A change of culture, but how?

Iona Heath writes her last column for us this week (doi:10.1136/bmj.f1004). Over the past seven years, her six weekly observations have acted as an external conscience for the BMJ. Her eloquence on the need to fight for social justice, personal integrity, and ethical practice has reminded us that we are not, and should never be, neutral on such matters. Readers have told us how her column sparks corridor debates. Her words have refreshed their sense of what it means to be a doctor working for the public good.

It is fitting, and perhaps not surprising, that her last column is a paean to the NHS. More particularly, it is a cri de coeur for those who work in the NHS, suffering as she sees it under continuous and unnecessary restructuring, ever increasing demands, and deliberate adverse propaganda. In the week after publication of the Francis report (doi:10.1136/bmj.f979), she offers a remedy for the devastating failings it so clearly documents: reciprocity. “If the government wants to see a health service permeated by the care, compassion, and respect that we all want for those we love, then it must pay much more attention to the importance of demonstrating those same qualities in its treatment of frontline health staff.”

This sounds much like the culture change called for by Francis. But how does an organisation the size of the NHS achieve such a change in culture? In a brief article in Forbes magazine usefully entitled “The key to changing organizational culture” (www.forbes.com/sites/johnkotter/2012/09/27/the-key-to-changing-organizational-culture/), Harvard emeritus professor John Kotter explains. “A powerful person at the top, or a large enough group from anywhere in the organization, decides the old ways are not working, figures out a change vision, starts acting differently, and enlists others to act differently. If the new actions produce better results, if the results are communicated and celebrated, and if they are not killed off by the old culture fighting its rear-guard action, new norms will form and new shared values will grow.” What doesn’t work in changing culture? “Some group decides what the new culture should be. It turns a list of values over to the communications or HR departments with the order that they tell people what the new culture is. They cascade the message down the hierarchy, and little to nothing changes.”

Sadly, unless there is a real change of heart at the top of the NHS, this last version of events is all too likely. The BMJ is not keen on witch hunts of the sort currently being pursued by the Daily Mail against NHS chief executive David Nicholson. But given the grim findings of the Francis report and the gathering clamour from people who say they tried to speak out but were silenced by senior NHS management (doi: 10.1136/bmj.f1083), we think there is a legitimate question on which BMJ readers should have their say. Should David Nicholson resign? We invite your votes in our poll (bmj.com) and views in rapid responses.