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Largest ever study into culture and behaviour of NHS

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A lack of clear aims, too much box ticking and varying standards in staff are thwarting efforts to provide high quality care in the English NHS, according to the largest analysis of how the service works.

“Looking after patients requires looking after staff,” one of the report authors Professor Michael West, of the Lancaster University Management School, said online in BMJ Quality & Safety.

Clear goals are needed that are “coherent from ward to Whitehall” and NHS organisations must constantly review, strengthen, and improve all their systems, it was suggested. A working atmosphere should be built so the focus is on the person rather than the task, it added.

The conclusions stem from two years of research including 650 hours of observation from 2010 - following the initial inquiry into the failings at Mid-Staffordshire through to the passing into law of the latest set-up of the NHS in England - the Health and Social Care Act in 2012.

Both “bright” and “dark” standards of care were unearthed by the 300 interviews with senior level executives, managers and frontline staff plus numerous patient and carer surveys.

Hundreds of sets of board minutes and performance data in all types of NHS trust along with cultural case studies of hospital wards, primary care practices and emergency care departments were also used to help draw a picture of life in the NHS

Poor care, harried, distracted staff, and evidence of structural and cultural factors which threaten the quality and safety of care contrasted with many examples of excellent care, practice and innovation across the NHS in England, it was found.

Having unclear or disjointed goals helps to eat up resources and the excessive box ticking needed was more about trying to meet external requirements rather than improve services.

Other criticisms included the overlapping functions which in turn led to ambiguity, fragmentation and competing pressures from having many regulatory bodies and agencies involved.

Poor intelligence on which to base potential improvements, highly variable staff support and a lack of respect and appreciation were also among the key issues which came to light.

Staff also faced running the risk of being viewed as trouble-makers and whiners for trying to raise concerns when the “comfort-seeking behaviours” of the system meant focus on making a good external impression, it was found.

There was a lack of integration, leading to time-wasting, frustrating barriers and gaps in care plus indiscriminate or inappropriate use of quality improvement management techniques, according to the study.

For things to improve it is “essential” that a national approach is created which does not have confusing messages and signal. In order for this to happen responsibility and accountability should not be dispersed, the study found.

The new bodies that are part of the health system, including NHS England and clinical commissioning groups, should not be left to face a situation where they have competing priorities, it was argued.

Study author Professor Mary Dixon-Woods, of Leicester University’s Department of Health Sciences, said: “The NHS is far from unique in experiencing challenges.

“Every health system in the world is grappling with patient safety problems but the NHS is uniquely well placed to address them.”


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Readers' comments (1)

  • michael stone

    All seems both right and well-understood, I think.

    There are huge problems in the NHS around:

    1) Aligning behaviour across different professionals and different locations and providers (i.e. creating 'joined up and balanced behaviour' when different people and bodies have all got different objectives and priorities);

    2) The tension between training staff properly and then telling them 'to get on and do your job, and take personal responsibility for your success or failure', or 'putting in place idiot-proof tick-box processes';

    3) An obsession with 'auditing everything', which degrades the importance of many things which are very important but are not easily 'auditable'.

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