Toxic subcultures are thriving in the medical profession, often putting patients at risk. Everyone who works in the NHS has met these people, but dealing with the problem is a huge management challenge.
A senior manager recently described to me the struggle in his trust to stop surgeons bullying anaesthetists and admin staff. He got to the point of having to spell out that he would personally walk someone off the site, no matter how senior, if it happened again.
This experience is borne out by General Medical Council research which laid bare five distinct problematic groups of healthcare professionals. Ironically, the study aimed to understand how doctors approach the task of building good workplace cultures that deliver high-quality care.
It reveals the signs of poor culture, such as cynical staff, blaming and shaming, a defensive attitude to performance data and a lack of mutual support. Other flags include a focus on the technical side of medicine while ignoring patients’ experiences, professional battles taking precedence over patient needs and lax implementation of protocols such as surgical checklists. Stress and burnout are also often endemic in teams with a poor working culture.
Five toxic subcultures emerged: divas, factional, patronage, embattled and insular. Divas are powerful, successful professionals who think the normal rules of behaviour only apply to others. They are typically ill-tempered bullies who disrespect managers and colleagues, and ignore protocols.
Teams dominated by patronage have high-status, well-connected specialists who exert huge power over their colleagues. They will often be doing exceptional work, but the downside is that the leaders are difficult to challenge and manage, and will happily compromise other parts of the organisation in their lust for glory.
In factional groups – let’s not call them teams – disagreement becomes endemic and people start to organise themselves around perpetuating conflict. Faction leaders try to drag everyone else in. Patients suffer.
Just how bad this can get has been exposed by the culture of tribalism and mistrust that was allowed to fester for years in the cardiac unit at London’s St George’s hospital. Complex heart surgery was suspended amid concerns that the conflicts were causing avoidable deaths.
Embattled teams feel overwhelmed by all the unmet need they see in their patients. Staff are stressed, anxious and burned out. Believing their cause is hopeless they reject offers of help because they don’t see how anything could make a difference. Some GP practices – flooded with patients and short-staffed – slip into this siege mentality.
Insular teams have become isolated from the professional mainstream, and have often lost sight of what a good service looks like. Old-style, single-handed GP practices easily fall prey to this trap. Insularity is a particular problem for secure mental health units; isolated behind barriers, they focus on incarceration rather than care and treatment.
Hospital managers know that turning around a rotten clinical culture often takes years and can feel quite brutal. Confronting inappropriate behaviour by powerful staff eats time and saps energy. Sometimes the cause of the problem simply needs to be forced out of the organisation.
But managers need to check their own behaviour before judging that of others. Rotten cultures take root when senior leaders lack the skill or courage to act quickly and decisively when they see the warning signs. Bullying by managers is guaranteed to bring out the worst in people. Many senior doctors have justifiable complaints about their treatment at the hands of local executives or staff from NHS Improvement and NHS England.
Demonstrating behaviour they want to see in others, putting effort into building relationships and supporting colleagues, understanding problems from the perspective of frontline staff, showing up when things are tough and responding positively to difficult news are just some of the simple leadership actions that make a profound difference.
Medical leadership itself requires massive investment. Too many doctors thrust into the top roles still find they are largely left to make it up as they go along because training and support is inadequate.
Divas and bullies are the symptoms of a rotten culture, but not always the cause.
• Richard Vize is a public policy commentator and analyst
