It was Heraclitus, the pre-Socratic Philosopher who famously described the concept of constant change. As we move through our life and careers, what appears at first appear to be constant, in fact constantly shifts. I recently celebrated 10 years in my first consultant post (how did that happen?!). And while it has been in many ways a joyful constant in my life, the degree of change that I’ve experienced over that time has been immeasurable.

As a community general adult psychiatrist, I’ve seen many patients and staff come and go over that time. Trainees moving on to new teams and new organisations make way for new ones to start the cycle of training over again. Bumping into previous junior doctors at conferences and at the Royal College never fails to stir up some happy reminiscing.

But what of culture in the NHS? What has happened to that? Has it changed or grown?

Recently on the Health Foundation GenerationQ programme we have been learning a lot about culture. It’s seen as integral to our learning on quality improvement, as culture is considered as a bedrock for improvement. You can use all the quality improvement tools you like, but if the culture is not ripe or open for improvement you may struggle. “Culture eats strategy for breakfast” is a quote that has been share with us time and again on the programme.

But how do you know what culture you are operating in, and can it be measured? There are a number of models of culture that seek to get under the skin of what it’s all about. I’ve been playing around with Schein’s “Three Levels of Culture.”

These levels include:

1. Artefacts
   a) Visible and feelable structures and processes
   b) Observed behaviour – difficult to decipher
2. Espoused Beliefs and Values
   a) Ideas, goals, values, aspirations
   b) Ideologies
3. Rationalisations – May or may not be congruent with behaviour and other artefacts
   a)Basic Underlying Assumptions
   b)Unconscious, taken-for-granted beliefs and values – Determine behaviour, perception, thought and feeling

(Taken from Schein, E. H. (2010). Organizational Culture and Leadership. San Francisco: Jossey-Bass)

I’ve found it helpful to think about it like this as it shows how culture is not one objectively defined “thing.” A learning culture or a quality improvement (QI) culture are of course important to aim for, but one can see how aligning the “artefacts” on the surface of an organisation with the “basic underlying assumptions” within and between individuals is challenging, and likely constant work. It also helps one understand how in large complex organisations like NHS trusts there can multiple cultures operating at the same time, in different areas, and between different groups of people. That is one reason why the same organisation can feel so different at different times and in different places. No wonder strategy has a job on its hands at trumping culture.

Billy Boland is consultant psychiatrist in community psychiatry, Hertfordshire Partnership University NHS Foundation Trust, Deputy Medical Director, Hertfordshire Partnership University NHS Foundation Trust, and Vice Chair (elected), Faculty of General Adult Psychiatry, Royal College of Psychiatrists.

Competing interests: Vice chair role at RCPsych as the faculty has been collaborating within the college to produce recommendations around outcomes.