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J R Soc Med. 2008 January; 101(1): 7–11.
PMCID: PMC2235922

What the NHS needs to improve: four behaviours to sort out the health system

This article argues that the NHS is destined to experience repeated mistakes, continued low morale and political instability unless leaders at all levels pay serious attention to four fundamental aspects of culture which are largely absent in today's health system - confidence, curiosity, connectedness and compassion.

While a focus purely on structural change will fail to cultivate the corporate spirit needed to challenge and motivate staff to really care, serve and succeed, investing in the appropriate values and behaviours offers the prospect of a widespread and potentially rapid transformation.

The bank and the flight of flamingos

‘I phoned my bank to arrange a payment. Something I have done many times before. The guy at the call centre was very chatty. As we went through the third level in the security process - I needed to make a large payment - he asked for my Zodiac sign. I stumbled to recall I am Virgo. He said the way I paused to think showed I wasn't an impostor (I am still not sure how he knew). I asked why they used this question. He said that he didn't personally believe in the possibility that burning balls of fire and huge lumps of rock millions of miles away affected his life - and also, he couldn't take Russell Grant seriously. But he likes asking this question as it brings in a touch of normal life to a serious and lengthy procedure. He said that this was a deliberate attempt to design in some humanity by the bank managers who had recently revamped their customer relationship system. This seemed a bit of a risk given how a religious, frustrated or anxious client might react. But an experiment they were willing to make.’

Having started this article with a tale about financial services in England in 2007 (the reason for opening in this way will become clear later) we want to share another story, and this one is not about health care either. We are shifting continents, centuries and contexts to South Africa in the early 1990s. At this time many feared that the end of Apartheid would only be possible after a bloody struggle at some time in the distant future. One of the activities that went on behind the scenes was an intervention that helped to open up the chance of peaceful change. This was the Mont Fleur scenario process led by a team with experience in scenario planning at Shell International (Figure 1). This involved political and business leaders representing the full spectrum of opinion in that nation.

Figure 1
The Mont Fleur Scenarios (Weekly Mail, 1992)

We believe these four scenarios that were developed over 15 years ago to inform a political, economic and social process 6000 miles away resonate and provide a useful metaphor and lens to understand the current situation of the National Health Service today. The four scenarios were:

  1. Ostrich, in which a negotiated settlement to the crisis in South Africa is not achieved, and the country's government continues to be non-representative
  2. Lame Duck, in which a settlement is achieved but the transition to a new dispensation is slow and indecisive
  3. Icarus, in which transition is rapid but the new government unwisely pursues unsustainable, populist economic policies
  4. Flight of the Flamingos, in which the government's policies are sustainable and the country takes a path of inclusive growth and democracy

So taking each scenario in turn as a description of a period in NHS history, Ostrich illuminates a past where the political settlement meant that the NHS was destined to muddle through with about 6% of GDP. This shifted dramatically at the end of the 1990s when the New Labour government accepted arguments that any radical reform agenda required extra resources.

The Lame Duck phase in the history of the NHS followed, a period in the late 90s and the first period following the NHS Plan of 2000 when the new direction was emerging. A consensus was achieved with signatories to the NHS Plan from many surprising bedfellows in the various stakeholder groups in the NHS. But the results were slow and frustrating to the political elite, informed by media horror stories and irritated focus group feedback.

A shift to Icarus occurs a few years into the new millennium, with decisions to hugely increase investment in national programmes and local organizations to drive change. Followed by the period around the 2005 general elections, when further decisions to close or merge many of these bodies - such as the Modernisation Agency nationally and Strategic Health Authorities and Primary Care Trusts locally. The frustration in achieving improvements leads to a plethora of national initiatives under the System Reform banner.

The result of these activities was that by 2006 the NHS, rather than enjoying the benefits of investment, was subject to ever closer scrutiny and doubt. The unprecedented media comment about the salaries and terms of key NHS clinical staff is testimony to this change of heart. It seemed the NHS couldn't ever stay still long enough to realize the benefits of investment and really improve. The chaos led many old hands working in management and leadership roles to comment that something was going on other than just the pain of yet another reorganization.

The missing ingredient

For us, the most significant thing is actually something that's absent! In today's NHS there is no lack of emphasis on ‘performance management’, ‘redesign’, and ‘productivity’. These are good things to invest in. There are valuable initiatives too on public health, patient experience and patient safety. But still things seem to be getting worse rather than better (at least relative to ever-rising expectations). We believe it is because there is a major missing ingredient in health care reform. Something without which there can be no fundamental and sustainable change. That thing is getting ‘the right culture’. To paraphrase a business saying ‘culture eats strategy for breakfast, change for lunch and improvement for supper’.

To have its full effect, the focus on structures and process needs to be balanced with far greater attention to the culture and values at work in every level of the health care system. Without this, no changes to organizational form and function will deliver the scale and type of lasting improvement that consumers of health care deserve and politicians intend. (Another of our papers, ‘Practising what you preach’, shares evidence of many attempts to change the ways of working in organizations and spells out the critical lessons for the way that leaders themselves behave.)

As we look around now in 2007, it is the beliefs, values and behaviours of all involved with health care that hold us back from achieving the ‘Flight of the Flamingos’ effect:

  • Amongst patients and the public: many national NHS figures bemoan the reluctance of their fellow citizens to entertain the need to change the range of pattern of services available locally. We have some sympathy with this view, but believe demonizing citizens and consumers is not a great place to start in any attempt to re-energize improvement. It is a bit like those hospitals which give the appearance that the four things most essential in tackling MRSA are shorter visiting times, two visitors per bed, definitely no sitting on beds and banning flowers. The critical role of staff hand-washing seems to come a pretty poor fifth in these places.
  • Amongst professionals and staff: there is a strong unwillingness among many clinicians to accept the need to put customer service, safety and productivity at the heart of their clinical care. Furthermore, some are not keen to accommodate the role of independent scrutiny in securing improved standards. For us, this is a pattern to challenge - and we see hope in motivating different attitudes and actions.
  • Amongst politicians and policy makers: the failure to engage with the need to lead through vision, values, behaviour - in a word through culture - is the most significant failing. Rather there is a fixation with ever more rational and econometric approaches. Incentives for this, targets for that; sanctions over here, sackings over there; blame for them, blessings for these. Basic group pathology and dysfunction.

Of these, it is senior figures who have both the greatest opportunity and the biggest responsibility to influence culture. Politicians, officials, senior professionals and managers have the scope to renew the relationships that are at the heart of the NHS. Leaders in the Department of Health and Strategic Health Authorities have the potential to shift the behaviours at the public and professional levels.


What does getting the right culture involve paying attention to? This is a question that is critical to organizations, not just those in public health care. Our work across sectors as diverse as finance and telecoms, social enterprise and property, charities and consultancies suggests there are four common characteristics that together can unlock organizational potential. These are confidence, curiosity, connectedness and compassion.

Having more of these things, we believe, would totally transform the success of the NHS and lead to a serious breakthrough in increasing levels of public and patient satisfaction.


The first is more confidence - from leaders in their people and amongst staff in their capabilities. This has to be the starting point for any significant cultural change as it is the essential ingredient in overcoming the inertia and defensiveness that springs from the constant criticism that is targeted at the NHS - the ‘blame culture’. The onesidedness of this is debilitating. Hence a well-known TV documentary programme will find some real poor (perhaps dreadful?) practices which inexorably lead expectant mothers to be worried about entering hospital and keen to get back out again as soon as possible.

Yet there is lots of excellent practice going on - celebrated for example by the Health Service Journal and other awards processes nationally and locally - that rarely or never get into the public domain. A recent national stakeholder forum highlighted almost every part of the health and social care system having outstanding successes at some place in the country. Staff need to be convinced that they can, and are, delivering a great service.

In this respect, it is leaders who can start the process of creating confidence: talking up the ambitions of the organization, finding and building on what is working well and celebrating and rewarding success.


More curiosity is the next thing which is required. Sadly, some individuals seem resistant to learning from others. Mistakes are repeated, there is lack of reliability in care and a premium is placed on coming up with new fixes over reviewing what has worked in the past or in other places. Hence, while guidelines aplenty are produced on every conceivable topic, there can be apathy in hearing what's being said.

This suggests a lack of humility, an unwillingness to say 'I don't have all the answers', a ‘not invented here’ philosophy. It's revealed in the way that new organizations are created which repeat the work of others only recently disbanded. With more curiosity - in effect, by asking more questions - comes faster innovation, lower costs and more consistency.


The third thing needed is more connectedness. ‘If only the NHS knew what the NHS knows.’ The best organizations truly have a rich ‘corporate memory’ that captures their stories, documents experience and skills, and provides an efficient vehicle for distributing insight and information to those who work there. We're not talking about some all-singing, all-dancing IT system, with sophisticated web portals and an army of knowledge management workers, but rather a willingness on the part of staff to record, reflect on and repeat to others the lessons of what they do and how they do it on a day-to-day basis.

This means working across professional ‘tribes’, going to the effort of joining up with others to make change happen, and taking the risk of sharing the credit for success. It is about developing a shared common purpose and looking for common connections. It is there when a ward nurse phones a colleague in social services to ensure a smooth discharge. It is seen when a senior official reaches across an administrative boundary in a creative way.


The final challenge is the biggest prize of all, the one which would offer the biggest transformation in the shortest period of time - more compassion. For the majority working in health care, it is assumed there is a desire to show compassion in the form of caring for others: healing and making a difference to lives. It is the reason many give for doing their job. And for some, this really is what brought them into the service in the first place. But is this still the honest answer for all, especially for those who have been in the NHS for many years (but maybe for those new to the work too)? Even if it's true that this is why people entered the NHS, over time other motivations - position, power, pay, pension - inevitably become as important, if not more so. There is nothing wrong with this but without the self-awareness to understand what drives them, people can tend to make special claim to having a ‘noble purpose’ when in fact that's not at all evident in how they treat others.

It's also true that medical professionals are encouraged, even forced, by the prevalent mechanistic model of care, to downplay and sometimes forget the human side of health care - ‘the emotional, psychological, social and spiritual needs of patients and their families’, as suggested by Dr Robin Youngson of Waiteakere Hospital, New Zealand in his work on restoring compassion as a core value in health care. Caring for the whole of the human being is what true compassion is. It is more than simply giving patients respect and dignity, though that is a good start. It is also about more than ‘listening to patients’. It about seriously trying to understand the suffering of others and doing all necessary to alleviate that - from clinical excellence to remembering your manners.

Back to banking

Where can leaders make a start on this? Perhaps the example from banking that we opened this article with gives some pointers.

The call centre story shows that it is possible for leaders to set the quality and style of the interaction on the frontline. If you are a leader, begin with the one person you have the immediate authority to change - yourself. This is done through practicing what you preach, taking a positive stance in your language and relationships, and encouraging and enabling the interaction and rapport between others. Encouragingly, it takes very little to help those in health care rediscover why they wanted the job in the first place.

In this way, what leaders say and do can lead to a hugely productive upward cycle in culture, rather than the downward spiral that stems from a negative attitude and approach (Figure 2).

Figure 2
The culture spiral

The next step is to understand what is really going on within your organization: to see deeply into the culture and do a ‘deep diagnosis’ of what is happening, with your colleagues, amongst your teams or on your wards. What are the stories that people tell about life in the organization, the language that is used, what gets attention, what is appreciated, what sense do people make of their work?

Take a moment to think about the organization you are part of and the leadership actions that are needed under these four headings (Figure 3). Which is the most important?

Figure 3
Confidence, Curiosity, Connectedness and Compassion

What do the answers to these questions tell you about the confidence, curiosity, connection and compassion where you are?

Of course, change does not happen overnight and the path to shifting culture is much less obviously charted out than the big red button on the desk with ‘restructure’ written on it. This means leaders intent on getting the right culture need the energy and attitudes to keep going, to take the time to see things through.

Risks also need to be taken - allowing others to experiment with new ways of working together, supporting each other and serving all those who come to you as customers. It means involving everyone in the organization, as culture emerges from the relationships between all and not just through the interactions of a few.'

Are the flamingos about to take flight?

Are we hopeful that the NHS is entering a more positive future, a scenario where confidence, curiosity, connection and compassion are the dominant characteristics? Yes we are.

We see the eradication of MRSA infections led by Trust chief executives whose passion for keeping patients safe has galvanized new practices through learning and invigorated staff to believe that harm to patients can and must be avoided.

We hear the language from the Prime Minister and the Darzi review, which talks of personal care and mending relationships. At the very least, this is an important symbolic shift.

We read a newsletter for a major teaching hospital: ‘It's not just a question of behaving as though we're running a hotel, though. We have to demand of ourselves that we deliver great service, but we also have to understand that this is a place charged with emotion; fear about a life-threatening condition, anxiety about a relative, joy that a baby has been born. People who come here are often vulnerable: they all need to be treated as individuals.’

We feel the potential in our personal experiences: the investment by a Trust management in continuity of care through a nurse practitioner supervising treatment for a son who provides a friendly and interested presence over the course of a year, who voluntarily makes herself available out of hours for a chat and who lobbies those in charge of the surgical lists to bring an operation forward in response to a parent's anxiety.

If these leaders have made a start in addressing the failures of confidence, curiosity, connection and compassion then so can others. It is probably more challenging than yet another structural shift but it will be infinitely more rewarding for everyone: patients, staff and public. Surely, if those running a call centre can design in some humanity, the NHS can, too.



Competing interests PH and RP are the co-founders of idenk, a consulting firm advising and supporting business leaders and their teams on issues of strategy and organization

Funding Not applicable

Ethical approval Not applicable

Guarantor PH

Contributorship PH and RP contributed equally

Acknowledgements None

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press