This isn’t confined to the rivalries between certain clinical professions (which of course make the irrational hatred between people from Portsmouth and Southampton look trivial).

Clinical sectarianism of that kind is obviously not a good look. What’s even more embarrassing to a profession which is at heart in the business of helping the sick – a genuinely noble calling – is the monumental cultural disconnect that can too often be seen between older clinicians brought up in the ‘school-of-hard-knocks-humiliation-only-made-me-mildly-psychopathic-so-it-won’t-hurt-you’ era (the Stone Age of medical culture) and their younger counterparts.

 ‘There is not a little work for the professions to do within and among themselves to get their houses, guilds and royal colleges in order’

Clearly, this isn’t universal. There are many superb older clinicians who nurture and inspire and value younger colleagues; there are some younger clinicians who are every bit as lacking in basics of empathy and sociability (though it’s rarer as the workforce feminises).

But there’s still too much of it about, and if clinicians seriously want to help shape and drive the future of the NHS, then there is not a little work for the professions to do within and among themselves to get their houses, guilds and royal colleges in order.

The culture of concealment is a genuine problem in the NHS management community, however. Its cultural roots are obvious: old NHS management hands accurately describe the chief executive’s job as tripartite: ‘don’t embarrass the minister, don’t kill patients in such numbers people may notice and don’t blow up the money’.

The incentives for candour are frankly not all that great, whatever the rhetorical duty may be. The NHS old boys’ and girls’ network has not always accurately differentiated between people who made honest mistakes and should be given another chance and people whose incompetence (or worse) have caused a reign of havoc ending in their being forced out with a payoff and a nod-and-a-wink about a comeback.

Non-disclosure agreements are particularly toxic in this context. Too many NHS managers have followed a ‘lawyers-first’ approach when staff problems arise. It is not without good reason that the law firms have all the best freebies at NHS conferences.

Difficult conversations

An aspect of culture that it would be good to see eradicated form the NHS is the ‘no blame culture’. That is a stupid concept, and one behind which genuinely incompetent or (mercifully rare) malign staff can shelter. What the NHS needs is not a ‘no blame’ culture, but one of just accountability.

Because healthy cultures in the NHS are ones where difficult conversations can be had, based on data and evidence and respectfully if robustly conducted. This stuff is a million miles from bullying: this is ensuring that a high-risk industry learns from the inevitable mistakes, and uses human factors approaches to learning and improving.

At a basic level, the NHS is a symbol of national mutual respect and valuing. It is a statement that we believe people should have access to healthcare using a mutual risk pool. Those are good stories for a nation to tell itself. We must tell ourselves better stories about NHS culture. Meaning is everything.

Andy Cowper is comment editor of HSJ