How we behave in the NHS is a problem, but it’s also the solution

From Whitehall and Westminster, the NHS can look like an enormous machine made of units of governance, categories of activity, and financial flows. But from my point of view, having spent most of my career as a psychologist and a leader, it looks more like a culture and a society of hundreds of thousands of human beings, with values, histories, and deep affiliations.

It is in this social world that the knottiest problems in our health service lie—and nearly all of the solutions.

The way people speak and relate to one another should not be an afterthought. It lurks at the heart of the most troubling and tragic failures in our health service. Overconfidence and a culture of “them and us” can cause a reluctance to involve colleagues or refer patients elsewhere. This was identified in the Ockenden review1 as a driver of the maternity incidents investigated, along with the failure to learn from them. New and troubling examples of toxic mistrust among healthcare teams causing harm to patients continue to emerge across the NHS.

An even more consistent theme has been a culture where raising concerns is difficult, unwelcome, or resisted. The Francis report,2which recorded failings at Mid Staffordshire NHS Foundation Trust, described a culture “which ascribed more weight to positive information about the service than to information capable of implying cause for concern.”

The hard truth is that a desire for good news to feed the system, and a tendency to blame instead of learn, are widespread in the NHS. It is often an awkward subject to discuss because so many people are implicated, from politicians demanding success at the top through to individual professionals who fear for their careers.

On Friday 7 March, I’m pleased that we will work with The BMJ to hold a frank discussion on “What stops NHS staff from speaking up?” chaired by Kamran Abbasi at our Nuffield Trust Summit. We want to ask what continues to stop staff feeling able to raise everyday concerns about resourcing and capacity, thereby hiding the problems which can escalate into truly terrible failings, or linger at a cost in burnout and disillusion. We want to look at how we could change this.

NHS policymaking in England today is close to a frenzy, with a huge process to plan for the next decade surrounded by multiple other plans and reforms. I have had the interesting experience of sitting on the “Mobilising change” workstream for the 10 Year Health Plan, a notable attempt to take culture and human factors more seriously. We have seen many recent examples of what happens when social behaviours are ignored in the face of what seem like harder, more no-nonsense considerations.

One popular policy option, time and again, has been financial incentives for professionals and NHS trusts. At times these incentives have delivered results. At least in the cash-rich conditions of the time, competition for funds based on choice in the New Labour era was associated with better efficiency.3 The Quality Outcomes Framework(QOF) rewarded GPs for delivering certain standards and successfully accelerated improvements on some measures.4

But these incentives achieved this by displacing other behaviours and priorities. In professions with a strong sense of duty and purpose, other behaviours and priorities often reflect “intrinsic motivation” to deliver for patients, which can be pushed aside5 when money becomes the goal. There is a risk that less effort is made in areas that matter to patients, but which are not incentivised—with signs of a slowdown in measures not incentivised for GPs in QOF, and of higher readmissions and cancelled operations linked to financially rewarded hospital choice.6

Another example is changes in “skill mix”—exemplified by the expansion in physician associates, advanced practitioners, and new roles in general practice. Hiring these new staff proved relatively straightforward after a few pulls on the usual policy levers of guidance and subsidies. It seemed to offer more capacity which would allow the NHS to do more.

But our research into implementation7 of these roles finds that too little thought was given to exactly how these staff should operate relative to their colleagues, leading at times to inappropriate deployment. The need for supervision, training, and induction into a complicated system was not considered adequately. And because NHS finance and policy change much faster than people’s careers, when new roles were expected to be welcomed as new hands tackling excessive work, they sometimes came to represent a threat to longstanding professionals who saw there may not be enough training or job slots to go around.

As I will warn in my keynote speech to the Nuffield Summit, this is no time to forget about human factors in a rush to drive reform. Getting it right after such a chequered history means thinking about behaviour and human relations in the NHS more than ever before.

The NHS is a public service running on morale and values, with strong professional groups. Culture is a force so powerful that supposedly more solid considerations often melt away before it. It is tempting to believe there is “no time” to worry about or deal with these issues. In fact, at this difficult moment for the NHS, they must be the very first focus for policy makers if we are to avoid repeating the mistakes of the past.