It is generally accepted that organisational culture reflects its overall performance and, therefore, for the health of the nation, NHS culture should be positive and constructive.

There is also evidence to show that high performance strengthens organisational culture, incentivising employees to drive performance further forward.

In recent years, the NHS has been financially constrained, one could argue, as a deliberate austerity measure, eroding the service to a level that was recently reflected by the British Social Attitudes Survey (2023) as being at an all-time low.

The NHS is failing to deliver predictable healthcare, with organisations, including the BMA, repeatedly highlighting the detrimental effect of constraining staff and resources. Poor performance affects staff, the extent of which is hard to gauge, beyond reports of toxic working environments and unprofessional, or even illegal behaviour.

Healthcare is a high stakes, high risk service, so, early management of suboptimal practice is essential. The NHS already has established alert mechanisms, which should be both reliable and effective at eliminating unprofessional behaviour and practices, yet, despite these processes, we continue to read about an unacceptable working culture in the NHS. So, why aren't existing processes effectively addressing these issues?

One could argue that, if these mechanisms are challenging to access and complete, then, the reporting threshold is raised, with the converse being true for mechanisms, which encourage people to speak out. Also, if people cannot see the outcomes when raising concerns, they may question the effectiveness of the process, which disincentivises further engagement.

A potential solution, therefore, might be to remove reporting thresholds altogether, by introducing frequent and regular routine feedback instead, providing constant evaluation reflecting NHS culture. Big data management facilitates recognition of themes and clustering of both good and concerning organisational behaviours. The ability to raise specific concerns is still necessary, however, since any serious issues may not be reflected appropriately by routine feedback.

At present, the only visible feedback seen by staff and patients tend to be thank you cards taped to hospital walls outside wards, yet, complaint letters are quietly managed away from the public eye. This one-sided reflection of performance is unhelpful in reporting overall performance; the best of the NHS as well areas for improvement should be routinely fed back by patients and staff, with constant feedback helping to foster a more open and collaborative working environment. Constant and transparent reflection should help to enhance the NHS's overall performance.

As healthcare professionals, we need to respect professional boundaries and avoid workplace banter, which risks being misunderstood or causing offence. Working professionally does not equate with a dull working environment, but rather, a safe space within clear boundaries, whereby staff and patients can expect civility and mutual respect, even when the NHS itself fails to deliver the tools required to provide reasonable healthcare.

A high-performing organisation typically does not have a poor working culture and when the NHS, as a publicly funded health service, has sufficient resources to perform well, this should positively affect working culture.

Iona Collins is BMA Welsh council chair