The NHS is facing challenges that require fundamental changes to the way care is delivered, but it is not enough to change the models, the measures or the medicine – the culture must be looked at, too.

The NHS Long-Term Plan (LTP) is the new strategy for the NHS to improve the quality of patient care and health outcomes. It sets out the strategic directions and actions which will support the NHS to continually move forward and provide a health service fit for the future. The LTP covers all the essential topics you would expect – health prevention, service models, digital, to name a few. Crucially, there is a whole section focusing on the workforce. Under this theme, termed ‘backing our workforce’, the LTP carefully sets out the plans to hire more staff, to train them more effectively, and to help them feel rewarded in their jobs, ultimately making the NHS ‘a better place to work’.

But does this Long-Term Plan focus enough on culture in the NHS? How can it harness workplace culture to grow the workforce it needs to achieve its objectives?

Happy people, happy patients

Organisational culture includes the ideas, rituals, values and behaviours embraced by staff every day. For service organisations, your people are your most important asset. A culture that facilitates employee happiness means lower turnover and greater productivity at work. Evidence shows that within the NHS, the Trusts with consistently high levels of staff engagement also have better patient experience and outcomes.

Quite simply: happy people means happy patients.

So, the focus on workforce within the LTP is positive and important. However, the current culture has some serious challenges. For example, 25% of staff have experienced harassment, bullying or abuse from other staff in the last 12 months (section 4.40). To improve an entrenched culture, it is not enough to increase the number of staff, or their pay, which is what the Plan majors on. For great patient care, the NHS must be a great place to work, with a great, supportive culture.

What does a good culture look like?

‘Culture’ is a notoriously difficult thing to pin down, but it can be done. Organisations with ‘good cultures’ have alignment on their ideals, values, behaviours and rituals so that one drives the other. The cultural values are exemplified by the behaviour of staff. When there is a gap between these cultural aspects, a detrimental culture forms. Organisations may claim to be ‘innovative’, however, if staff are given no time allowance to develop new ideas, or are criticised if an initiative fails, the behaviour of the organisation opposes its values and you do not foster a culture of innovation.

Characteristics of a great culture revolve around the employees. For example, staff feel empowered and trusted. They are valued – genuinely appreciated – and feel able to ‘speak up’. Positive feedback mechanisms exist to support and develop the workforce. Although the focus is on the employees, it is leaders who set the culture.

How do you improve an organisation’s culture?

Culture change is hard. New cultures cannot be ‘traded in’; the legacy that an organisation has is unique with ingrained cultural norms. Given the NHS has just celebrated its 70th birthday, that’s a decent cultural history.

Nonetheless, there are several key principles which, if adhered to, set the momentum for a successful culture change:

Set the vision of the organisation

Have a clear, forward-looking vision which focuses on compassionate care for the communities the Trust serves. The strategic agenda can then be linked to the case for culture change, outlining the drivers behind it. A set of values can underpin the vision, but don’t restrict inspiring words to a page. Embed them into practices throughout the employee lifecycle to bring them to life: how are they enacted during recruitment, onboarding, and appraisals?

Engage, engage, engage

Culture change must be driven via top-down and bottom-up approaches. In both directions, staff take responsibility for leading change; both leadership teams and general staff must be considered.

Some research shows that the most important determinant of organisational cultures is leadership1. The environment leaders create and endorse is the environment staff will create in turn for their patients. If leaders and managers create positive, supportive environments for staff, they, in turn, create caring, supportive environments and deliver high-quality care for patients.

But true changes will not happen unless your people are on board; it is the staff behaviours and perceptions en masse that will create the momentum behind any culture change. Trusts must encourage engagement from all staff – clinical and non-clinical.

Action and evaluation

You wouldn’t embark on an IT project without a clear plan and measures of success, so why would you embark on a culture change without one? Integrate multiple interventions into a plan, focusing on a few critical shifts in behaviour to truly embed the desired culture. During the evaluation, harness people data to adapt your culture interventions ‘live’, further improving and embedding the change. Measuring and monitoring culture change is essential to identify backsliding and foster continuous improvement.

It is important to recognise that culture change is never ‘finished’. It is something leaders in every Trust, CCG, care home and practice will need to continually attend to and work to improve. The Long-Term Plan can be as ambitious and detailed as it likes, but without the necessary culture change, it will not be achieved.


Lucy is a manager in our health team. She is committed to improving service user experience in healthcare, combining a practical knowledge of the NHS with a transformational programme experience in multiple sectors.