Intended for healthcare professionals


Ending blame culture would improve NHS care in three years, US health leader says

BMJ 2016; 353 doi: (Published 27 May 2016) Cite this as: BMJ 2016;353:i3042
  1. Matthew Limb, freelance journalist
  1. BMJ Careers
  1. limb{at}


Developing a culture of trust would allow NHS trusts to improve services and save money, the King’s Fund’s leadership summit heard. Matthew Limb reports

NHS trusts in England could deliver much better care at lower cost if they were to transform the way they lead and manage staff, says John Toussaint, the chief executive of the not for profit US education organisation ThedaCare Center for Healthcare Value.

He said that freeing frontline clinicians to genuinely solve problems, rather than controlling or “blaming” them, could yield major improvements within three years. ThedaCare, based in Wisconsin, works with health organisations in the United States, Canada, and Europe on educational and leadership programmes.

Toussaint gave the headline talk at the King’s Fund think tank’s sixth NHS leadership and management summit in London on 25 May. He said that organisations should radically change their leadership behaviour, make “respect for people” a guiding principle, and ensure that productivity improvements did not lead to employee lay-offs.

He outlined a framework for leadership and management system reform based on the “lean” system developed from manufacturing. He said, “It’s about redesigning care to take wasteful steps out of the process to improve quality and lower cost at the same time.”

Leaders must act with humility, take a “sincere interest” in what their staff were telling them, and build a culture of trust and systems geared to continuous improvement, he said. Senior executives should scrap surplus strategic initiatives that were contributing to staff burn-out, focus on a few core goals, and give proper authority to clinical teams, he argued.

Toussaint described the way that some services, such as emergency departments and patient consultations, had been successfully redesigned using these principles and methods. He said that Western Sussex Hospitals NHS Foundation in the United Kingdom had adopted elements of the approach and this year had achieved an “outstanding” rating from the Care Quality Commission.

The King’s Fund chief executive, Chris Ham, said that delivering better outcomes at lower cost was the “Holy Grail” sought by everyone in healthcare. He asked how long it would take for the hard pressed NHS to benefit from implementing the methods.

Toussaint said, “Our hypothesis is, if we sequence this right, then within three years a trust should be able to be basically on the right path with significant results on both quality and cost.”

The “hardest” challenge was, he said, to spread the improvement, as this meant involving administrative support functions, such as human resources, finance, and information technology. “There is waste everywhere,” he said. “We’ve got to attack the waste there just like we attack the waste in frontline clinical care areas. If we don’t have a process to make sure we can redeploy people as we start to take the waste out of the systems we’re not going to go anywhere.”

He added, “This is a cultural transformation that requires a leadership behavioural change, starting at chief executive level. So they have to understand what their role in this work is.”