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Culture more important than ever at a time of transformation

16 May 2025

In this blog Isabelle Brown and Laura Turner from NHS Providers' policy team highlight the importance of culture at a time of NHS transformation.

  • Leadership

  • Workforce

  • NHS architecture

An picture of Isabelle Brown

Isabelle Brown

Policy Advisor,
NHS Providers

The NHS workforce, at every level, is under considerable operational pressure from the combined effects of record demand and shortages of capital and resource. In addition seismic shifts are on the horizon, including the abolition of NHS England (NHSE), the expected recommendations from the second Penny Dash report on patient safety, and the upcoming 10 Year Health Plan.

The level of change the NHS is facing, as a safety critical sector, makes culture a strategic priority. To achieve the ambition behind these changes, we need an engaged, motivated workforce and a supportive, enabling environment. Getting the “how” of any reform that may be introduced by the 10 Year Health Plan right is just as important as the “what” and the ”why.” 

Research has long pointed to the important role that organisational culture plays in enabling high quality patient care. The seminal report To Err is Human: Building a Safer Health System examined how organisational culture can promote or hinder patient safety. Similarly, researcher and author Roger Kline noted how research has found that, “in hospital settings, managing staff with respect and compassion correlates with improved patient satisfaction, infection and mortality rates, Care Quality Commission ratings and financial performance.”

The message is clear: to improve patient safety and quality of care, we must prioritise people and culture. 

Trust boards must, and do, pay close attention to culture in their organisations, but we also need widespread prioritisation of culture across the entire healthcare sector—including within national bodies, regulators, and arm’s length organisations.

National leaders, including government and arm’s length bodies, play a vital role in shaping the values, behaviours, and practices of the sector. Indeed, after the public inquiry into failings at Mid Staffordshire NHS Foundation Trust, Sir Robert Francis concluded that systemic problems were a major factor. Mary Dixon Woods and colleagues     described this as a large scale failure of control and leadership at multiple levels, from “the blunt end” of the system (where decisions, policies, rules, and regulations are generated) through to “the sharp end” (the frontline).

The upcoming reforms to the NHS will focus on the structure and oversight of the service, but there is also the chance to reset the relationship between national bodies and local systems, away from the command-and-control-style leadership that has been all too prevalent. It is wasteful, duplicative, and distracting for the centre to take this     approach with board-led statutory organisations such as integrated care boards (ICBs) and NHS trusts. Boards need to be empowered to lead as they hold the accountability for their decision making.

Crucially, we must not forget that in the NHS the people are the system. This means that when implementing structural changes, the experiences of the workforce must be carefully considered. The abrupt nature of the announcement of NHSE’s abolition will have caused fear, demoralisation, and uncertainty for those working in NHSE and the wider system, undermining the culture needed to achieve reform.

Indeed, alongside taking a toll on workforce wellbeing, research shows that job losses and restructures often inadvertently have a negative impact on marginalised groups. In this period of profound change, there must therefore be a sustained focus on policies that promote      staff wellbeing and culture; clear and values-led communication; and equality, diversity, and inclusion in the NHS. The centre must prioritise listening to trusts so that decisions are aligned with realities on the ground.   

Staff are more than enablers or hurdles to government ambition; they are active and essential constituents in the new system. Listening to and involving them is essential. The recent evaluation of the People Promise Exemplar Programme demonstrated that investing in people brings broader organisational gains, such as improved retention rates and associated cost savings. As the King’s Fund highlights, investing in staff unlocks enthusiasm, creativity, and leadership, transforming passive participants into passionate leaders of change. 

NHSE has previously encouraged trusts to create positive, people-centred cultures to improve patient safety and quality of care. With the forthcoming changes to the NHS architecture, it is critical that the focus on workplace culture is not lost. Patient safety and staff wellbeing depend on a sustained, united commitment to positive culture and quality across all levels of the healthcare system. As Bob Klaber from Imperial College Healthcare NHS Trust notes, “at the heart of outstanding care is kindness. Not kindness as a soft and frivolous thing…but as actions and decisions we choose to make every single day.”

Given the upcoming structural changes about to take place, the way we treat those working in the system is more important than ever. If we are to drive change and deliver a truly reformed health system, focusing on people and culture is non-negotiable.

This article first appeared in the British Medical Journal

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