The real cultural rot in the NHS

“A cultural rot that places protecting the reputation of the NHS above protecting the public. These are not the words of a GB News presenter but that of the likely next Labour Health Secretary, Wes Streeting.

This assessment may not be news to those who work in or closely with the NHS or those who have read any of the dozens of inquiries into safety disasters in its hospitals and mental health providers. Most of these inquiries talk of cultural failings both in terms of how front-line teams mistreat or ignore patients and in the way that the hierarchies within those institutions become defensive and slow to respond. Or, as Mr. Streeting puts it: “brave whistleblowers are hounded out, bullied and silenced as heretics.”But tackling this cultural rot requires more than making sure that “managers who silence and cover up whistleblowing will be sacked and never allowed to work in the NHS again.”

At Carradale Futures, when working with NHS management, we find the main cause of these safety failures is not a minority of bad managers and bad front-line staff acting badly. More alarmingly, it is that they do not know—or rather cannot know—what they are doing wrong until it is too late.

Inquiries big and small have the same tortuous process of reviewing documents, interviewing staff, and seeing four failings:

1. Poor culture within clinical teams and between those teams and their management that do not place patients—despite all the language on their websites—at the heart of everything they do.
2. Inadequate staffing.
3. Gaps in training.
4. Failure to adhere to policies, pathways, standard operating procedures, protocols, guidelines, checklists, and templates.

Could it be that the last—and seemingly least important—criticism is the most important one?

All the maternity inquiries at Morecombe Bay, Telford, East Kent, and now Nottingham hospitals, all the review of mental health services at Southern Health, Essex, and Manchester Trusts, and all the clinical negligence claims investigated by coroners have noted failures to follow policies and practices. So why are they not following maternity processes, mental health discharge processes, and safety checks that are evidenced, written down, and validated by all the professional bodies?

Our work with hundreds of healthcare organizations and thousands of staff—in this country and abroad—proves that they cannot refer to those documents. The use of the thousands of policies, templates, Standard Operating Procedures, protocols, and guidelines that are supposed to govern clinical and administrative processes are not monitored or managed. We know that because everyone we have reviewed is out of date, and none of them have any mechanism—beyond when they were created—to check they have been read or understood. We also know it because not one senior manager has ever been able to even guess how many of these documents—supposedly the bulwark of safety in a Trust—exist.

This is not surprising since they are stored on document management systems that make it almost impossible to organize, update, or access those documents in an office in front of a computer, let alone on a busy ward.

So why has so little been done to ensure these documents fulfill their primary purpose of guaranteeing standards? There appear to be six reasons:

1. Clinical autonomy and a failure to embrace standardization. Too many healthcare providers, Royal Societies, and others believe that professional training and experience is the main guarantor of safety and the one thing professionals want is freedom to practice according to that training and experience. But more training does not necessarily lead to more consistent following of instructions. Why have governments tolerated thousands of reinterpretations of national policies and guidelines when consistency of service based on evidence is the best guarantee of safety?
2. Paternalism and an absence of patient rights and knowledge. An expectant mother who does not know what part of the delivery process is most dangerous is far more likely to suffer harm than one that does. Every patient should be told, if they want to be told, what to expect and their role in mitigating risks. As Mr. Streeting promises in the most significant sentence in his article: “We will give power to the patient, so they can easily judge providers by league tables, be told what they should expect from the service, and choose to switch if they want to.”
3. Distractions from doing the job well. Staff in healthcare organizations spend so much of their time asserting that they are inadequately staffed that they seem distracted from the more boring task of making sure that tasks are carried out consistently and well. It is also common that staff are forced to spend much of their time and energy navigating variable and inefficient processes that distract from quality improvement and direct patient care.
4.  Slow decision-making. NHS organizations run on consensus, fear, and meetings. Trying to find out what happened is almost impossible as it depends on faulty memories and no digital data. Add to that a pervading culture of consensus-seeking, and it is easy to see why what looks like deliberate delay is in fact furious behind-the-scenes scrambling to find out who did what, when.
5. A culture of fear and retrospective blame. Inquiries contribute to the fear and defensiveness they decry. Faced with the threat of public shame and losing your job forever, you might not wish to explain that you had forgotten the eight-step protocol or paid no attention to the checklist hidden on your useless intranet. The irony of inquiries decrying the culture of defensiveness that they create seems to be lost on politicians who keep ordering new ones that look very much like the old ones. Clinicians pay much more attention to external agencies of accountability—coroners, the Care Quality Commission (always arriving on the scene of the crime a few weeks after Channel Five has started investigating it), NHS England, inquiries current or future—than they do to their own management. Blowing the whistle to their own management and then to external agencies about failures in processes must be as important as highlighting examples of individuals providing bad care. One of the unacknowledged costs of this over-reliance on external regulation is the undermining of managerial authority within trusts.
6. Faith in documents, meetings, and committees. The NHS continues to rely on over-long documents as means of conveying important information. NHS England conveys policies via emailed letters, policies are hidden in massive PDF documents, and ‘assurance’ is provided by committees. Most dangerous industries invest in data that proves processes are running consistently and smoothly. The NHS’s biggest tech investment is in Electronic Health Record systems that reveal little of whether safe processes were followed.

Mr. Streeting is right to talk of a ‘cultural rot,’ but it is not a question of brave whistleblowers, a few incompetent or overworked clinicians, and disingenuous managers. It is both worse and better than that. Better because the root cause can be fixed. Worse, because the real cultural rot is a top-to-bottom failure of the NHS to follow its own policies, guidelines, and procedures and make the delivery of care consistent for, and transparent to, the patient.

—

Jake Arnold-Forster

Executive Chair  

Carradale Futures

The company created SOPHIA, a technology platform that enables organizations to create, update, measure, audit, and automate critical processes and policies.