Culture and culture change in the NHS: comparing professional and patient perspectives Frederick Konteh, Russell Mannion, Huw Davies The Centre for Health and Public Services Management (CHPSM) The University of York

Introduction  SDO-sponsored organisational culture study  The culture of health care in the NHS ‘which so critically affects all other aspects of the service which patients receive must develop and change’ (Kennedy, 2001, p2003).  Growing interest among key actors in managing organisational cultures. Wide-ranging culture change initiatives since Kennedy - emphasis on quality care around needs of patients/carers.  Need to co-create healthcare culture for more beneficial outcomes  Aim - collect and compare professional and patient reps’ perspectives on local health care cultures: how they are conceived and can be shaped towards desirable ends.

Methods  R&D approval from 276 (or 85%) NHS organisations; clinical governance leads and patient reps surveyed (Oct Feb 2007).  Response rate after follow-ups – 77% and 37%, respectively.  Information on views, perceptions and experiences of respondents relating to: use of culture as part of the language of the local organisation; meaning of culture; place and significance of culture in clinical governance and quality and safety improvement; specific cultural attributes for change initiatives within the NHS organisations data captured and analysed using SPSS.

Methods (contd.)  FGD with clinical governance leads (8 participants).  Eight and ten semi-structured interviews with clinical governance and patient representatives, respectively.  Transcribed and analysed the data using Atlas.ti.  Data complements the bold statistics generated by national survey

Results The Usage of culture in the NHS Table 1: Use of culture to describe the way things happen in the organisation Clinical gov. leads (n=212) Patients Reps (n=102) “Yes often”5653 “Yes some times”3435 “Not really”99 “No rarely”13

Usage of culture in the NHS  Qualitative data - culture change integral to local quality improvement activity even when concept not used explicitly: We don’t talk about culture specifically, but we do sort of try and see where we have come from and where we want to go and how are we actually going to get there… [FGD participant no. 2]  Researchers’ definition of OC “the shared beliefs, values attitudes and norms of behaviour in the work place, including the local routines, tradition, ceremonies, and ways of making sense of the local work environment”  CGL (100%) and PR (97%): definition consistent with their understanding.  Tendency to conceptualise/emphasise culture from own perspective and principal concerns – CGL: staff satisfaction and performance; PR – patient safety.

Local culture, clinical governance and quality service  ‘Understanding the local culture is a central task for clinical governance’ within their organization – in agreement 97% for the clinical governance 88% for patients’ representatives.  Results reinforced by semi-structured interviews. Yet PR underscore the criticality of leadership (executive) role... NHS officials pointed to the top-to- bottom practice of taking decisions and transmitting orders as counterproductive.

Established local cultures as significant obstacles (or as helpful) to health care improvements  Did respondents agree?  Obstacles: nearly 9/10 thought so; more CGL (53 percent) in ‘strong’ agreement than PR (36%).  Certain aspects of their organisation’s local culture, which were ‘very helpful’: CGL – 91% PR 79%. Again a stronger positive agreement from managers than patient reps. (33% as against 22%)

Local culture’s prospects for supporting performance Table 2: Local organisational culture a long way to supporting performance Clinical gov. leads (n=212) Patients Reps (n=102) “Strongly agree” 912 “Tend to agree”1943 “Tend to disagree” 5638 “Strongly disagree” 167

Culture assessment variables for high quality health care delivery  Culture instruments based on cultural parameters considered key to ensuring high quality service delivery.  How important were certain culture attributes to respondents?  Very similar results for both sets of respondents although (consistently) greater % for clin. Gov. than patient reps.  Between 80 percent and 95% considered the following attributes to be ‘very important’: patient centredness; quality focus; senior management commitment; safety awareness; and team working.

Conclusions  A high degree of convergence in the views of health professionals and patient representatives on culture and culture change in the NHS.  Culture part of the everyday language of NHS trusts and a critical ingredient of efforts at improving quality and safety.  Positive and subversive aspects of the local culture - need for prudence and caution on relevant.  Greatest responsibility with clinical governance managers and trust’s leadership.  Change cannot happen over night and need to get all levels of personnel and stakeholders on board

Key References  Kennedy I. Learning from Bristol: Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary London, Stationery Office,  Davies HTO, Nutley SM, Mannion R. Organisational culture and quality of health care. Quality in Health Care 2000;9:  Mannion R, Davies HTO, Marshall MN. Cultures for Performance in Health Care. Open University Press, Milton Keynes,  Leape, LL, Berwick, DM. Safe health care: are we up to it? British Medical Journal 2000;320: