Final Report > Chapter 22: The Culture of the NHS > Introduction

Introduction

1 At the centre of the patient's experience is an encounter with the culture of the NHS. This culture, by which we mean the attitudes, assumptions and values of the NHS and its many professional groups, conditions the patient's journey and thus the quality of care received. We believe it essential to explore the prevailing culture of the NHS (`the way things are done around here'), to understand its strengths and its problems and to consider how it may need to develop and grow.

2 As `The NHS Plan' put it, the NHS bears too many of the hallmarks of the 1940s: `... the whole culture is more of the last century than of this'. [1] We agree. However well we are able to meet our Terms of Reference in recommending systems and policies to `secure high quality care', such systems and policies will never succeed if the deeper, underlying culture of the NHS remains the same.

3 To speak of the culture being outmoded or in need of change is not to say that it is uniformly negative. Indeed the culture of the NHS has many strengths. They include the values of public service and social solidarity which have been at the core of the NHS since its foundation. They also include the commitment to access and equity on which the NHS was founded and which `The NHS Plan', when implemented, should help to reinforce. The dedication and commitment of all who work in the NHS is a further, some would say defining, strength.

4 We recognise and celebrate these features of the culture of the NHS. Yet it is clear that there are also aspects of that culture which have acted, and continue to act, as a barrier to improving care for patients. By drawing attention and giving emphasis to these less positive aspects of the culture of the NHS, we aim not so much to criticise, as to understand them and how they came about and thereby to suggest where change may be needed.

5 Before considering these cultural barriers to improving care in more detail, we need to refer to two particular influences. The first is the role of resources. We are not of the school that argues that any problem can be solved if enough money is thrown at it. Indeed, the evidence of Bristol demonstrates that without, for example, proper leadership, good communication, good relations between professional groups, and agreement on such crucial issues as who is in charge of the Intensive Care Unit (ICU), more resources on their own would not have made the difference. Thus, we must put any reference to resources in context. It is one of a number of factors influencing the culture of the NHS. In the NHS healthcare professionals and patients have been consistently asked to participate in and tolerate a service which has been increasingly underfunded in terms of what has been asked and expected of it. Underfunding, of course, is not a neutral or objective term. It means the provision of a lower level of funding than others would argue for. The NHS, like any other public service, is funded to a level arrived at in a fragile compact between government and governed. Moreover, this is a compact at the mercy of the nation's economy and the delicate balance involved in decisions about taxing and spending. This is how a parliamentary democracy works. What marks out the NHS, is that successive governments have made claims of excellence which simply have not been realisable, given the funds allocated. Patients have been led to have high expectations, only to be disappointed too often. Those working in the NHS have become increasingly frustrated that they are unable to give patients the service which they joined the NHS to provide. They have found themselves battered from all sides: taught what is the best, but expected to practise in circumstances in which `getting by' is prized as success, and make excellence very difficult to attain.

6 A second influence of great importance on the culture of the NHS is that the NHS historically has been seen as more than a health service. It was seen as a national icon: a commitment to a particular set of values. This commitment and these values were challenged, particularly in the 1980s and 1990s. It is little wonder that, collectively or in groups, healthcare professionals have felt beleaguered and have reacted in ways that others might see as unhelpful. It is no surprise that many withdraw into a kind of professional bunker and view everything outside as a threat. For instance, many professionals saw the introduction in 1991 of the purchaser-provider split, trust status and contracting, as offending against the concept of public service by reducing healthcare to a commodity rather than a right. To protect patients, as they saw it, clinicians fought a rearguard action against what was termed `management'. Suspicion became the order of the day, particularly among doctors and nurses, a mentality which some feel still pervades these professions: suspicion of government, suspicion of trust managers, suspicion generally borne of years of genuine frustration that the NHS was failing to provide them with the tools they needed. As they saw it, and with justification, they were not able properly to care for the patients they were there to serve. Managers for their part also felt a sense of frustration. They struggled to deliver the service which they aspired to give. The workforce was disenchanted and blamed them. The government, as they saw it, constantly bombarded them with initiative after initiative. It was no surprise, therefore, that some managers felt that they equally had neither the tools to manage the workforce nor the wherewithal to meet the targets imposed on them by successive governments. Little wonder too that the public started to question the NHS and to question healthcare professionals, as the dissonance between what the NHS had claimed to offer them and their own experience became apparent. The public became more consumer-minded. They came to demand more and better care and to show a greater readiness to complain if care fell short of what they expected.

7 This is the context in which the cultural problems within the NHS need to be properly and honestly addressed. Seen in context, it becomes clear that the problems are not intrinsic to a system of a publicly funded, national healthcare service, far less insuperable. Rather, they should be seen as responses to circumstances. Change the circumstances and there is the prospect of resolution. Make the patient the centre of the service. Set standards for the safety and quality of care. Support professionals. Liberate and empower the professionals, all the professionals, to do their jobs, within clear and agreed frameworks. Give them decent resources, equipment and facilities, and care of a high quality, delivered consistently across the service, will then be a realistic goal.

8 What this discussion of culture means for us here is that new models of patient-centred care for securing quality cannot simply be grafted on to the existing attitudes and ways of working within the NHS. The new models have to be accepted, endorsed and embraced by all who must make them work. They have to find their way into the very grain of the NHS. They must not be seen as a threat or challenge to fixed professional power bases. The way forward for everyone involved in the NHS and particularly for those who lead and manage the service, is to generate a new and different culture: one that builds on and reinforces the historic values of the NHS, but one which ensures that the actions taken in the name of those values truly reflect the interests of patients, now and in the future. In short we must begin the patient's journey by identifying the organisational culture and values which are necessary for the quality of care to improve and flourish.

Footnotes

[1] `The NHS Plan', Chapter 2, London: Department of Health, July 2000