Coaching for culture in the NHS

Sue Smith OBE is a coach, supporting new directors in the NHS. She retired from her role as an executive chief nurse/deputy CEO in 2021. She is also Chair of Transform Healthcare Cambodia and a non-executive director at St John’s Hospice.

The findings of the recent Ockendon report, published a number of years after Kirkup, is a harrowing and stark reminder of the real and traumatic impact of poor culture and inadequate governance on the lives of too many families. In my role as an executive chief nurse, I worked closely with families who had suffered similar experiences in maternity care and this experience shaped my own beliefs and values.

Whilst these reports are focused on maternity care, there needs to be an acknowledgement that these same issues aligned to culture and governance impact many specialties within the NHS. Importantly, the response by national leadership and regulators requires reflection because too often the response is to view a report such as this in isolation.

Ockendon should be used for every specialty and for every board to consider within and across the NHS and wider healthcare. It absolutely must result in a review of the impact of the way regulation adds layer upon layer of complexity to NHS governance.

I believe that NHS governance and culture are inherently linked. Atkinson (2012) describes cultures as weak or strong, negative or positive, forcefully shaped or cast and blown about like a paper bag in the wind, unsure of focus, intention and purpose.

The NHS is a complex organisation, culture is influenced directly by government, regulators, board, team and individual experiences. There are cultures within cultures, influenced by professional codes/ethics; specialty guidelines and widely held expectations of how they perform from the public, politicians, regulators, professional bodies, peers and the media.

Dysfunctional culture in the NHS can impact on every aspect of service delivery and the ability to provide effective governance, leading to increased mortality and morbidity, poor patient and staff experience. It can also impact negatively on the service’s ability to run safe, effective services that people want to work in or be treated in. Culture influences the effectiveness of clinical and corporate governance in the NHS; cultural impact can be internal or external.

Following the golden thread

Too many NHS trusts receive high and sometimes confusing levels of regulatory and media coverage despite making improvements across several areas. For example, Trust A had introduced high levels of leadership training and support and the culture had improved significantly. However, it became obvious that long-standing, intrinsic poor behaviours and relationships within some teams had a negative impact on patients, staff and the reputation of the organisation and required a different approach.

Governance processes were complex, cumbersome and poorly understood within a number of front-line teams. A project team was commissioned to work with staff, from frontline services to board, to understand how governance was working for them – and to understand whether the ‘golden thread’ could be followed throughout the organisation.

Linking a total redesign of governance systems and processes, to coaching, and board support and leadership should, in theory, help to engage and empower staff at all levels, enabling a simple and cohesive alignment of organisational and team/individual strategy and objectives that everyone could understand and focus on.

The Good Governance Institute was commissioned to work with the trust and identified coaches to support a year-long programme to not just rewire the trust’s governance system but to review it, strip out the parts that made is unwieldy, rebuild and ensure the new wiring provided a safe and easy way to keep patients and staff safe for years to come.

Increasing regulation

The golden thread had become knotted at every level and could not be easily followed. The reason for this is that, over several years of high levels of regulation, layer upon layer of additional governance processes had been put in place – often at the request of regulators – but they did not add value, they added complexity and confusion. Regulators and commissioners requested data in different ways, did not liaise together and the trust was spending its time responding to an industry of data requests rather than focusing on stripping out the duplication and confusion.

This ethos of increasing regulation was then inadvertently cascaded through each level of the organisation. This is not unique to Trust A; many NHS organisations experience similar over-regulation that results in governance processes that become slow and clumsy, and I believe that the national NHS regulation and governance process needs a similar overhaul to make it simpler and fit for purpose.

Staff on the front line and their leaders described being called to numerous meetings where they were asked for the same information, often in different formats. By the end of the project year, the number of meetings from service line to board had fallen by a third, and duplication of information had been significantly reduced.

Several people who attended meetings made no contribution at all; as a result, attendees were reduced to only those who were needed and contributed. To ensure that key messages were understood from service to board, 3As reporting was introduced by GGI. At the end of each meeting, a summary of items that needed to communicate for alert, assurance or advice were included in a one-page summary of the meeting and cascaded up and down the organisation.

These simple steps resulted in people having more time to improve their services (less time in meetings or activities that did not add value) and provided clear sight of the key issues that everybody needed to be focused on – in turn supporting the delivery of improved understanding, ownership, team and organisational performance.

Over a period of 12 months, working in partnership to challenge culture, beliefs and the way we do things around here resulted in a simpler, useable governance process that resulted in key messages being shared and owned with clarity of roles, responsibilities and ownership.

Simple governance in a complex system

Atkinson is clear that a strong and vibrant culture will enable new initiatives to flourish and grow and will encourage high-flyers to be attracted and retained, and that the relative health of your business culture will either support you in achieving results in difficult times or act as a barrier, a hindrance and an obstacle that denies innovation or change.

He argues that openness to explore the strengths and limitations of the current culture is critical. This can be achieved quickly if all managers are involved in the process. He states that critical to this process is changing the behaviour of key players and ensuring that these fit within the core values of the organisation. I could not agree more.

The NHS is complex, but governance can be simple and meaningful. It is our role as leaders to work together with the right partners to support and coach teams to influence simpler governance, and improved culture and learning, resulting in better outcomes for patients and staff.

Coaching for culture and improving governance in the NHS is not a simple task – it can even feel scary at times. It requires a lot of work, patience and challenge. However, if we are to make the NHS safer and better for staff and patients, it is important to move forward with determination, making use of the great resources available to us, to make it easier to do the right thing, communicate the right thing and ultimately, to consistently learn and improve.

This is happening piecemeal across NHS trusts, but if the NHS is to survive the complex changes it is going through, who will ensure its wider regulation, culture and governance are fit for the next decade?