Can NHS Organisational Culture Really Change? Lessons from Alder Hey Children's Hospital
Looking back at one of the most important experiences of my consultancy career and what it taught me about leadership, learning and lasting organisational change.
We hear a great deal about the need to change the culture of the NHS, usually following another inquiry into something that has gone badly wrong.
But can organisational cultures really change? And if so, what does it take?
I believe they can. One of the most significant experiences of my consultancy career helped convince me of that.
Rebuilding trust at Alder Hey
When I was invited to work with Alder Hey Children's Hospital in Liverpool, the organisation was living through one of the most difficult periods in its history.
The organ-retention scandal had profoundly damaged public trust in a hospital internationally recognised for its care of children.
I remember nurses telling me that they were reluctant to display their uniforms when travelling to and from work because of the public anger associated with the Alder Hey name. These were dedicated professionals who had spent their working lives caring for sick children, yet the reputation of their hospital had become associated with something deeply distressing.
For the families whose children's organs and tissue had been retained without appropriate consent, the consequences were, of course, incomparably greater.
The challenge was not simply to restore the hospital's reputation. It was to acknowledge and learn from what had happened while helping staff rebuild confidence and create a different future.
Leadership begins at the top
I worked closely with the hospital's Chief Executive, Tony Bell OBE, whom I came to admire greatly.
Tony personally wrote to the parents of every child whose organs had been retained without proper consent. He recognised that rebuilding confidence required openness, honesty and a willingness to face the past rather than pretend it had not happened.
He was equally clear that changing Alder Hey's culture required changes in leadership behaviour throughout the organisation.
And importantly, he included himself.
We developed a programme called Excellence through Learning, designed to build leadership, encourage organisational learning and involve staff throughout the hospital in improving their work.
Central to the programme was the development of facilitators — people within the hospital who could help colleagues examine problems, improve processes, work together more effectively and learn from experience.
But Tony did not simply send his managers and staff on development programmes.
He and his executive team undertook the same facilitator training that they were asking leaders throughout the Trust to complete.
I personally took Tony and his senior colleagues through that programme.
For me, this demonstrated something fundamental about leadership. You cannot credibly ask people to change their behaviour if you are unwilling to examine and change your own.
Tony and his executive directors also developed standards against which they agreed their own leadership behaviour should be evaluated.
There was no suggestion that senior management was somehow exempt from the changes expected elsewhere.
Putting CHILDREN at the heart of the programme
We also wanted the programme to have a strong identity that people throughout the hospital could recognise and relate to.
After all, this was a children's hospital. Its purpose had to remain at the heart of everything it did.
We developed eight guiding principles around the mnemonic CHILDREN:
C — Communicating: Keeping staff, patients, families and the community informed.
H — Honesty: Openness and honesty in how we work.
I — Innovation: Building on Alder Hey's reputation for excellence in paediatric healthcare.
L — Leadership: Everyone taking responsibility for improvement.
D — Developing staff: Helping people reach their full potential.
R — Respect: Respecting children, families and one another.
E — Energy and enthusiasm: Creating a healthy, creative and healing environment.
N — National pride: Rebuilding legitimate pride in Alder Hey and what it stood for.
That final principle was particularly significant.
Pride could not simply be demanded. Staff needed to experience changes that gave them genuine reasons to feel proud of their hospital again.
The CHILDREN principles were therefore more than words on posters. They were intended to influence how the programme operated and how people behaved towards one another.
If we wanted greater openness, the development process itself had to be open. If we wanted participation, people needed genuine opportunities to influence decisions. And if we wanted better teamwork, we had to create opportunities for people to work together on real organisational problems.
Learning by doing
One of the approaches I have used throughout my Organisation Development career is to develop facilitators within organisations rather than make them dependent on external consultants.
At Alder Hey this was particularly important.
Staff were encouraged to use their developing skills to examine and improve the services they provided.
An improvement project might aim to reduce delays, improve communication or make a service more responsive to patients and families. But the process of working together could also achieve something less immediately visible.
People who had rarely worked together could begin to understand one another's problems, challenge assumptions and discover different ways of working.
In other words, the improvement project was also a culture-change project.
This was a practical way of developing the behaviours we wanted to encourage.
Recognition and continuing development
In 2006, Excellence through Learning won the national Organisational Learning category and then the overall Excellence in Human Resource Management Award.
That recognition was particularly encouraging for everyone involved.
But what has interested me even more is what happened subsequently.
More than twenty years later, when researching the updated edition of my book, I looked again at Alder Hey's organisational history.
I was surprised and rather moved to discover that the hospital still identifies Excellence through Learning, from 2002 to 2007, as an early foundation of its subsequent improvement journey.
The hospital has since moved into an extraordinary new building and continued to develop its clinical services, research, innovation and approaches to improvement.
It would be wrong to suggest that our earlier programme was responsible for everything that followed. Many leaders, staff, patients and families have contributed to Alder Hey's development over the intervening years.
But perhaps that is precisely the point.
A successful culture-change programme should not depend indefinitely on the people who originally developed it. Its real achievement may be that the organisation becomes increasingly capable of continuing to improve and renew itself.
What can the NHS learn?
Looking back at Alder Hey, several lessons have stayed with me.
First, culture change has to begin with leadership behaviour. People pay far more attention to what leaders do than to what they say.
Second, staff need to become participants in change rather than simply its recipients. Information can be cascaded through an organisation, but ownership cannot.
Third, changing a culture requires more than workshops, slogans or new management arrangements. People need opportunities to experience different ways of working.
And finally, culture change is not a project with a convenient completion date. It is a continuing process of understanding, learning, improvement and renewal.
My experience at Alder Hey reinforced my belief that organisations really can change. But lasting change requires commitment, courage and leaders who are willing to change themselves.
These are among the experiences and lessons I explore in my substantially updated book, Beyond Reorganisation: The Practice and Reality of Organisation Development in the NHS.
I have made the full digital edition freely available because I would rather these ideas were read, challenged and used than simply sit on another bookshelf.
I would be interested to hear from others who have been involved in changing organisational cultures, particularly in the NHS.
What made the difference in your experience?
Michael Wash
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