There are plenty of positive examples across the NHS of the kind of supportive, compassionate and high quality culture and care that must become the norm, says Michael West
Times have been tough in NHS of late. The service has experienced the biggest structural earthquake in its history and has taken a sustained public battering from many sides. Ironically this is all after a period of major improvements in services, such as reduced waiting times and treating heart disease.
‘The most outstanding trusts and their boards are already nurturing the cultures needed to provide high quality, improving care’
NHS staff continue to suffer among the highest stress levels of any in the UK working population and public confidence has been undermined by the sustained criticism of the service. Yet the NHS is a service that is admired around the world.
Because of the intense focus on the NHS, there is an opportunity to nurture a rapid and healthy change in culture across the service. This cultural change must include the Care Quality Commission, Monitor, clinical commissioning groups and NHS England because they powerfully influence cultures across the service.
Their cultures must be shaped to be supportive, developmental, appreciative and visionary by their leaders. Regulation methods should reflect this to support the diffusion of good practice and the development of healthy cultures. The Keogh review provided a fine template for the approach while not losing the sharpness necessary for decisive intervention.
The most outstanding trusts and their boards are already nurturing the cultures needed to provide high quality, compassionate and continuously improving care. Lancaster University Management School’s research offers evidence based prescriptions for how to achieve this.
‘The best trusts avoid “priority thickets” − so many priorities and initiatives from higher levels that frontline staff are simply besieged’
We found the best boards go beyond merely articulating a vision and ensure that they and their leadership community embody the vision through their work. It is what they focus on, monitor, reward and reinforce in their daily activities. They also clarify their five or six improvement objectives as a team, defining how they will uniquely improve their assistance to their trusts to achieve the vision. And they recognised that if quality is not improving, it is getting worse so continuous improvement in care is a central concern for all staff.
These trusts ensure all directorates, departments, teams and individuals have clear, challenging and measurable annual improvement objectives that include care quality as the top priority. They replicate this clarity at every level of the organisation, ensuring through this disciplined approach that staff are not confronted by what we called “priority thickets” − so many priorities and initiatives cascaded from higher levels that frontline staff are simply besieged.
Being the best
The best are excellent at listening to the experiences of patients and the views of staff. These are not box ticking approaches that prioritise bureaucratic compliance with external requirements, but vigorous and sustained methods of gathering rich, in-depth views from both patients and staff.
They use the data they collect intelligently and feed the knowledge back into the system and to frontline staff so that improvement and innovation are guided.
Every day the vast majority of NHS staff strive to deliver the highest quality of care but we saw some fall woefully short − usually in cultures characterised by “command and control” toxicity and internecine conflict that sapped emotional resources.
‘Abusive, aggressive, arrogant and disruptive behaviours should be called out immediately and poor performance managed’
In the best trusts we noted an implicit recognition that if staff are to treat patients with compassion, respect, dignity and professionalism, leaders and managers and staff must treat each other with compassion, respect, dignity and professionalism. National staff survey data clearly bear this out.
Such interactions become culturally contagious. In the best, staff were valued, supported and, above all, when they identified barriers to quality care, they were carefully listened to. And systems difficulties were confronted. And the leadership collectively agreed that abusive, aggressive, arrogant and disruptive behaviours should be called out immediately and poor performance managed, no matter how senior the individuals concerned.
The best trusts we studied across the country have embraced team based working focused on delivering high quality, compassionate care that is consistently improving and working supportively across professional boundaries. Status and professional identity are not barriers to effective team working because there is a widespread commitment to the trust vision and inter-professional respect and valuing. Every team has its objectives and the intent to improve the effectiveness with which they work with other teams in the organisation.
We found these trusts had positive, optimistic cultures where there was a strong commitment to work cooperatively, supportively, cohesively and transparently. There was a commitment by leaders across these trusts to create a culture of high quality, improving care characterised by compassion − taking notice, responding empathically and taking intelligent action to help.
Many trusts we studied are working towards achieving such cultures. Monitor, CCGs, the CQC, NHS England and all those responsible for safeguarding our health services at this time of change and opportunity should do so too.
Michael West is professor of organisational psychology at Lancaster University Management School