Finding and filling gaps in knowledge. Arlou Andrei/Shutterstock

Why the NHS needs a culture shift from blame and fear to learning

Being a sacred cow cannot forever protect the NHS from having to confront its shortcomings. Critical reports abound from the King’s Fund, Nuffield Trust, and the Institute of Economic Affairs. The list of scandals grows longer and, out of 35 countries in a European healthcare league table, the UK is in 16th place between Estonia and Slovakia.

A British Medical Association survey of doctors in 2018 revealed a culture of fear and blame in the NHS. The workforce is demotivated with low morale and early retirement is increasingly being sought. Despite all this, no politician will openly acknowledge the deep-seated cultural problems of the NHS. The government announced in 2018 that it would allocate an extra £20 billion annually by 2023 – with no plans for reform.

From a historical perspective, the NHS is just another victim of politicised bureaucracy. There is a yawning divide between the bureaucrats and the healthcare professionals. For example, the biggest quango is NHS England, which oversees budget, planning and delivery within the NHS. At the time of writing in June 2019, it did not include a single NHS clinician in its list of directors.

The NHS politburo operates a carrot and stick approach with financial rewards for meeting targets such as the Quality Outcomes Framework, and the Clinical Excellence Awards, with the imposition of sanctions when targets are not met. Such extrinsic motivation, imposed by the bureaucrats, can lead to a dysfunctional organisational culture by ignoring the accumulated wisdom and assumptions of the people working in the organisation and meeting its challenges, often over many years.

Ideally, such wisdom and assumptions should generate values and behaviour patterns that serve as intrinsic motivation for doctors and nurses whose efforts and ambitions are rewarded by fulfilment, satisfaction and professional esteem. Even the business world increasingly believes it is better served by intrinsic rather than extrinsic motivation.

Promoting intrinsic motivation

A Lancet Commission in 2010 concluded that leadership had to come from within the academic and professional communities. This hasn’t happened because clinical staff have been disempowered and marginalised by the prescriptive and managerial nature of today’s NHS. Clinicians denied autonomy cannot use their experience to formulate the professional values and standards that are the drivers of intrinsic motivation.

In education, free schools and academies have successfully released senior teachers from bureaucratic control and allowed them to learn how to solve their own particular problems. If clinicians were allowed a measure of autonomy, they could establish a culture of learning in which their professional values would encourage intrinsic motivation. Such learning is no longer a haphazard and opportunistic activity, but is now informed by the principles and practice of Continuing Education, the main component of Continuing Professional Development (CPD), the process by which clinicians improve their performance to achieve better patient health.

All clinicians are under a moral and professional obligation to engage in CPD. To do this, they must examine their practice, looking for gaps that are defined as the difference between “what is” and “what could or should be”. Such Professional Practice Gaps (PPGs) must then be analysed to determine whether they are caused by inadequate knowledge, competence or performance. Performance gaps can occur despite satisfactory competence because of barriers that prevent that transfer of that competence, such as poor working conditions, badly trained staff or inadequate technical support. Poor performance is also a hallmark of a demotivated workforce.

When the cause of a performance gap has been discovered, education is designed to teach clinicians how to fill it. In modern Continuing Education, education providers use Moore’s Outcomes Pyramid (below) to help them deliver appropriate education. For example, didactic classroom teaching is suitable for a knowledge gap (level 3), but a competence gap (level 4) or performance gap (level 5) would need interactive small group discussion, demonstration or simulation.

Moore’s Outcomes Pyramid. Author provided

It is now generally accepted that when Continuing Education is properly designed and delivered to fill a specific performance gap, not only competence and performance, but also in some cases patient health (level 5) may be improved. It was recently suggested that analysis of PPGs across whole populations, rather than in individual patient groups, should enable Continuing Education to affect community health (level 7) at the summit of the pyramid.


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In addition to the limited autonomy of clinicians, the other major obstacle to the implementation of a learning culture is the lack of an organised and funded infrastructure for CPD. A recent paper, which we published in the Journal of European CME, advocated that in a reformed NHS, a new supervisory body or an existing organisation such as the Academy of Medical Royal Colleges would have its responsibility redefined to include the design and delivery of continuing education and CPD at various levels.

Under these reforms, all major hospitals would set up CPD departments and the supervisory body would encourage clinical societies and Royal Colleges to set up specialty and national departments respectively. These departments would interrogate big data from organisations such as UK Biobank or NHS Digital in order to seek and analyse PPGs at hospital, specialty and national levels and then design appropriate education to bring about necessary changes in clinical behaviour. In some cases, financial savings would occur because clinical leadership would be more likely to deal sensibly with end-of-life care, poor prognosis cancers and dementia than at present.

CPD activities would be integrated into hospital management structures and at a national level, CPD experts from the specialty societies and Royal Colleges would contribute to the work of NHS quangos. The change of emphasis from extrinsic to intrinsic motivation would improve morale and retention. Doctors and nurses would again be able to consider themselves as professional people rather than healthcare technicians.

This shift from a culture of fear and blame to a culture of learning would revitalise an ailing NHS and restore to it the reputation for which it was once justly renowned.