Letters Mid Staffs inquiry

Culture change is not easy but not that difficult

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1365 (Published 05 March 2013) Cite this as: BMJ 2013;346:f1365
  1. Nick Toff, patient safety adviser and airline pilot1
  1. 1Cambridge University Hospitals NHS Trust, Cambridge CB2 2QQ, UK
  1. nt{at}toffmail.com

Organisational culture is expressed in shared expectations of which attitudes and behaviours are desirable, acceptable, or tolerable. If standards and expectations are high, we strive to do better; if not, we may bend or change. Unclear, unrealistic, or conflicting demands may result in fear, uncertainty, and erratic outcomes.

Hudson describes how a safety management system was a necessary first step in achieving a safety culture in the oil and gas industry.1 2 This was also a key driver in creating and sustaining a safe culture in aviation.3 4 The NHS has no safety management system—now is the time to act. Every organisation needs such a system, to ensure a coherent set of rules and standards, and clear accountabilities.

Every board needs a director of safety and of quality. Safety should be independent of the operational and other functions of the organisation, and the organisation’s structure, function, and expectations should be made explicit in a manual. Organisations will also need to revisit their processes: do they fit with the way people really are, what could be standardised, and how can resilience be achieved when faced with unexpected events? Human factors science will have an important role to play.

Change will need to be supported nationally, facilitated by the Department of Health, whose managers will need a clear vision. Support means a simpler regulatory structure, effective reporting and learning, and independent investigation of serious adverse events. Service and financial arrangements in the NHS should also be reviewed. Is it a coincidence that managers at Stafford were reported as being preoccupied with financial management and targets? Unrealistic or conflicting demands are not only generated internally.

The answer to Godlee’s question is: it’s not easy, but not that difficult.5


Cite this as: BMJ 2013;346:f1365


  • Competing interests: None declared.


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