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February 07, 2013



It all depends on what is meant by "culture". The suspicion (looking at the language and context of the Francis report) is that the word is being deployed in the modern, debased sense of a business culture.

In other words, we can expect nurses to be dragooned through courses explaining what "care" is, managerial aways days to develop a fresh mission statment (the Hippocratic oath is clearly inadequate), and a rash of patronising posters all over wards and canteens.

The root problem, as Francis makes clear in his comment on the primacy of corporate over patient interests, is managerialism. Unfortunately, this is not a recent problem that can be blaimed on Blairites and Tories (though they have both hugely exacerbated it for different reasons). This goes back to the foundational design of the NHS, in particular its adoption of industrial paradigms of organisation and delivery and its insistence on hierarchy and control.

Real cultural change in the NHS would require workplace and patient democracy.

David Ellis

A self-serving bureaucratic management headed by those appointed as the result of political patronage and Old School Tie nepotism doesn't help the NHS and now that private companies have taken over the provision of NHS services a gaggle of self-serving fat cat executives appointed by indifferent (except to profit) shareholders are set to make things worse.

Occupy Health! It is time managers and leaders of hospitals, trusts and any National Health Service were elected by those who work in them and for it.


@FATE - instinctively, I agree. I just have 2 qubbles:
1. As I say formal institutional workplace democracy won't create real democracy if workers (and patients) continue to defer to senior managers and doctors, or if decades of being told what to do mean they lack the motivation to exercise their formal powers.
2. Workplace democracy increases the power of peer pressure, but this is a 2-edged sword. Ther good thing is that it allows 360 degree monitoring. The bad thing is that it means that a group of bad workers can really screw things up.


1. Agreed. Hierarchy has been particularly pernicious in the NHS since Bevan's original compromise with the BMA, and has not been helped by the unwillingness of the RCN to act as a trades union (a point Francis makes).
2.The point is empower both workers and patients, so you have some checks and balances. This would also go a long way to encouraging the "candour" Francis advocates.


Allowing the patient to take his or her custom (and funding) elsewhere would be a big step in the right direction. One suspects if Tesco had systematically killed up to 1200 of its customers they might be struggling to get many back through the doors right now, and being wound up by administrators on commercial grounds, if not closed down by criminal charges first.

But hey, the NHS is the wonder of the world! It definitely isn't staffed by self interested morally bankrupt automatons. All the staff are angels in human form. Anyone saying otherwise must be rounded up for 're-education' as enemies of the people.


I haven't had time to read Francis yet, but I do know a lot about org/group/societal culture from my work.

The answer about institutional and culture change is that it isn't an impasse (although it remains hard.) It is necessary to change institutions and also find ways to lever the culture in certain kinds of direct change. Of course, certain economists (like the WNF guys) tend to call everything an "institution" but I think that muddies the water and leads to confusion and learned helplessness. And you're right Chris, I think to suggest that Democracy isn't the only starting point that needs looking at - many institutional changes to the NHS could involve more democracy, but they could also solidify power hierarchies, much as has happened in our nation.

The Gonch

@ Jim,

Tesco maybe not the best lazy analogy? http://www.bbc.co.uk/news/uk-21054688

And, wasn't one of Francis' points that the hospital compromised care because it was trying to compete with other hospitals (it was a Foundation Trust, thus able to compete for services).

So, um, I'd try again!


"The question for anyone hoping to change the culture of an organization is the same it has been for Marxists for decades: is this an insuperable impasse or not?"

Not ... it is suprisingly easy, if you are at the top of an organization.


A Current example:


"Barclays chief executive Antony Jenkins said he was “shredding” the former boss Bob Diamond's legacy. Mr Diamond lost his job when the bank was hit with a £290m fine after traders tried to fix Libor rates.

The beleaguered bank had become “too short-term focused, too aggressive and too self-serving”, Mr Jenkins told the Parliamentary Commission on Banking Standards, in devastating testimony about previous management failures. Mr Jenkins, who plans to outline his own strategy in detail next week, was speaking shortly after the bank set aside a further £1bn to cover compensation to people who were mis-sold payment protection insurance (PPI) and to small businesses that mis-sold interest-rate-swap contracts.

Mr Jenkins told members that changing the bank's culture would take “an iron will” but pledged that “you absolutely will see changes”.

He said: “We should shred the past, where we were too short-termist. We are shredding that legacy.” He spoke after the commission's chairman Andrew Tyrie said: “It doesn't seem to matter what the scandal is, Barclays seems to have a finger in each pie, quite a big one.”

Mr Tyrie also called into question the sincerity of the bank's reform pledges after its chairman Sir David Walker leapt to the defence of its remuneration committee that sets pay rates for top bankers. At an earlier hearing, the pay committee chair Sir John Sunderland said that even with hindsight he would still have paid Mr Diamond a bonus for a 2011, despite the former chief executive saying himself that performance was “unacceptable” with the bank missing targets. Sir David earlier ducked questions about the bank's controversial fundraising during the financial crisis which is now subject to a Serious Fraud Office investigation."

Of course this doesn't change my plans for the banking industry, which are more fundimental.


This is an awfully perceptive piece I think and goes a long way towards explaining why Mrs Thatcher's 1980's policies of trying to improve services by privatization failed so often. The culture of lethargy and avarice in British society was not simply dispelled with a wave of her neoliberal wand.



"Mrs Thatcher's 1980's policies of trying to improve services by privatization failed so often. The culture of lethargy and avarice in British society was not simply dispelled with a wave of her neoliberal wand."

And yest she set the agenda for the next twenty years with New Labour and the current government. In fact we arev still paying the price for her failures including then 'Big Bang'


I would try to get away from using the word "institution" and instead refer to organizations and such, because institutions the way institutional economists use the word are habits of thought, and to deny their definition of the word also signifies the weakness of your argument in refusing to even consider those habits of thoughts ie institutions. ;)

john malpas

Was the NHS so casually indifferent in the 50s and 60s. Not so much.
The nurses were real nurses not graduates. The doctors worked in teams junior and senior.
And hospitals were ruled by the sort of women who you automatically stood to attention when talking to them.



Though what you are saying is true, you are diluting my argument far too much, confusing deregulation with privatization. The deregulation of the city was following a worldwide trend which would have occurred anyway. We are talking more parochially of national, domestic culture which, as the author of this blog points out, is ingrained in the way we work as a people.


I was wondering when Hattie Jacques would turn up.

The chief ideological theme of public services since the 1980s has been relative failure. This contrasts with the theme from the 1950s through the 1970s, which was the perils of collectivism and uniformity, symbolised by Hattie Jacques's hectoring matron as a sort of hospital sergeant-major.

Failure serves two purposes. First, it is the corollary of choice. League tables and inspections allow us to discriminate: hospital A is better than hospital B, school A than school B. This prepares us for the full marketisation of the service. Choice necessitates failure.

Second, failure allows us to accept that people are innately uncaring and must be incentivised or coerced to do the right thing. For some, only self-interest can work as the motivator, hence Cameron's immediate response to the Francis report was to advocate performance-related pay for nurses.

As you can see, the cultural change envisaged by some will only make things worse.


Institutions are part of a culture. They are produced by it and in turn re-shape it. This is part of the problem about reform of institutions because it is not something discrete that you can operate on. Not getting this was one of a number of weaknesses in the book Why Nations Fail, but I would still recommend reading it as there is much to provoke thought. I reviewed it in June last year: http://acorn-review.blogspot.com/2012/06/acemoglu-robinson-why-nations-fail.html


Recommending Tesco as a model for the NHS is odd when it turns out they and other competative firms have been floging horse to their customers. May be for years. There is no easy way to improve large impersonal organisations and no way to do without them either. As for cutting or raising workers pay that is irrelevant since who will do the appraisal? The same managers who are covering up the failures to expand their own pay and perks.

Doly Garcia

We can think of lots of examples of culture changing fairly quickly for the worse (anyone seen a good neighbourhood gone bad quickly?). So changing culture quickly is perfectly possible. The difficulty is changing culture quickly for the better. And it's difficult, because you have to start by identifying what will change things for the better, as opposed to what some manager believes, with more or less fundament, that will improve things.

The process needs to be:
(1) Identify what seems to be the worst issues, in detail. So, if lots of people are dying unnecessarily in hospitals, why is this, exactly? This part of the work seems to have been done.
(2) Identify what, exactly, might have prevented those issues. That is much harder. The main problem of the NHS is that they know what the problems are, but they don't know yet what are the solutions. They are just jumping on to the first thing that looks like a solution because there is so much pressure to perform. People need space and time to work out solutions, and that's exactly what they never get at the NHS.

Ask all staff the question: If you had access to unlimited money and resources, and people had to do as you said, what is the one thing you would do to improve patient's lives? Then get somebody to read all the answers and produce a report. And then do something about it, and tell all staff what you are doing. That's how you change culture to one where people are comfortable speaking their mind. Let them know that speaking out has the results that one would hope speaking out would have.

Churm Rincewind

Doly Gardia: As a way forward you recommend surveying NHS staff on "the one thing you would do to improve patients lives. The get someone to read all the answers and produce a report."

It's been done. The Blair government undertook extensive surveys amongst NHS staff and patients. The overwhelming concern amongst patients was waiting lists. It was not, however, a top concern of NHS staff.

In the event the Labour Government decided to prioritise the views of the public over the views of the professionals and went on to introduce an eighteen week waiting list target. It was of course roundly condemned by the medical establishment for doing so.

Doctor knows best? Only sometimes.


I think Tesco & the horse meat burgers/lasagne is a very good comparison actually. Lets looks at the situation - supermarkets are found to have sold perfectly safe, but incorrectly labelled products. What is the outcome? All supermarkets are now testing every beef product on their shelves to see if it is affected, and any products found to be contaminated with horse meat will be immediately removed and (most likely destroyed). There will undoubtedly be legal cases brought as a result, some meat processors will probably be bankrupted and have to close, with the attendant job losses, mostly among people not responsible for the wrong doing. The FSA have said that criminal activity is most likely at the root of it all. Charges will undoubtedly be brought if enough evidence can be found. And all this for a perfectly safe product. No one has as much as had an upset stomach over it, and yet many heads will roll as a result.

Compare the NHS at Stafford Hospital: up to 1000 people have died through active negligence. Who is being sacked? Who is being charged with at the very least manslaughter? No-one of course. No one is to blame, just the 'culture'. Boll*cks. The entire hospital staff should be sacked without compensation, for their complicity in the affair, whether they were involved or not, to show others what could happen to them. I seem to remember that the Left were baying for the Railtrack board to be done for corporate manslaughter after the Hatfield rail crash, in which caused 4 deaths. 1000 have died at Stafford and its the usual 'Lessons must be learnt','No individual is to blame' and business as usual?

Give me strength. The NHS is actively killing 1000s of its patients every year through negligence, and tens of thousands more via its euthanasia 'Care Pathway', and you people still defend it to the hilt because its a totem of your beloved Socialism. How many people does it have to kill before you realise what it is - an utterly self centred organisation that puts its own welfare and survival before that of the patients, even to the extent of killing thousands of them in one hospital alone?



Ahem. Actually, I'm right wing.

Igor Belanov

Oh dear Jim. The 'Care Pathway' you comment on as 'euthanasia' is specifically designed to make sure that patients who are dying get the comfort and care they need rather than being seen as dispensable and left in a corner to die. Some people even recover after being placed on the Liverpool Care Pathway- it's not the equivalent of a lethal injection. The NHS does have numerous procedures in place for various situations, but the problem is that these often involve a level of paperwork that is a bureaucratic nightmare. Some 'audits' that take place are a permanent affair, necessitating the employment of staff that drain resources from patient care at a time of shortage. As such, there are problems that can't be dealt with just by waving a magic wand or by invoking the equally magical 'free market'.


@ Jim "supermarkets are found to have sold perfectly safe, but incorrectly labelled products..."

I disagree.

as the FSA person said on Sundat radio 4 World at One, we don't know if it is safe or not. Just because horse meat is not inherently unhealthy, does not mean that the horsemeat in the Findus products is safe. We do not know where it was from, how the animals were kept, and what chemicals/additives it might contain.

It is alarming that Government ministers do not seem to have understood this point either.

Adidas Porsche Design S2

Maybe you have never really understand my existence.

mri brain coil

I'm 15 and I've already had a CT scan but now they are making me go in for a MRI on my brain. The CT only lasted several minutes but I've hear MRI's take much longer. I'm getting one without the injections so how long is the actual time you have to be in the machine and being scanned? Also what is the who run through, like the preparation and everything.

Work Space Search

Difficult to change habits which were taken a while ago. This problem is encountered at every level, personal and general as well. In order to effectuate changes re-education is often necessary.

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