“We focus on leadership as a concept, not on individual leaders,” says Michelle McKay, chief executive of Worcestershire Acute Hospitals NHS Trust. It is a noble concept, but one born out of pragmatism too – because when she joined the organisation in 2017, it was as one of four senior leadership hires during a period of turbulent change precipitated by the trust being placed in special measures by the Care Quality Commission (CQC).
That dramatic and damning verdict was the starting point for a turnaround other trusts will soon be clamouring to copy. But at the time, McKay found what can best be described as organisational stasis. “There was a considerable amount of change and what was quite apparent to me was that employees were talking about waiting for permanent leadership. There was almost a view that we couldn’t do anything until we had that.
“It was like people were waiting to ask permission to do things where permission wouldn’t normally be required. I saw it as a cultural issue, which is why we took real action early on.”
McKay and her team attribute the positive uplift in morale over the past year – and, more importantly, tangible improvements in patient care – to treating culture as the foundation of positive working practice at the trust. Working with cultural change specialists Pulse UK, they profiled and diagnosed problems within the organisation and decided employees badly needed both a sense of achievement and a sense of connection with each other.
Those can sound like ephemeral concepts. But the team quickly made them tangible, asking departments and individuals to think about four distinct behaviours they could develop and demonstrate: do what we say we will do; no delays, every day; we listen, we learn, we lead; and work together, celebrate together.
The 6,000 employees, who work across four hospital sites, quickly set about owning and reporting initiatives that showed the behaviours in action. In the palliative care team, for example, that meant surveys and focus groups to inform care plans, as well as greater reflection on patient care, new links with other local trusts, a new approach to communication and psychological supervision to ensure staff wellbeing.
It’s striking how much of the cultural work undertaken across the trust has led not just to ‘soft’ outcomes that drive engagement but to realignment of processes and practices that directly impact front-line care. “The big thing we’ve seen is different teams working together,” says McKay. “We were in a bizarre situation a year ago where our surgeons and anaesthetists had never been in a room together to talk about theatre scheduling, whereas now we see them working together all the time.
“All the work people do in an organisation like this is linked to a patient. You might be on the front line, which is very obvious, or you might be a cleaner supporting infection control efforts. When people showcase what their team is doing, it is always linked to the business outcomes they are responsible for delivering.”
But why is culture the glue that binds such behaviours? McKay describes culture as “the way we do things here” and says the idea of changing something that fundamental resonates more than academic definitions. “Health is a team sport and that requires people to work together and have an idea of where they’re trying to head,” she adds. “Culture is what makes that actually happen. To me, it’s critical and there’s lots of evidence that you need a culture driven from the top and implemented by everyone.
“You can have a lot of values stuck on the wall. People might be able to repeat them, but they can’t describe how they actually do them. Many of us will have experienced working in organisations that have respect as a value but have high rates of bullying, for example – so that’s why we talk about behaviours as something we actually do.”
And the behaviours are backed by a strong set of measures driving accountability among teams. Tina Ricketts, director of people and culture, points out that when the executive team has been through substantial change, it becomes easy for cultural shift to feel like “just another initiative”. Worcestershire had to ensure the concept of culture was a permanent fixture. “That’s why integrating it into the fabric of everything we do is so important. When people can see the benefits of showcasing their achievement, they want to join that movement,” says Ricketts. “There are still naysayers, and we still have work to do to get them to understand, but we will get there.”
A lot of culture programmes can feel optional, adds McKay, but this one is substantially different. It is also clearly working. Not only have medical vacancies dropped 40 per cent year on year, agency costs are also down 10 per cent, largely due to improvements in sickness absence. Operating theatres are far more productive and medics praise process improvements affecting the way patients flow through hospitals. Best of all, the CQC has hailed the trust’s progress.
The team can’t afford to be complacent in what is a long-term project. Winter pressures will necessitate significant resourcing and Brexit will challenge the local healthcare system, says Ricketts. But McKay, for one, is pleased that what she describes as a “complex organisation” is improving – to the extent that a patient recently wrote to her to laud how the behaviours he saw written on a staff poster were being played out by the nurses caring for his relative.
“When teams have to work together to deliver outcomes, that needs time, energy and money put into it. It doesn’t just happen,” she says. “Working in a challenged NHS trust is incredibly tough. But if you can keep looking at what’s within your control, rather than all the countless things that aren’t, it keeps you motivated to deliver more.”