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NHS culture: picking up the pieces

A modern approach to professionalism may help to crush a culture of fear which has devastated parts of the health service

The findings of the public inquiry into catastrophic failings at the Mid Staffordshire NHS Foundation Trust made distressing reading.

crackThe report painted a picture of healthcare workers under pressure to meet targets while patients were subjected to unnecessary suffering and denied basic needs.

Shockwaves were felt throughout the medical community, which questioned how such failings could have occurred.

The Department of Health is expected to publish shortly its full response to the recommendations of the public inquiry that was set up to investigate what took place at Mid Staffs.

Among the recommendations of public inquiry chair Robert Francis QC was the call to reshape the NHS culture to ensure caring and quality were made top priorities.


Ideal leaders

As part of its ongoing response to the inquiry, the BMA has been looking at medical professionalism and leadership — both identified as important for doctors in the report by Mr Francis — and now wants to hear members’ views on how this ideal can become a reality.

BMA council chair Mark Porter says: ‘The whole of the medical profession was shocked by the failures at Mid Staffs which brought into sharp focus the need for a change in the culture of the NHS and for us to reassess the leadership role played by doctors.’

As a professional body, the BMA wants to support clinicians to restate and re-establish these values that are central to the doctor-patient relationship and to the delivery of high quality services for patients.

Professionalism has been defined by the Royal College of Physicians of London as a set of values and behaviours incorporating integrity, compassion, altruism, continuous improvement, excellence and working in partnership.

However, the BMA is aware these values can be compromised by external pressures such as prioritisation of financial targets over quality of care, restructuring of the NHS, under-funding, competition between providers, and failure to recognise the importance of professional development activities.


Patients must come first 

Dr Porter adds: ‘Professionalism is central to the doctor-patient relationship and yet our doctors feel that political pressure to prioritise financial targets and those with little clinical relevance over those governing quality of care has weakened their position as clinical leaders.

‘This, coupled with a workplace where their warnings are ignored or their advice dismissed, easily allows demoralisation and disengagement to set in.

‘Worse are the reports that many of our members are working in a climate of fear, where they don’t feel confident raising concerns for fear of reprisal. It is often this culture of control and fear which prevents doctors and other NHS staff from speaking out.’

In the face of change, political interference and constrained resources, BMA members have argued that putting patients first is more important than ever.

Doctors at Mid Staffs found themselves in conflict with senior colleagues over management priorities that did not meet the needs of patients.


Investigating sectors

The drive to achieve foundation trust status meant the need to deliver high-quality care became lost.

As part of its work, the BMA has been investigating how other sectors have sought to overcome organisational challenges and foster a culture which puts patients first.

The association interviewed four organisations from different industries to find out how they overcame challenges and managed safety problems.

Among these was AmicusHorizon, a large housing association servicing London and the South East which, after being taken into regulatory supervision in 2007 due to poor tenant satisfaction levels and low staff morale, made a dramatic turnaround and has since won awards for management and quality services.

Strong morale was key to delivering its organisational change. Although there was some regulatory intervention, much improvement was driven from within by involving residents and repeating a single clear message about change.


'Just culture'

It was recognised that, despite being uncomfortable, change would ultimately benefit not only the organisation but also individuals.

A common consensus from all four companies interviewed was that improvement must come from the active engagement of those involved rather than regulation or sanctions.

The companies also emphasised the importance of a ‘just culture’ which recognised errors occurred and sought to learn from them rather than looking for scapegoats.

It is clear from the Francis Inquiry report that tensions and conflicts within the NHS have been ignored.

However, if appropriate processes are put in place to manage conflict there is no reason why disagreements cannot be used positively to drive improvement.


Demotivation threat

Although the NHS faces unique challenges, one clear message from other organisations is that excellence rests on people who are supported to act as individual professionals.

This message certainly has implications for the NHS where over-reliance on standardisation and protocols can weaken clinicians’ expert status and prevents patients from being seen as individuals.

Many have questioned how medical staff at Mid Staffs could forfeit basic standards of care.

Mr Francis asked why there was ‘a loss of individual and collective personal responsibility and engagement’.

The evidence he found — borne out by the BMA’s work — shows demotivation is a key factor.

When a doctor raises concerns which go unheeded or is excluded from decision making, demoralisation can set in, causing an acceptance of poor standards over time, according to the BMA.

Fear, personality clashes, poor communication and a lack of internal committee structures that allow clinicians a voice are also contributing factors.


Out with the old

A modern approach to professionalism could be the key to strengthening the role of doctors, the association suggests. This means doctors must accept and embrace their leadership role, insist on the provision of the clinical perspective in managerial decision making, and participate in strategy and planning meetings.

Doctors need to voice and act on their concerns, foster networks with other clinicians and demand adequate time in job planning to continue professional development activities.

The importance of leadership needs to be emphasised early in doctors’ careers, either formally as leaders of clinical teams and management roles or less formally as mentors and exemplars.

Dr Porter says: ‘All doctors are leaders and it is only right that they feel confident and empowered to exert a positive influence across the NHS on behalf of their patients but in order for this to happen there needs to be a fundamental change in NHS culture.’

If doctors can regain confidence as autonomous professionals responsible for ensuring high standards of care, the fear of acting on concerns may be lessened.

The BMA has also published an update on its ongoing work on raising concerns. It plans to publish a final set of recommendations to help shape a positive NHS culture, based on the views of its members.

Find out more about the BMA's NHS culture project

Read the BMA paper: Supporting doctors in raising concerns (PDF)

Read the BMA paper: Examining professionalism (PDF)


Help the BMA answer these key questions


How has your approach to professionalism been affected in recent years?

Do you think professionalism is being eroded?

Do you feel your organisation encourages meaningful engagement with clinicians? If so, how? If not, what needs to change?

Should doctors accept they have an element of corporate responsibility as well as their commitment to good therapeutic practice? What happens  when there is conflict between the two elements?

How can doctors begin to restate their professionalism?

 Take our survey to tell us what you think 


Raising concerns

Do you believe a more open and honest culture is achievable in the NHS? Please explain why.

If you were worried about the personal implications of raising a concern, what additional safeguards would need to be in place to do so?

 Take our survey to tell us what you think