This week, Donald Berwick came across the Atlantic to tell us how to make the NHS safe. Among the many expected things that he said was the ubiquitous concept of “the safety culture.” In fact, wherever I go I encounter this nebulous concept of culture; ‘It is a question of culture. We must change the culture. It’s all in the culture.’
A huge amount has been written, of course, about this concept of culture. However, organisational culture is usually treated as a discrete entity, disembodied from the broader society and from the subsections or departments that make up an organisation. If so many of the failures of the NHS are a question of culture, then part of the problem may lie not in the health service itself, but in broader society. So what can we say about British culture as a whole; are we a nation of high rectitude or turpitude?
It turns out that there is a scale of national morality. I refer to Fisman and Miguel’s paper on “cultures of corruption” from 2006. These brilliant authors linked the New York Police Department database to that of the United Nations diplomatic corps. They were thus able to determine the extent to which diplomats from various countries violated their parking privileges. I knew that Norway would be squeaky clean, while there were other countries that I suspected would frequently violate parking restrictions under diplomatic immunity. I suspected that the United Kingdom would be down there in the middle grade. However, I was as surprised as I was delighted to see that we score among the highest probity countries, such as Denmark and Japan. In case you are wondering which country recorded the highest rate of violation per diplomat, this was Kuwait, followed by Egypt, Chad, Sudan and Bulgaria. High offending countries tended to have high scores on the international corruption index and also lower per capita GDPs (gross domestic product). As a fan of Max Weber I suspect that moral behaviour generates wealth rather than the other way round, and there is some evidence in favour of my position from John Kay.
Of course diplomats are not a random selection of the countries from which they emanate, but one has to consider the results as reassuring. To what extent does national culture determine the culture among particular services; doctors and nurses, teachers and the police, for instance? I don’t know; do you? And to what extent is a culture in an individual department a reflection of the organisational culture. On this latter point there is evidence from NHS staff surveys. Local culture trumps organisational culture and this is consistent with my own research work  and that of others  showing that standards of care are poorly correlated across organisations.
So what we have is people nested in departments, nested in organisations, nested in countries. It would appear that there is little correlation between culture in departments and in organisations, but the extent to which organisational culture correlates with national culture is more ambiguous. I suspect that national culture is more important than organisational and even departmental culture in determining the behaviour of individual clinicians. I would be extremely interested in any further evidence on these points.
In the meantime, we will carry on talking about culture, as though we understand it; and plan to change it, as though we could do it. What else can we do? And the evidence base does give us some strong clues. For example, we should be very leery about the use of financial incentives. I read a report on a paper recently that showed that performance following the withdrawal of incentives is worse than performance among people who never had the incentives in the first place. What about targets? The situation here seems very nuanced; sometimes they seem to work well (infection-control) and sometimes they displace other worthwhile objectives (waiting times). I hypothesise that targets work best when the people at whom they are directed are convinced that the target is worthwhile. In any event, once the structure of a health service is well established it is through hearts and minds that objectives are achieved and, quite reasonably, we codify this idea through the concept of culture.
My research work shows that, from a technical point of view, the NHS has improved over the last decade or so.[7,8] The patient survey shows that there has been some improvement in the caring side of health, but not enough. Changing culture so that people become more caring in their attitude is a big challenge since behaviour in this regard depends largely on a person’s innate characteristics and on their upbringing. The NIHR recently elicited a call for research into this topic. Unfortunately I did not have time to apply and I look forward to reading about the results in due course. In the meantime I reflect that organisations are increasingly seeing the moral education of their staff as a worthwhile and important objective. As our churches empty, senior managers must assume the mantle of St Paul.
 National Advisory Group on the Safety of Patients in England. A Promise to Learn – a Commitment to Act. Improving the Safety of Patients in England. 2013. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf [Accessed 9th August 2013].
 Fisman R, Miguel E. Cultures of Corruption: Evidence from Diplomatic Parking Tickets. NBER Working Paper No. 12312. 2006. Available at: http://www.nber.org/papers/w12312 [Accessed 9th August 2013].
 Kay J. The Truth about Markets: Why Some Nations are Rich, but Most Remain Poor. London: Penguin Books Ltd . 2004.
 Wilson B, Thornton JG, Hewison J, Lilford RJ, Watt I, Braunholtz D, Robinson M. The Leeds University Maternity Audit Project. Int J Qual Health Care. 2002; 14(3): 175-181. [Article link]
 Jha AK, Li Z, Orav EJ, Epstein AM. Care in US Hospitals – the Hospital Quality Alliance Program. NEJM. 2005; 353(3): 265-74. [Article link]
 The Economist. Making Pay Work. The Economist 25th May 2013. Available at http://www.economist.com/news/finance-and-economics/21578377-why-bosses-should-be-careful-when-using-performance-related-pay-making-pay-work [Accessed 9th August 2013].
 Benning A, et al. Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation. BMJ. 2011; 342: d195. [Article link]
 Benning A, et al. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ. 2011; 342: d199. [Article link]