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  • Writer's pictureAndrew Laird

In the NHS – culture trumps everything

Updated: Mar 30, 2021

I realise that “culture trumps everything” is a provocative title in a world where the NHS is chronically underfunded. The national debate tends to focus on funding and structures at the expense of all else – but when you look at the organsiations who have achieved outstanding CQC status, the game changer is usually leadership and culture.

Recognising the importance of the NHS workforce the Nuffield Trust (working with the Health Foundation and The King’s Fund) has produced a weighty report outlining a detailed set of proposals for overhauling how the NHS recruits and keeps its staff. The headline is the need for £900 million per year by 2023 to provide more, better-supported GPs and nurses.

Funding, structure (and also technology) are critical enablers (and I will say more about structure later) but you can’t simply provide them and expect outstanding leadership and an excellent, supportive culture to follow.

Here are a couple of examples:

In January, Surrey and Sussex Healthcare Trust received an outstanding CQC rating. They said the trust had ‘a culture of continuous improvement’ and that ‘staff told us they felt well supported, valued and that that their opinions counted‘ and also that ‘the Trust had a very clear strategy, vision and values, which underpinned an exceptional culture which placed patients at the heart of all they did.’

Last year, CQC rated Manchester cancer specialist hospital The Christie as Outstanding. CQS said “staff are highly motivated and speak positively about the care they provide, and what they told us is a reflection of the friendly and open culture at the trust.”

These are essentially a human to human services. Getting the right structure and digital innovations etc. in place (and yes of course adequate funding) can create the environment for a good culture to develop and enable it to have an impact – but they can’t guarantee it. Only a good leader can do that.

So what sort of structures and working arrangements can create an environment for a good leader to develop and grow a great culture?

We will shortly be producing research on the impact and replicability of the wide range of “mutuals” operating in the health and social care space. These are groups of NHS and council staff delivering primary care, community nursing, adult social care and much more who have transferred to a social enterprise model. Sometimes formal ownership remains with the public sector but often staff and/or service users take an ownership stake.

Here are a couple of things we have learned:

Developing a seamless pathway between NHS and Council services is a priority within the NHS Long Term Plan. The success of this depends almost entirely in getting groups of staff from very different backgrounds and perspectives (e.g. social workers from councils and nurses from the NHS) to work together. Giving them a feeling of shared “ownership” of the new arrangements through mutual learning and working arrangements can only help this process.

Mutual working arrangements could embed staff and user led governance within Primary Care Networks (another cornerstone of the Long Term plan). The mutual model offers bottom-up involvement in decision making and can help formalise the working arrangements between GPs and other out of hospital providers to meet the needs of the local population.


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