The notion of ‘organizational culture’ became prominent in the management literature of the 1980s1
and has increasingly found its way into the discourse of those who advocate organizational change in health systems, including the British National Health Service (NHS).2
Academic analysts generally agree that culture signifies something which is shared
between an organization's members, for example: the prevailing beliefs, values, assumptions and attitudes, and from these the local norms of behaviour. These shared ways of thinking and behaving help to define what is legitimate and acceptable within an organization. They are the social and normative ‘glue’ that bind people in collective enterprise; or ‘the way things are done around here’ and help guide the discretionary behaviour of professionals and underpin management strategy and practice.
A diverse range of conceptual frameworks and models for understanding organizational culture and culture change have been developed. This diversity reflects a lack of theoretical consensus surrounding both definitions of organizational culture and the processes of organizational change.3
Perhaps the most critical cleavage in contemporary definitions is that identified by Smircich;4
in brief culture may be treated as a property of an organization (something it ‘has’) or something that the organization ‘is’. The former approach defines culture as the values and beliefs in an organization that organizational members have in common. Thus, this approach treats culture as a variable or attribute, alongside organizational structure and business strategy that can be managed or manipulated to improve organizational performance. In contrast the latter approach implies the existence of fewer levers by which management might secure change, since the entire organization is seen as a cultural system in itself with analytic interest focused primarily on how it is accomplished and reproduced.
Appeals for ‘culture change’ imply that deep‐rooted changes in the kinds of characteristics listed above will lead to new patterns of behaviour and hence performance. It is unsurprising therefore that such change has been seen as a possible route to system‐wide performance improvement in healthcare.5,6
Over recent years NHS reforms in England have been based on the idea that major cultural change must be secured alongside structural and procedural change if the desired improvements in performance are to be achieved, with the National Patient Safety Agency the Healthcare Commission, and the Clinical Governance support team all prescribing culture change and transformation as a lever for quality and safety improvement.7
Recent NHS system reforms have focused on the implementation of pro‐market policies, including an expanded role for patient choice,8
competition between providers and a new prospective Payment by Results funding system for hospital Trusts.9
In this context, a ‘market‐oriented culture’10
is officially seen as a prerequisite for successful healthcare providers.
In this paper, we examine how senior management culture within English NHS acute hospital Trusts has changed since 2001; that is, we explore cultural change over the period where official policy has revived ideas about hospital competition. To assess changes in senior management cultures we used a validated culture measurement tool, the Competing Values Framework (CVF),11
which has been employed to analyse a number of health systems.12
The CVF uses two main dimensions in order to generate a two‐by‐two matrix that articulates four basic organizational cultural ‘types’ (). The vertical axis denotes how flexibly or mechanistically processes are carried out within the organization, while the horizontal axis denotes the orientation of the organization to the outside world. The values denoted by CVF ‘compete’ in the sense that scores in one direction on an axis are allocated at the expense of scores in the other direction. Nevertheless, organizations are not deemed simply to fall into one of the four cells in . Rather, they are seen to exhibit competing values while nevertheless having a more‐or‐less strong tendency to one particular ‘dominant’ culture type.
The Competing Values Framework for modelling organizational culture