Penny Campling: What does apologising for a dysfunctional culture really mean?

The Francis Inquiry report rightly focuses on the need to transform the healthcare culture. It has made it clear that fault lines run throughout the NHS, from top to bottom, and that the inhumanity exposed at Mid Staffordshire is not restricted to that locality. The huge number of recommendations in the report (290) is presumably an attempt to capture the breadth, depth, and complexity of change that needs to occur. No quick fix this time.

When I first wrote this blog last summer, it was still hard to get people to think about the culture of healthcare. This has changed dramatically over a few months with people talking about it all over the place and the secretary of state, Jeremy Hunt, publicly recognising its importance and its relevance to the need to support healthcare staff psychologically process their experience. There is a danger, however, that the concept will become over simplified and the real challenge involved, avoided. What, for example, does the emphasis on culture mean in terms of individual accountability? Cure the NHS (the campaign group started by relatives) understandably want to see particular local clinicians punished and have explicitly called for the resignation of Sir David Nicholson.

Clearly, the blame for a dysfunctional culture cannot be pinned down exclusively to particular individuals. Culture is, by definition, a group process encompassing the behaviour and aspirations of everyone in the system.  It is something we all absorb, and to which we all contribute, often without conscious awareness. The culture of a hospital can hit you as soon as you walk through the door, although it is sometimes possible to protect sub-cultures within the larger organisation as we saw at Mid Stafford hospital, where some wards continued to function well. Most importantly, culture impacts on individual staff and patients through relationships and can be “diagnosed” by observing everyday interactions—the warmth in a greeting, an encouraging smile. These behaviours reflect interpersonal qualities such as respect, attentiveness, and empathy—qualities that are not just humane, but crucial to efficiency and survival.

There is a real danger that the concept of “culture” in the inquiry becomes narrowly interpreted as “nursing culture”—and, of course, there are lots of changes that need to be made within the nursing world. But culture is influenced by the big things: resources, power relations, ideology.

Competition, the business culture, regulation, and the way these things are managed, all contribute to culture. They set the tone for relationships throughout the system. The culture of fear in the NHS has been the focus of many a media article, highlighting not just the fear of patients, but the fear that stops staff speaking out. A bullying culture at the top level of the Department of Health has been reported in the HSJ, with a third of CEs reporting they are afraid to speak out.

I would like to know what politicians and Sir David Nicholson mean when they make their apologies? Are they apologising on behalf of the nurses, doctors, and managers most directly involved at Mid Staffordshire? Or are they expressing remorse at the role they have played in successive disruptive re-organisations and for the way the system has been regulated and managed? Are they sorry for their contribution to the culture of neglect, fear, and demoralisation?

Penny Campling is a psychiatrist and psychotherapist and was a clinical director for many years.  She has recently co-written a book entitled “Intelligent Kindness: reforming the culture of healthcare.”

  • I am sympathetic to much of what Penny has to say here, but really think we need to get away from using ‘the’ or ‘a’ in front of ‘culture’. Hospitals have lots of different sub-cultures. Committees have sub-cultures, depending on who turns up at them. Wards can change from shift to shift. Saying there is ‘a’ or ‘the’ culture hides too much – to be sure there are group effects that happen at particular times and places, and these may even persist and be dysfunctional, but we have to be clear about exactly what it is we are talking about. If it is poor nursing care, then we need to label it as such. If it is lack of managerial oversight and control, then again, let’s make it plain. If it is an obsession with targets and a need to chase them in a way that detracts from patient care, let’s say so. All of these things can be tangibly investigated, and hopefully changed. But using vague and ephemeral terms like ‘the culture’ don’t help us either work out what went wrong with any precision, or point to ways that we can do better.