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This is my longest article since I started the blog two years ago. That’s because it’s dealing with a tough, complex subject – how to change the culture and performance of the NHS following the recent spate of scandals and the hundreds of unnecessary deaths in mid-Staffordshire.
If you’re not British or living in the UK you might not know what the NHS is or why it’s hitting the headlines right now. So let me explain. The National Health Service (NHS) – launched in the UK in 1948 and funded by taxation – offers free medical treatment at the point of delivery. So for example if you go to a NHS hospital for surgery, you won’t have to pay. But the NHS is caught in a scandal that’s hitting the headlines and isn’t going away.
At a mid-Staffordshire hospital, investigators found there’d been hundreds more patient deaths than there should have been. Behind this, they uncovered a disturbing lack of patient care. This led to a public enquiry. Its report came out earlier last month:
Other reports have said the mid-Staffordshire events aren’t isolated, that “there’s a pervasive culture of fear in the NHS”; that “virtually everyone is looking up (to satisfy an inspector or manager) rather than looking out (to satisfy patients and their families)”.
Media commentators had a field day:
Articles continue to appear most days in British newspapers calling for the central CEO’s removal and an NHS culture that (1) puts the interests of patients first (2) allows NHS staff to flag up mistakes and failures while (3) becoming ever more efficient.
But the question is, does anyone in power know how to achieve such culture change? So far, I’m not sure they do.
Just as important, isn’t the latest report creating a Catch-22?
You see, UK governments have tried for years to improve NHS performance by setting nationwide targets. The targets are so ingrained that meeting them is now the NHS’s priority.
But everyone’s saying they want a culture that encourages whistleblowing. Yet hospital staff still believe that if they speak out about failures or question the targets they’ll lose their job and get a bad reference. So while the top-down target setting approach continues and the fear of losing their job if they speak up remains, calling for a more open culture is like asking people to plunge into a pool full of crocodiles.
I’m not suggesting I have a ready-made solution to what’s a complex problem, but here are six thoughts that may point a way forward:
Thought #1
Every organisation (including a hospital) needs a sense of direction, of destination, if it’s to perform well year after year. Why? Because most people respond to a vision of what together they’re trying to become or achieve; one that motivates or – better still – inspires them. After all, who wants to work for long in an organisation that’s got no drive to become more (whether that’s better or different) than it is today?
If people know what they’re aiming to accomplish together and why it’s important – and they feel it matters to them – they’ll give everything they’ve got. But organisations lacking a shared motivating vision aren’t going to inspire people to give their best. High performing organisations therefore start with an inspiring – or at least a motivating – vision and then set targets as short-term markers on the way to the destination. Note that: vision comes before targets.
Now ask yourself, who decides whether the vision is motivating or even inspirational? The answer is the people who have to achieve it.
With these insights we’re now perhaps getting a glimpse of what’s going wrong.
First, an outside organisation (the government in this case) is imposing targets without a compelling, inspirational vision. So they’re just targets. Worse, they are targets set by people who don’t have to achieve them, which means there’s no guarantee the NHS staff agree with them and find them inspiring. Remember, the people who decide whether targets are motivating are the ones who have to achieve them – not the people who set them.
So in my view, the British government is overreaching. It’s assumed that if it imposes performance targets from the centre it will give every hospital the all-important sense of purpose and vision it needs. But although an inspiring vision can drive effective target setting, target setting doesn’t necessarily create a motivating sense of direction. In other words, the government has put the cart before the horse.
The solution? Why not put the horse back in front of the cart (vision first, targets after) and let the people who have to deliver decide what they should be?
Thus, you could allow the local operating units to decide their vision of their future and then set their own performance goals. After all, hospitals and doctors’ surgeries are there to care for their patients, so surely their leaders can create a vision that’s not just inspirational, but downright noble.
Thought #2
Some might react to what I’m suggesting by saying, “But surely that means the standard of patient care will vary around the country depending on what each hospital or NHS trust is emphasising.” My answer to that would be yes, but so what if the standards of patient care are demonstrably rising?
The fact is that organisations are run by people – and people differ. You are not going to have uniformity. Yes, you can impose certain minimum standards, but you don’t have to insist on sameness. The attempt to drive sameness only stifles initiative, creativity and individuality.
Thought #3
Does my suggestion of local vision and target setting mean the NHS central staff or the government have no role? No.
But in my view they shouldn’t be setting specific targets. They can certainly suggest broad areas of emphasis. Perhaps they should also set certain minimum standards of performance and make sure the local leaders are equipped to lead. But that should be it.
Thought #4
There are many articles in the newspapers and discussions on TV and radio about the culture of the NHS and how it’s got to change following this scandal. But how do you change an organisation’s culture?
Well, once you know what you want your organisation to become (the vision), you first have to understand what its existing culture is. At its root, it’s simply the beliefs shared by the people in that organisation around what’s important there to survive and do well career-wise. These beliefs then shape norms of behaviour, which is why you will often hear culture defined as “the way we do things round here”.
So if you want to change an organisation’s culture you have to change what people believe matters most if they are to survive, prosper and feel good about the work they’re doing.
Thought #5
How do you get that culture change – that change of beliefs and behavioural norms?
Well, I’d start by understanding what the current culture is.
In other words, I’d want to understand what beliefs and values are truly driving people’s behaviour in that hospital or surgery. I don’t mean the beliefs and values they’d like to hold or they say they hold; I mean the beliefs and values they really hold – the ones controlling the behavioural norms. And to do that I think you’ve got to get among the employees, ask questions and listen until you’ve understood what you’re dealing with. The key is to understand your starting point.
Okay, so let’s assume you know the starting point. What now? How do you begin changing the prevailing beliefs so they support the vision you and your colleagues have set for your organisation?
Where does any culture change begin? It starts with a few people (probably less than 10) expressing new beliefs and then it ripples outward. This is where leadership is so important. You need a small group of leaders who understand the importance of an inspirational vision and who, through their example, can cause others to join them in creating the first wave of change.
To be clear, you don’t have to change everyone’s beliefs at the start. You just have to change a critical mass of people’s beliefs. What’s a “critical mass”? How long is a piece of string? It depends. It’s whatever’s enough to get change going. It could be 5%, 10% of the people or 25%. But it’s not 100%.
So if you haven’t got a few senior people in a hospital or an NHS trust who can do this, you will either have to help them change – and as an executive coach I’d suggest coaching is probably the most powerful means of change, but then I would, wouldn’t I? – or you’ll have to replace them with people who can.
After that, the key is to have this “hard core” group find others in the organisation of like mind and together they can start to positively change the organisation’s DNA. That way, gradually, change ripples outwards.
However, if the new beliefs are to translate into performance and results, it’s essential that members of the leadership group don’t just talk a good game, but demonstrate the behaviours and values they say are important to achieving the vision in their everyday actions.
This includes facing facts and recognising what’s not working; regarding “failure” and “mistakes” not as a mortal blows to their self-esteem, but as signs they need to change something. It’s no good telling themselves everything is okay when it isn’t – for if this group of wayshowers can’t admit the emperor has nothing on when he’s stark naked, everyone else in the organisation will get the message. And guess what? They’ll start covering up the truth all over again.
Thought #6
If local NHS hospitals concentrate on creating a new culture founded on an inspiring vision with targets to match – and an attitude that candour comes before pride – imagine what will happen. You won’t have to do what the NHS report recommends and create rules making it easier for whistleblowers to speak up and threatening punishment if they don’t.
Why? Because whistleblowing won’t be “whistleblowing” any more as it won’t run against the grain and won’t demand extraordinary acts of courage. Telling the truth will now be part of the culture – a culture of facing facts because everyone at the hospital will know what they want to become and what they want to achieve. So speaking up will be as natural as, well, speaking.
So where does this leave us?
In my view, it means government has to stop overreaching and let local hospitals and NHS trusts define their visions of the future based on what they judge is important to them and their patients… and then set targets.
And it means we need people who know how to lead change in the local hospitals, who will set their egos aside, work together for a cause bigger than themselves and share leadership by setting the right example in their daily behaviour.
To be clear, this isn’t about having single heroic leaders to act as the catalyst for change.
Yes, of course you need capable CEOs. But in my view the key at each hospital will always be a small group of influential like-minded people – perhaps orchestrated at first by one of them – deciding together that they want change and then figuring out what that change looks like. And from there, inspiring others to care as much about the vision and targets as they do by their actions. In other words, not “top-down” but “small group outwards”.
And the role of the centre? It would still be crucial, but different to what it is today. For me, it’s to set the context for such change, perhaps by insisting on certain minimum standards, but no more than that. Its other role is to make sure the trusts and hospitals have people who know how to lead – whether they’re managers, doctors or nurses – and are willing to cooperate as leaders.
The author of this blog is James Scouller, an executive coach. His book, The Three Levels of Leadership: How to Develop Your Leadership Presence, Knowhow and Skill, was published by Management Books 2000 in May 2011. You can learn more about it at www.three-levels-of-leadership.com. If you want to see its reviews, click here: leadership book reviews. If you want to know where to buy it, click HERE.
Make the most of my leadership book
Where should I send your free download?
Ideas, thoughts and tools to release your potential to lead. You'll also receive updates on my latest thinking, articles, tools and blog posts.
