Chapter 39. Culture of the NHS

Thousands of pages have been written in the last 25 years about the culture of the NHS. One approach is to consider ‘culture’ the umbrella term for the behaviours common to a particular group (ward/department/hospital). Another approach, adopted by the NHS for most of this century, is to identify a desirable culture in the hope and expectation that behaviours will align with that culture.

From the Mid Staffordshire inquiry to the present

As is clear from Part 1 of Sir Robert Francis’s report prepared for this Inquiry, there have been many other inquiries that have called for an improvement in NHS culture, in particular for an improved safety culture or ‘open’ culture.¹ Sir Robert Francis’s first recommendation in the Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust was: “The Trust must make its visible first priority the delivery of a high-class standard of care to all its patients by putting their needs first. It should not provide a service in areas where it cannot achieve such a standard.”² In his Part 1 report for this Inquiry, he said: “While directed at the Trust in particular, the recommendation contained an implied requirement for the NHS as a whole. The NHS Constitution … contains a requirement to put patients at the heart of everything it does.”³
Despite these recommendations, and the focus that has been placed on the need for a safe culture, patients have still suffered avoidable harm through the actions of NHS staff and shortages of resources. Sir Rob Behrens referred to his report Broken Trust⁴ and its related press release. The press release said: “Every time an NHS scandal hits the front pages, leaders promise never again. But the NHS seems unable to learn from its mistakes and we see the same repeated failings time and time again.”⁵ It referred to “continued failures to accept mistakes and take accountability for turning learning into action” and added: “We need to see significant improvements in culture and leadership.”⁶

Finance

Sir Rob Behrens also referred to “a healthcare system at breaking point”.⁷ That was in 2023. Levels of financing remain a concern for all who are running hospitals. There is a constant risk that financial concerns drown out concerns for patient safety. Professor Dixon-Woods pointed out, in connection with the first report of Sir Robert Francis into Mid Staffordshire, that: “The Inquiry identified that a key contributor to the disaster at Mid Staffordshire was that clarity of purpose in relation to patient safety and quality of care tended to be displaced by issues of finance and performance.”⁸ Sir Robert Francis said in evidence:
“[I]n … a service in which resources are never going to be enough, we can never do everything all the time. They [leaders] need to be able to understand how to prioritise things – and to protect patient safety and the provision of the fundamental standards and they must have those standards and the interests of the patient in the case of a hospital always at the forefront of everything they do and they must make sure that everyone in the organisation does the same.
… you need to make sure that your finance department has at the front of its mind the interests of the patient, what is the best thing we can do for the patient and you will tend to find that the money then follows … you need to understand how to prioritise and you need to understand how to protect patient safety in your organisation.”⁹

‘No blame’ culture

Since 2000, the culture to which the NHS has aspired has been described in academic and policy literature as ‘no blame’. Developments in the approach to risk in aviation, rail and other industries demonstrated that it was possible to reduce the risk of accidents significantly by changing systems. Errors could be designed out. Where such systems are in place and an error does occur, it is said to be the result of an imperfection in the system rather than the fault of an individual. Professor Dixon-Woods’¹⁰ impressive exposition of the history and development of the ‘no blame’ culture is set out in her report at paragraph 2.1.¹¹
The central premise of a ‘no blame’ approach is appealing – that doctors and nurses are fundamentally well intentioned (or ‘good apples’, to use Professor Dixon-Woods’ phrase). With that assumption in mind, NHS executives began to try to design out errors. This was the systematisation of risk management.¹² Within the NHS, HSSIB and the Healthcare Safety Investigation Branch before it have taken a systems-based approach to investigations. Disclosures to them are protected by law. HSSIB are rightly regarded as a successful organisation, despite a small budget and a small team. I deal with them in more detail in Chapter 43.
Accompanying the ‘no blame’ principle was an expressed desire to learn from mistakes. This was described as a ‘learning culture’ – that is, one in which errors are often described as ‘opportunities for learning’. As I have said in respect of the submissions of the NMC, if an error is to lead to an opportunity for learning, there must be an honest acknowledgement of the error, an apology and explanation, and then a plan to prevent recurrence. I hope it is not unfair to observe that in some parts of the NHS – maternity units in particular – errors and learning opportunities have not led to improvement but to more of the same.
Throughout the time when the description ‘no blame’ was attached to NHS culture, there was, and still is, a lot of blame within the NHS. That is why it was necessary to introduce whistleblowing protections for those who spoke up about errors and failures within the NHS, and why in 2016 the concept of Speak Out Safely was introduced and, more recently, Freedom to Speak Up. These two steps demonstrate that (a) errors are not always reported or acted upon – because of a fear of blame; and (b) blame is placed on the reporter when they point out errors.
‘Blame’ and ‘responsibility’ are often synonymous; in the following simple example both have negative connotations: “Who is responsible/to blame for this mess?” However, whilst blame is always negative, responsibility is not, as in the example “Who is responsible for this well-run department?” With responsibility for error comes responsibility for putting things right. It is likely that, had the culture of the NHS been described as a ‘no responsibility’ culture, the term would never have got off the ground.

Blame for clinical and other errors

In every workplace, people make mistakes. For most people, errors at work do not lead to injury or death. For doctors and nurses and other healthcare professionals, the reality is different, from the time they qualify. The effect of the law of tort is that, where an error leads to injury or death, the health professional may be liable in negligence. Healthcare professionals live with that reality. A question may arise as to whether the fault, blame or responsibility lies solely with the individual, or, as often happens, whether there was a broader systems error – faulty equipment, shortage of drugs, staff shortages, etc. If the latter, then the blame or responsibility, as well as financial accountability, lies with the organisation via the decisions of its managers.
Separately, managing allegations of misconduct against a backdrop of a ‘no blame’ culture can be difficult; HR and patient safety processes can be seen to run contrary to one another.¹³
Sir Robert Francis points to the innate tension between central commissioning and local delivery: the very structure of the NHS pitches them against each other, with senior managers looking to central government for guidance while central government gives them increasing responsibility for care in their areas.¹⁴ Fundamentally, there has been, for decades, a deliberate policy of distancing central government from the business of providing NHS services in the community and in hospitals, running in direct contradiction to any suggestion that the NHS operates a ‘no blame’ culture. This can lead to what Professor Dixon-Woods refers to as “blame engineering”, where an organisation actually becomes preoccupied with avoiding blame, leading to an over-focus on process, and reputation management becomes a central organising principle of leadership.¹⁵ This is what happened at the Countess.

The effect of a ‘no blame’ culture

Ironically, the push towards a culture that ascribes ‘no blame’ leaves the system, and the people who are part of it, unable to comprehend (or at least accept) that there may be healthcare professionals who are not well-meaning.¹⁶ There was clear evidence of this at the Countess. This is an axiomatic failure; we know that not all healthcare professionals are well-meaning, and very few do cause harm deliberately, whilst others do so negligently and, sometimes, recklessly. Instead of being safe, patients are at greater risk of harm in a ‘no blame’ culture.
Focusing on system faults rather than the failings of individuals, whether manager or clinician, coupled with a learning culture that omits the first step of acknowledging responsibility/blame, makes the ‘no blame’, culture innately forward-looking. Whilst superficially attractive, it avoids difficult conversations about conduct. This avoidance directly or indirectly undermines patient safety.

Moving on

The government’s 10 Year Health Plan does not mention a ‘no blame’ culture.¹⁷ The notion seems, quietly, to have been dropped. That is a positive development, reflecting the reality that, after 25 years, ‘no blame’ has run its course.
Recently, there has been a move towards a ‘just’ culture.¹⁸ Accepting, as I do, that a ‘just’ culture is a better description of a desirable culture than a ‘no blame’ culture, I question the value of identifying a desirable culture and then adding a single adjective in front of the word ‘culture’ with the intention and hope of influencing people to behave in accordance with that description. I cannot see why this will succeed. Notwithstanding the huge learning and interest in NHS culture and the repeated calls for changes in culture, I am not persuaded that ‘culture’ can be more than a description of behaviours.
Responses to the Inquiry questionnaire, administered and analysed by the Nuffield Trust, support this, with most senior managers suggesting – in responses to questions about culture – that they were not well placed to define the culture for the whole organisation.¹⁹ Indeed, the list of factors that influence culture – positively or negatively – was exceptionally broad, encompassing relatively superficial initiatives, such as ‘board breakfasts’, as well as much more serious issues, such as bullying or harassment.²⁰ At the very least, the strength of the concept of ‘culture’ as a guide for managers looking to drive up standards is limited by the idea that there could be many different cultures, influenced by a huge range of factors.
It is behaviours that need to change. I am fortified in that view by Sir Robert Francis’s evidence about patient safety conferences that involve well-meaning professionals meeting to agree that the culture in their Trusts needs to be improved before they “go back to wherever they come from [and] nothing much seems to happen to change it”.²¹ What is currently being done is not working.

Back to basics

Earlier in my Report, I found it useful to identify the core purpose of a hospital: to treat and care for patients, and to do so with respect and kindness. The starting point for everyone must be patient safety. If, as I have said in respect of managers, patients are at the centre of all that is done in a hospital, appropriate positive behaviour should be expected and should follow.
Sir Stephen Powis said in his evidence that “do no harm” – the original and enduring first duty of a doctor – remained a guiding principle for all in the NHS, although the duty is now more usually described as ‘keeping patients safe’. He was asked about the effect of finances on that principle. He said:
“Patient safety is … at the very top of NHS England’s responsibilities and I would say that for every leader within the health system that is and should be top priority. ‘First do no harm’ is a phrase that you will recognise, it is a phrase that clinicians … live by and it’s the same for organisations and senior leaders: our first duty is to ‘first, do no harm’.”²²
He then added:
“[O]bviously it is important to acknowledge that particularly in financially challenging circumstances, senior leaders have to make a decision about where they deploy their resources. But I go back to my previous answer. At the very top of everybody’s list is patient safety … we are very clear currently that the priority is not to harm and therefore I would say deploying resources to support patient safety would be at or near the top of most people’s priorities.”²³
I note the slight step back in the last remark. There should be no compromise on this. Patient safety must be the top priority for all managers – indeed, for all people working in the NHS. All behaviour must be directed to that priority.

The Countess

I have said much earlier in this Report that, in early 2015, the neonatal unit at the Countess was characterised by good relationships between, and across, professional groups. It was a place where young doctors wanted to work; and it had a reputation for good training and high standards. It was also an active participant in the Operational Delivery Network.²⁴
Once concerns rose about the number of deaths, staff on the neonatal unit became anxious. Later, when it was realised that the doctors had suspicions about a nurse, things changed. Ms Powell made her views plain, in strident terms. Ms Kelly and Mr Harvey ignored deteriorating relationships. The nurse managers accepted in evidence that, from that time, relationships could be described as ‘nurses against doctors’. Whilst no one suggested that this adversely affected care on the neonatal unit, the unit became a very different place. Relationships were cooler.
At the heart of this deterioration in relationships was a well-known cultural phenomenon: sometimes referred to as tribalism, it is unthinking loyalty to one’s team or profession. The senior nurses demonstrated unquestioning loyalty to Letby throughout the events with which I am concerned. It ran together with their certainty that there was nothing in the consultants’ concerns. Ms Powell said to Dr Green in her grievance interview at the end of 2016 that Drs Jayram and Brearey were not usually malicious, but that view does not seem to have caused her to ask herself whether there might be something in their concerns even when asking herself, repeatedly, whether she was missing something. I accept that she, Ms Rees and Ms Kelly believed that Letby was not responsible for the deaths, but loyalty seems to have prevented them from considering the doctors’ concerns with an open mind or thinking about safeguarding. The email sent by Ms Rees to Ms Kelly on 9 September 2016 contained the words:
“[A] Clinician is being listened to and supported, with potential devastating consequences for a nurse. How are the nurses on the NNU [neonatal unit] going to react? I have already witnessed that senior nurses on that unit do not even want to answer the telephone to that consultant, who is making these allegations and making clear his personal view.”²⁵

Mr Baker KC described this as frank tribalism.²⁶ It was clear evidence of unthinking loyalty.

The senior managers were concerned for the reputation of the hospital, which in general is not of itself a bad thing but here it contributed to the very long delay between those concerns being raised and contacting the police in May 2017.  In evidence and in closing submissions the executives said that the reason for the delay in contacting the police (which they accepted occurred) was not because they intended not to call the police; it was so they could approach the police “at the right time when the precise nature of the concern was clear and could be fully articulated”.²⁷ That submission is not borne out by the evidence that I have set out in detail.
It follows that I find that culture, as described, did play a part in the failures by managers at the Countess.