Only a culture shift will enable the NHS to face the future, warns David Prior, the chairman of the Care Quality Commission.
The NHS is a monumental paradox. On the one hand, it is a truly great humanitarian undertaking, a universal (if peculiarly British) moral being. It is an organisation built upon wonderful values and an almost Panglossian confidence that people — especially doctors and nurses — will behave well, work hard and always act in the best interests of patients.
And yet, parts of the NHS have developed a culture that doesn’t listen — or worse, that stigmatises and ostracises those who raise concerns or complaints.
Too often, it delights in the ritual humiliation of those deemed to fail, tolerates and institutionalises outdated working practices and old-fashioned hierarchies, and can almost encourage “managers” and “clinicians” to occupy opposing camps.
I have worked in the NHS for 12 years. I love it — I am often overwhelmed by the kindness, care and skills of its staff — and yet am too often shocked by some of the behaviour I see. In evidence to the Mid-Staffs public inquiry, an A&E doctor told how, in a dysfunctional environment, staff walked away — or stayed and became “immune to the sound of pain”.
To do the right thing, sometimes you have to speak out against the organisation that you love.
Recently, I visited the United States to see what we can learn. There is little to envy about their funding model. But when it comes to the way the health care organisations themselves work, there are powerful lessons.
First, about learning. In the US, the best organisations are open, trusting and, above all, constantly learning. Mistakes and complaints are sources of improvement, not retribution. High reporting levels of errors, and near-misses need to be seen as a sign of good practice, not a badge of shame.
There comes a point when the surgeon who does not follow the safety checklist or the doctor who does not comply with infection-control policy has to be told “we don’t want you working in our hospital”.
There is no substitute for great, visible, brave leadership. In the USA, the leaders of successful hospitals are paid serious money, and are often in post for many years. This reflects the complexity of the job and its importance. They take tough decisions and live with the consequences.
Here, hospital chief executives are routinely shuffled around. There is little incentive to tackle long-term, deep-seated cultural issues. When things go wrong, they are hauled over the coals, often in public. Meanwhile, the major challenges go unaddressed.
I believe that the NHS needs major long-term change to deal with the needs of our ageing population and increasingly tight budgets.
We need to see successful hospitals taking over failing hospitals and community services, and ensuring better care outside hospitals.
We need larger centres of excellence, with savings from shared services such as pathology labs and radiology. Small hospitals will not be able to offer the quality we need 24 hours a day unless they become part of larger operations and radically change or integrate with community services.
Without serious change, the NHS will deliver poor care, and ultimately go bust.
We need more competition to drive up standards of care; more entrants into the market from private-sector companies, the voluntary sector and other care providers.
Perhaps most crucially, we need to change the culture.
For us, as a regulator, that means looking holistically at the performance of hospitals, using measures that matter to patients and that continuously improve performance.
We need the Government to change the way it holds the NHS to account: an end to trusts being blindsided by waiting targets that miss the point, skew priorities and have unintended consequences.
To make these changes, we need to radically alter the relationship between NHS staff and management. In far too many hospitals, there is a “them and us”, with those few clinicians who go into management branded as “going over to the dark side”.
This is not the case in the USA, where many clinicians are on the executive teams. Doctors and nurses here need to recognise that an involvement in management enables them to affect the care of thousands of patients.
Above all, clinicians need to take a leading role in changing the culture of the NHS.
Studies have found a powerful correlation between staff and patient satisfaction.
The best US organisations know that a happy staff leads to happy, well looked-after patients. Yet when more than 100,000 NHS workers were asked how they felt about their working environment, the results were alarming. One in four reported feeling bullied.
The rift between management and clinicians costs us deeply — jeopardising safety, silencing whistle blowers and blocking improvements in care. It must be healed.
That means stronger clinical leadership and a workplace that encourages learning, openness and respect.
If the health service is to move beyond the scandals of recent years, now is the time for radical change — to honour the values on which it was founded.