Dare we use the C word?
Just in case there is any doubt I am referring to culture and its significance in failing organisations.
A great deal of attention last week was devoted to the problems that were identified in the Francis Inquiry into Stafford Hospital.
This inquiry was set after the scandal of maltreatment of patients and the fact that there was a higher-than-expected mortality rate at the hospital between 2005 and 2008.
It should probably come as no surprise that a 'whistle blower', Helene Donnelly, had raised concerns 100 times over six years on the basis of what she witnessed. In particular she believed that at Stafford Hospital there was a culture of neglect.
The Francis Inquiry heard evidence from over 160 witnesses and sat for 139 days and has recommended that there needs to be a "fundamental change" in the culture if the NHS to make sure that patients are the priority rather than efficiency and cost reduction.
Significantly the report also recommends that it becomes a criminal offence not to disclose information about substandard patient care or mistakes that may have occurred.
Additionally there believed to be a need for a code of conduct which will guide the conduct of senior managers and that the recruitment and training of nurses should place more emphasis on compassion and the needs of patients.
When your read this it reads from the manual of the bleeding obvious and to quote from that wonderful sage Oscar Wilde, who was talking about the death of Little Nell in The Old Curiosity Shop, you'd have to have a heart of stone not to laugh.
In no way would I wish to disagree with the findings of Francis' admirable investigation; quite the contrary.
What has been exposed has shone a light into the practices of NHS hospitals which, as we know, are revered and part of a system that are believed to the exemplar for countries around the world.
The fact that there have already been five major investigations into hospital care before the Francis inquiry should make us wonder what is really going on and what culture in the NHS really consists of.
What makes the Francis' findings so shocking is that they are so utterly at odds with my extremely limited (thankfully) contact with the HNS or its staff.
Those I know who work for the HNS are characterised by their dedication to giving the best care possible with the resources they have at their disposal.
This is backed up by research into culture and change in the NHS. However, in contemporary studies it seems that what most interviewees castigate is increasing bureaucracy they have to cope with.
An immediate observation of what will happen in the aftermath of Stafford Hospital and the other nine hospital trusts that are to be investigated as a result of their high mortality rates is that there will be a push for even greater levels of bureaucracy.
Given that we are in the midst of the worst recession in living memory will there be more investment in the NHS (though my sources tell me that after the next election it won't exist)?
There still remains the question as to how the culture can be changed? To quote the quality guru Dr. W. Edwards Deming, 'By what means?'
Culture change seems to be on everyone's lips at the moment.
The incoming Chief Executive of Barclays Anthony Jenkins has stated his intention to change the culture of the bank in order to win the trust back.
No-one could realistically argue that banking can be compared to healthcare. However, what Jenkins has said about what he wants to achieve would suggest that he is a man on a mission and will not compromise:
"My absolute conviction is that there is no choice between doing well financially and behaving well in this business. Our values are simple: respect, integrity, service, excellence and stewardship. These are not just words. We have defined the explicit behaviours we expect colleagues to exhibit if they are living up to these values. "They define the work we will do and the work we won't do. They define the way we hire, develop, promote and reward our people. We never want to be in a position again of rewarding people for activity that is inconsistent with our values."
As some commentators have identified Jenkins is effectively saying that Barclays will return to its old and traditional image of boring retail banking and by reducing its investment banking division is willing to eschew the part of the business which in the past produced the spectacular profits.
In culture change a major influence is the leadership style that is exhibited by those at the top of the organisation.
In the case of Barclays there is a chief executive. However, when it comes to the NHS, apart from the whichever politician is the current Secretary of State for Health - Jeremy Hunt who succeeded Andrew Lansley last September - there is no one person in change.
The present government is wedded to a belief that there are too many disparate parts and that breaking it up is the solution.
Barclays and the NHS are not exceptional; every organisation wants to instil a culture that will increase its chances of success. The trouble is it is never that easy or straightforward.
Organisational culture is regarded as an important component of every business and management course.
But as every student will tell you, whilst there is broad agreement as to what culture consists of - though there are literally hundreds of definitions - there is great debate as to what achieving 'successful' change based on culture really means.
Perhaps explaining how culture came to assume significance in organisations provides a cautionary tale.
One of the most successful business books ever published In Search of Excellence, described what the authors Tom Peters and Robert Waterman had found in the organisations they had identified as being 'excellent' and studied in order to learn the secrets of their success.
Here is what they said about culture:
"Without exception, the dominance and coherence of culture proved to be an essential quality of the excellent companies [they studied 62]. Moreover, the stronger the culture and the more it was directed toward the marketplace, the less need was there for policy manuals, organization charts, or detailed procedures and rules. In these companies, people way down the line know what they are supposed to do in most situations because the handful of guiding principles is crystal clear. (1982:75-76)"
So there you have it. Get a strong culture and your problems are solved.
What happened to the excellent companies Peters and Waterman studied suggests that success is transitory. Within a couple of years half of them had gone bankrupt.
Making statements about improving the culture of an organisation suggests that there is an easy elixir. Besides, what would we expect a new chief executive to say; 'I'll change nothing.'
The really smart top managers are genuinely interested in what goes on and find out what people really think.
As a result they find out what the existing culture is. If this is not considered good enough then it becomes incumbent on managers to lead change from the front and to show what is expected. If there needs to be pain in terms of any change they should experience it.
It could be seen that Barclays by shedding jobs in its investment banking division is showing it means to really return to its old values.
What to do about the problems in the NHS is quite another matter though there is now the distinct possibility of hospitals being shut down. How this improves the lives of patients is very debatable.
There is metaphor of culture change based on a bath of water and a dripping tap. The latter is the thing that is meant to alter the former. But the dripping tap simply dilutes extremely slowly and, in likelihood, everyone, including management may become disillusioned.
A much faster way to change the bathwater is to pull out the plug and refill it. In organisational terms this is a very dramatic step and will probably mean that all the existing values - including those that are virtuous - go down the drain.
The organisation will lose good people and have to rebuild.
Sometimes that may be the only way to create improvement but, in the case of the NHS it is hard to see that it is a positive way forward.
Organisations which have embraced a 'quality culture' have shown that it is possible to radically alter what goes on and that way that things are done.
Culture change may not be easy and will rarely be achieved quickly. But for those organisations where there is a sense of leadership who are dedicated to working with all stakeholders, most especially the employees, the benefits can be considerable.