The toxic culture in the NHS

A few random thoughts in warming up for the forthcoming big NHS campaign:

·         One of the most important principles of any therapy is to establish an environment which feels emotionally safe (free from extraneous anxiety) for its participants – and this is not the case for many people in the NHS now.

·         In the NHS this is a task for managers nowadays, but they are not succeeding at it – probably because they do not feel safe themselves.

·         Professionals do not feel trusted to do anything apart from what they are asked – or told - to do.

·         Staff who feel exposed and in fear of criticism will not function at their best; some will crumple under the strain – and become unable to work. This leads to high levels of long-term sickness and early retirement on medical ground.

·         Working in the NHS has many inherent anxieties (including uncertainty, death and limited capabilities of medicine) – to add a massive tranche of ‘governance anxieties’ with threats about matters such as corporate risk and policy compliance is intolerable.

·         When professionals feel disempowered – by having little control over the way they work – primitive mental processes will lead to behaviour that will undermine the enforced changes.

·         A culture of ‘zero tolerance of human frailty’ (for example) is logically equivalent to one of infinite intolerance!

·         Positive efforts to promote healthier working environments (such as the Royal College of Psychiatrists’ ‘Enabling Environments’ project www.enablingenvironments.com) receive little attention when the focus is all on fear, blame and keeping out of trouble.

·         Authoritarian managerialism’, without compassion, empathy or psychological understanding of the emotional needs of the workforce, seems to be the root cause – and comes from the tone set at the top of the organisation, and by its political masters.

·         The cause of ‘authoritarian managerialism’ itself is probably modern management’s need to have certainty, which is impossible in health – but is seen as desirable in business. Hence rigidity, lack of creativity and spontaneity, and policies for everything.

·         Other models exist, such as ‘therapeutic communities’ in mental health – where ‘us and them’ power imbalances (which are more a consequence of commercialisation than medical arrogance nowadays) are minimised through detailed attention to psychological factors and open communication.

Dates: 20 September, 8 November, 24 January (London); Others in regions to be confirmed; Launch of declaration 28 March.

Watch the Careers section of the BMJ for more details.