Creating a patient-centred culture has been a long-held objective for the NHS, so is there a need for the Francis report’s proposed culture overhaul? By David Buchanan, Mike Bourne and Steve Macaulay

Is Robert Francis right? Does the NHS really need a culture overhaul? A key recommendation from the inquiry into events at Mid Staffordshire Foundation Trust concerns changing NHS culture to one that pays closer attention to patients.

Creating a more patient-centred culture was an objective of The NHS Plan in 2000. Has nothing changed?

‘Any large organisation will have “bad apples”, but it is unlikely that the NHS has hired 1.3 million of them in recent years’

Culture is usually defined as “the way we do things around here”, and culture change in large complex organisations is notoriously difficult, expensive and time consuming. So before embarking on this enterprise, it would be wise to check if it is necessary. Evidence suggests that it is not.

We recently completed a study of more than 1,200 middle managers in six acute hospitals, focusing on those in “hybrid” positions combining clinical and managerial responsibilities, as well as on “pure” managers (operations managers and department heads). Hybrids include ward sisters, matrons, path lab supervisors, senior nurses, specialty leads and clinical directors. Together, these managers account for 30 per cent of staff in an acute trust, and hybrids outnumber the full-timers by four to one.

David Buchanan and Mike Bourne on post-Francis leadership by HSJ News

Far from the stereotype of pen-pushing bureaucrats, middle managers are on the frontline of change and innovation, as well as managing day-to-day operations. The motives of this group are central to the quality, safety and efficiency of patient care.

Our study sought to discover what motivates middle managers, the pressures they face and how their roles are changing. A mix of qualitative and quantitative evidence was gathered from interviews, focus groups and a survey with more than 600 responses.

Highly motivated, deeply committed

The top-five motivators for middle managers were identified in the recurring themes from interviews and focus groups. These were: “making a difference for patients”, “driving innovation and change”, “doing a good job”’, “feeling valued” and ”developing others”.

This was confirmed by the survey responses: 75 per cent said they were motivated by making a difference to patient wellbeing, 90 per cent were motivated by developing others, and 94 per cent felt their work made a contribution to the organisation. 

This motivation profile was the same in all six trusts. This is not a group of staff obsessed with money and targets and with no time for patients. Let’s define an organisation’s latent culture as “the way we want to do things around here”. By this definition, the service is already patient-centred.

Under pressure

How do we explain the failings at Mid Staffordshire? First, any large organisation will have “bad apples”, but it is unlikely that the NHS has hired 1.3 million of them in recent years. Second, we must recognise the ”fundamental attribution error”, which means blaming individuals and ignoring the context in which they work.

Evidence suggests that a latent, patient-centred culture is smothered by four context factors: autocratic leadership, burdensome regulation, constant change and demanding cost cuts.

  1. Autocratic leadership NHS governance is complex, hierarchical and bureaucratic. Central control is exercised through five-year plans, annual operating frameworks and NHS England’s planning guidance. This autocratic style cascades into the local hospital hierarchy, with ward sisters complaining that “we’re not trusted to manage”, “we’re not allowed to use our experience” and “our hands are tied with micromanagement, red tape and layers of policies”.
  2. Burdensome regulation Healthcare providers answer to many regulators, auditors, inspectorates and accreditation agencies, whose information requirements overlap. Regulatory demands are not all handled by corporate governance units. Middle managers are also involved. Seventy-six per cent of survey respondents said a lot of their time is “spent responding to requests for information, reports and action plans”. More than 80 per cent agreed the pressure on their departments “to meet targets has increased”.  Lead nurses spoke about “weekly performance management threats”.
  3. Constant change Hospitals now have to work with new national bodies while developing internal service line management structures. The funding model is also increasingly complex, and incentives and penalties are constantly adjusted to encourage or discourage particular behaviours. Middle managers therefore face considerable uncertainty, with 60 per cent of survey respondents indicating that their “priorities change every week”.
  4. Cost improvements The “Nicholson challenge” to find £20bn in savings by 2015 has been described as an “NHS recession”, a “funding ice age” and a “perfect storm”. Many cost improvement programmes involve major organisational changes, demanding staff time and energy.  While 4 per cent sounds like a small amount, a hospital with an annual expenditure of £400m has to repeatedly cut costs by £16m a year. 

Bad barrels and barrel makers

Exploring “bad behaviour”, the American psychologist Philip Zimbardo talks about “bad apples”, “bad barrels” and “bad barrel makers”.  Robert Francis described Mid Staffordshire as a ”serious systemic failure”, an implicit reference to the “barrel makers”. He also criticised the NHS leadership. In search of those barrel makers, we have to start at the top, with government ministers and those who frame policy.

‘Will the threat of prosecution make leadership and management roles in the NHS more attractive to anyone?’

In the government’s response to the Francis inquiry, the word “criminal” appears 17 times in just 84 pages. Four other aspects of its response raise cause for concern. 

The first is the introduction of a statutory duty of candour, leading to criminal prosecution for boards who misreport performance data or conceal instances of poor care. Individual sanctions will not be introduced, as this might “create a culture of fear”, but “hospital information will not be limited to aggregated ratings but will drill down to information at department, speciality, care group and condition-specific level”. 

Second, the chief inspector of hospitals will become the national “whistleblower in chief”, with power to alert other agencies to “criminally negligent practice”.  Third, a system for identifying and blacklisting “failed” managers will be developed. Fourth, those aspiring to board level positions will have to pass a “fit and proper person” test.

Will the introduction of new legal procedures and the criminalisation of aspects of performance management and serious incident handling really engage and motivate staff, encourage openness and stimulate creativity and innovation? Will the threat of prosecution make leadership and management roles in the NHS more attractive to clinical staff − or indeed, to anyone?

A problem solved

Solutions are already in place for the problems which these proposals address. The changes that are now necessary lie elsewhere.

  • First, the NHS needs a supportive leadership style. Recent commentary accuses NHS management and staff of not listening to patients. At Mid Staffordshire, leaders at all levels did not listen to management and staff. In the absence of supportive leadership, we are likely to see more care failures.
  • Second, the regulatory regime must be streamlined, and NHS Confederation chief executive Mike Farrar’s bureaucracy review may recommend this. Targets work well when they are used to give direction and supportive feedback. Targets have perverse outcomes when used as a basis for punishment. Let’s have appropriate targets – without the terror. Those regulators, auditors, inspectorates and accreditation agencies are expensive, and therefore a source of significant savings.
  • Third, the service would benefit from a period of stability, with no more reorganisations, or shifts in policy, or new priorities. Changes under way need to be embedded. The service is meeting the costs of recent changes, without the benefits; this is a waste of money.
  • Fourth, rethink the cost-improvement programmes; if not the scale, perhaps the pace. This recommendation may be unrealistic in the current economic and political climate, but could be funded by reducing the number of regulators and inspectors and by avoiding costly change initiatives.

In the light of this evidence, it would be wasteful to attempt to change “the way we want to do things around here”. The factors that hold back those aspirations should be addressed instead.

David Buchanan is professor of organisational behaviour, Mike Bourne is professor of business performance, and Steve Macaulay is learning development executive at Cranfield University School of Management