Five minute Francis: Chapter 20 – Culture

Selected, illuminating quotes concerning cultural aspects of the NHS.




Sir Bruce Keogh, on how doctors respond to critical data:

Your first response is to say, “The data’s wrong”. Your second response is to say, “Okay, the data’s right but your analysis is wrong”. And your third response is to get your head down and try and sort out the problem.



Ann Abraham (the then Parliamentary and Health Service Ombudsman), on use of data in the NHS:

Lots of data, a lot less information and even less knowledge, and that’s bad for patients and their families, it’s bad for clinicians, bad for managers, bad for regulators and bad for policy-makers.


I suggested to a very senior doctor recently that he might ask his patients for feedback, and he wasn’t unreceptive to the idea, but it was clearly a novel concept.


Toni Brisby, former Chair of the Trust, on her reaction to the patient stories in the first Francis inquiry’s report:

 One [set of reactions] is … that it is really profoundly shocking, and I can absolutely see that. The other is a reaction that I’ve had from quite a lot of people within the NHS, which is actually that’s the sort of thing that goes on in virtually all hospitals, and there but for the grace of God go we. Now, I’m not saying that to defend poor care, because I think poor care is indefensible, but I am saying that Stafford is not a peculiar hospital in spite of the shocking nature of part 2 of the report.



Francis: Failure to put the patient first in everything done

– Many of the negative aspects of culture mentioned above derive from a failure to see things from the patient’s perspective and to understand the effects of actions – or inaction – on them. In the maelstrom of discussions and efforts devoted to reorganisation, devising and implementing new systems and so on, the core purpose of healthcare services has all too often been overlooked.-



Professor JP Martin (author – Hospitals In Trouble) on doctors and harm:

To start with the most direct and intimate relationship we should consider staff views of patients. Human beings do not harm others callously unless they can justify this in some way. This is so in all walks of life, but in a hospital setting, so deliberately dedicated to the care of others, it is particularly necessary. Such rationalizations do not have to be consciously articulated, but somewhere or other in their minds some latent defence must be lurking ready to be voiced if callous behaviour is challenged. They are, as AM Rees has put it “a way of articulating the inacceptable”.


Professor Sir Ian Kennedy, on patient centred care:

I don’t think putting the patient at the centre of what you do is a function of any particular structural approach. It’s a function of culture, of what culture you’ll be bringing to work every day. And that’s the culture of professionals – of all ilk, whether nurses, physiotherapists, managers, and you can have as many structures as you like, and we’ve had pretty much all of them, but if you don’t address the cultural challenge of “What are we going to work for today?”, then it’s going to be hit and miss whether it works.


 Anna Walker, former Chief Executive of the Healthcare Commission, on blame:

And, secondly, that where there is a safety incident, you at least start with a no blame culture, because the moment that there is a blame culture, and staff feel they’re going to be blamed, these things will go underground.



Dr Woodward of the National Patient Safety Agency, on blame:

… what we have found is that in some organisations where the culture is one where an error or an incident occurs, the staff member is suspended or blamed and may be put on different duties associated with the incident outcome. What we tend to find is that the other staff members worry about what happened to their colleague, and consider that may happen to them.


So … there is some concern as to whether they would then report themselves if they were either party to or witness to an incident. So we do find that the blame culture that exists in the NHS means that some incidents are kept unreported.




Sir Cyril Chantler, Chair of University College London Partners,

drew attention to the distinction Viscount Slim made between management and leadership:

Leadership is of the spirit, compounded by personality and vision – its practice is an art. Management is of the mind – a matter of calculation, of statistics, timetables and routine – its practice is a science. Managers are necessary, leaders are essential.




Sir Donald Irvine, Chair of the Picker Institute and former President of the General Medical Council (GMC), on a recent visit he made to the Mayo Clinic and the Amplatz Children’s Hospital, Minneapolis.

Wherever you go, you cannot escape it – in the hospital, the medical school and in research. What happens to patients matters from their point of first contact with Mayo to their last consultation. The effect, from the CEO and Board of Trustees down, is a relentless focus on clinical quality and on being sure that patients have the best experience.


A nice non-clinical example is the patient’s main car park, which staff and consultants are not allowed to use, which is the nearest to the hospital entrance! The contrast with even the best NHS hospitals, with their competing values and priorities imposed on them from on high, is quite stark.



Professor Sir Liam Donaldson, on dehumanisation:

Absolutely they do. Absolutely they do. Some people sometimes say that you’re either a born communicator or you’re not. That’s absolute nonsense in my experience … obviously, people come into the professions with compassion and interpersonal skills, but in the pressure of modern care environments I can remember it myself, when you’re pulled out

of bed at night two or three times to go down and see somebody who, you know, is lying, having had a stroke, and you’ve hardly had any sleep and you’re being called to another part of the hospital, to keep in your mind that that person is somebody’s mother, grandmother – it’s vital that you do see that person as a person and not just as a diseased object to be processed, and that needs to be reinforced all the time.


People instinctively know it when they come in, but when they’re subjected to the pressures of a modern care environment they can become inured to suffering. And it may be shocking to people but in another way it is a human reaction to [a] high stress, high pressure job.


Cynthia Bower, former Chief Executive of the WMSHA and then of the CQC, on ineffectual responses to criticism:

…if you find a problem with an NHS organisation, there’s always some clinical audit that the chief exec could do, or there’s a Royal college that might come along and help them, or there might be some peer review work. There’s an entire industry, if you like, around the NHS, saying “Yes, we know that’s a problem but somebody from down the road is just about to come and help us with that”. Or “We’ve clocked it and we’re doing some training”.



The Rt Hon Andy Burnham MP, speaking of his time as a junior Health Minister, on disempowerment:

I came to the conclusion that the NHS is not good at giving its front-line staff a sense of empowerment. People with good ideas do not feel that they can easily put them into action, there is a prevailing sense that those decisions are taken by somebody else.


Nigel Edwards and Ruth Lewis of the King’s Fund pointed to research indicating the importance of developing a culture of improvement encouraging “discretionary effort (that which we do willingly because we want to)”, through promoting the engagement of staff and exploiting their passion. This is the exact opposite of the attitude reported to these researchers by one chief executive: 


“I find a lack of anger in clinicians at the moment; previously they would tell you it’s wrong, doesn’t seem to happen now, people’s heads are down and they are getting on with it.”



Sir Donald Irvine the culture at the Mayo Clinic:

… patient centred and driven by the pursuit of excellence. It is professionalism which encourages maximum performance, rather than reliance only on regulatory compliance … At Mayo, if a doctor or nurse does not embrace the culture, and reflect it in their practice, sooner than later they will go. Persistent underperformance has direct consequences for the individual.


Contrast this with the culture in the NHS where too often poor practice is tolerated, something patients are expected to put up with. The consequences for such practice are exceptional – with a heavily unionised workforce jobs tend to be protected.



Marcia Fry, previously Head of Operational Development of the HCC, on criticism:

I think you’ve got to recognise the reality that in human nature people don’t like to be criticised. So it’s trying to find some way beyond that in the culture of an organisation allows mistakes to be recognised and learning to be acted on. And it can only come the leadership and the tone that’s set at the organisations’ highest levels.



Professor Sir Liam Donaldson:

Honest failure is something that needs to be protected otherwise people will continue to live in fear, will not admit their mistakes and the knowledge to prevent serious harm will be buried with the patient.


He pointed to “spectacular” successes in other parts of the world, for example: 

I’ve talked at length to one team in – in North America … who had a policy of immediately going to the family and telling them what happened, apologising, and then staying with them through the whole period of bereavement, telling them they would understand their anger … but working it through, making it clear it was an honest mistake, and then asking that family to be part of the planning to ensure that the incident’s being properly understood and that policies have been put in place to prevent it happening again.







Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s