By Neil Small, Emeritus Professor of Health Research, Faculty of Health Studies, University of Bradford, UK (see contact details at bottom*).
Keywords: Culture: hospitals: childcare: neoliberalism: care failures.
Culture as diagnosis and prescription
It can seem like every failure in public services is, in the end, blamed on a breakdown in culture and all proposed reforms assume a “change in culture” is what is needed to put things right. The culture as diagnosis and prescription is a glib formula that lets people of the hook.
The culture of blaming the culture is not new but it has become ubiquitous since the publication of the Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry in 2013. In each of the many failures in care that have been revealed since 2013, in hospital after hospital, in care of older people, in learning disability services, in maternity care, in mental health services we have this same formulation.
Likewise in breakdowns in childcare from Rotherham onwards we find it’s the culture that keeps appearing in the guise of chief villain and culture change as the chief tool in the repair kit. It’s the culture that is wrong with the Metropolitan Police, with local government and its even invoked to explain contempt for social distancing rules in Johnson’s Downing Street. Sometimes a further word is added to identify what sort of culture is to blame, a damaged culture, a toxic culture or to specify what sort of culture we should aspire to; a culture of openness, a culture of achievement, an open culture – as if adding one vacuous word to another adds to the voracity of the whole.
What do we mean by culture?
Why do I argue that culture is a vacuous term? It’s used in a way that assumes we all know what the term means but, as Raymond Williams said in his 1983 book Keywords, it’s one of the two or three most complicated words in the English language. Cultural Anthropologists have scores of definitions of the term, although there are two overarching typologies – culture as ideational, here culture resides in the minds of culture bearers or in the products of those minds, in shared meanings and symbols: and culture as something manifest as behaviour and the products of that behaviour, hence a “sociocultural system”.
Whatever definition we use we will find multiple cultures; it is a manifestation of a lingering colonialism to assume there is one (or one superior) culture. Can we say there is a culture of the NHS, or is there a culture of a hospital, or even of a ward or a team, is there a management culture, a medical culture and a nursing culture? They won’t be the same. More fundamentally, do organisations have a culture and if they do can it be manipulated, or is it where organisations end up after a period of change – a starting point or a destination but not a tool or a process? We should all ask what is meant by the term, ask how a causal link might be traced from culture to failure that doesn’t have to pass through a more useful phrase like “cuts in resources” or “different priorities” then ask how a focus on culture might translate into positive change –what’s the route from saying “change the culture” to having a mechanism to achieve this and a measure to show it’s been done? Then we should ask, “what is talking about culture diverting attention from?”
Neoliberalism
If we set culture to one side what can we use in its place to help us see not only why there have been so many high profile care failures but why, in so many different sectors , they show considerable similarities in how they manifest.
Let’s look at prevailing material circumstances as an alternative. With relatively little respite we are forty years into a neoliberal ascendancy that has shaped our economics and politics and has had a profound impact on our welfare state. Two things are pertinent here, first the promotion of market economics, including in public services, and second periodic resorts to austerity to preserve the interests of business and the wealthy. Market economics in public services promote a managerialism that transposes private sector concerns with competitiveness and productivity into a public sector where they can relegate safety and quality of care to a subordinate position. When these sorts of concerns coincide with austerity, as they have since the financial crash of 2008, we have the paradox of an economics seeking to constrain the resources available to a service where demands are increasing as a direct manifestation of the impact of funding cuts and wage restraints emanating from a different part of that very economic orthodoxy.
The material circumstances of the neoliberal years also come with an ideological carapace. There is a valorisation of the competitive and individualistic “economic man” (sic) who can rationalise a mantra of maximising personal success as the route to social good (the discredited idea of trickle-down economics is the clearest manifestation of this bit of self-justificatory cant). But as well as an economics of self-interest economic man also equates material success with moral worth. It is a short step from this to see the less successful as not only of less worth but as a hinderance to the “deserving”.
In all the care failures there has been evidence of both neglect and cruelty. The former might be put at the door of resource allocators but the latter involves actions chosen by individuals. The patient, or the young person in a care home, realises they are not the institutions or the individual care provider’s main focus. Neglect and cruelty may be caused by different things but if you are in bed waiting for care that doesn’t come, or if you are an abused young person in the care system, the felt experience is similar. (Neil Small, Health and Care in Neoliberal Times www.routledge.com/9781032365145 ).
Damage is done to the most vulnerable.
Between January 2005 and March 2009 up to 1200 patients were believed to have died prematurely because of poor care at the Mid-Staffordshire Trust – there were other activities documented that caused suffering to hundreds of people under the care of this trust. The management of the trust put corporate self-interest ahead of patient care – they were focussed on achieving Foundation Trust status even if that focus ignored or exacerbated deteriorating patient care. For example, they limited the size of the nursing workforce in order to meet financial targets even when workforce levels were already below those recommended and despite funding being available in their budget. The result, on two wards where the Public Inquiry found repeated care failures, there were three nurses responsible for 40 patients. (Neil Small, Failures in Health and Social Care, www.routledge.com/9781032365176 ).
Let’s throw culture as diagnosis and prescription onto the scrapheap.
The culture can’t apologise or atone, it can’t be fired, or be brought in front of a court and prosecuted or sued. It can’t be held to account in such a way that those who have suffered from failures in care can feel the damage done is properly marked. So, colleagues, get out your (electronic) red-pens and each time you see “culture” attached to an organisational failure call it out.
*Email.:N.A.Small@bradford.ac.uk
Website: https://www.bradford.ac.uk/staff/nasmall
Twitter/X @NeilSmallUK
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