There is a great deal of discussion in contemporary organisational life of the need to ‘change the culture’ in organisations. This is a way of talking that assumes that organizations do have discrete cultures and that they are manipulable, although the discourse can have it both ways with the term: on the one hand culture is known to be symbolic, intangible and abstract, on the other it can be the object of conscious and rational redesign and reframing. A good example of this way of talking about organisational culture can be found in the 4th edition of the eminent management scholar Edgar Schein’s book Organizational Culture and Leadership.
Usually a prime role is assumed for leaders or senior managers in making the changes to organizational culture because they are considered to have the necessary abilities and skills to diagnose what is wrong with the current culture and to design a better one: one which fits better with the environment. Schein states this very explicitly in his book: ‘In this sense culture is ultimately created, embedded, evolved and ultimately manipulated by leaders’ (2010: 3). As a result of their leaders’ efforts, employees will be obliged to commit to a fresh set of values, or reaffirm an existing set which are thought to have become moribund, as well as demonstrating a suite of required ‘behaviours’ or new procedures. The new values and procedures are then set ‘at the heart of everything we do’, are vigorously communicated and disseminated and form the basis of widespread training programmes for staff, and are then subject to regimes of inspection and performance management. Such change programmes can consume weeks and months of organizational time and resources.
The whole process is a good demonstration of the systemic assumptions behind organizational realignment: values, behaviour, systems, procedures, training, communication and quality regimes are all supposed to line up and fit over each other and form a coherent whole. The emphasis is on integration, stability and alignment. It is a huge reduction of the complexity of what is at stake when attempting organisational change.
A book recently published calling for radical change in the NHS is a refreshing attempt to explain why ‘culture change’ in organisations is likely to be highly problematic.  Instead of assuming that whatever we might mean by the term culture is contained within one organisation, even one as big as the NHS, Ballatt and Campling, an ex-senior manager and psychotherapist within the NHS, explain why the institution reflects much wider conflictual social processes, as well as provoking profound questions about what it means to be human. That is, they try to bring together society-wide trends in social patterning in the UK and beyond in terms of their impact on changes in the NHS, and they wrestle with the profound human difficulties and dilemmas involved in professionalising the often spontaneous and improvisational human response of caring towards another human being in need. Though written specifically about the NHS, I think the book also raises important questions for anyone thinking about what is involved in processes of organisational change and echoes some of the themes from the perspective of complex responsive processes of relating. There are some key differences, however, which I will also explore below.
Ballatt and Campling argue that a split in values has evolved in contemporary society, one side of which is privileges individualism, self-reliance, entrepreneurialism and competition, while the other emphasises kinship, solidarity and interconnectedness. They agree with psychoanalyst Adam Phillips and historian Barbara Taylor, that the former set of values has come to dominate over the latter, with ideological overtones that being competitive and individualistic is a form of tough and rugged realism, while the latter is a soft-hearted, amateur luxury. That we are ‘consumers’ and what we care about most is ‘choice’ has come to be accepted as axiomatic and natural. As a way of bolstering the second pole of the dualism, Ballatt and Campling build a case, drawing on a variety of sources, to argue that there is scientific evidence to suggest that reducing inequality, promoting common identity and purpose, communicating that value of and supporting combined effort and shared risk and reducing social isolation would be more effective in improving mental and physical health in the population, rather than encouraging more competition in society in general and health care in particular. What I think the authors are trying to do here is remind the reader that the NHS was founded largely as an expression of the second pole of their dualism: it was an attempt to institutionalise a particular attitude of caring, which came prominently to the fore at a particular point in history, which depends upon social solidarity and shared risk. They are pointing to what is at risk following constant rounds of NHS reform.
Ballatt and Campling argue that the NHS can be renewed with a recommitment to what they term ‘intelligent kindness’, rather than further reform in the shape of more marketisation and more inspection regimes. They understand intelligent kindness to be a kind of practice which arises from the ability to see the person in the patient and to form a ‘therapeutic alliance’ with them. This is a term borrowed from psychotherapy and counselling and describes a relationship of trust where the therapist or carer is believed to have the client/patient’s best interests at heart. The authors adduce research which suggests that a strong therapeutic alliance, where the client/patient feels that they matter to their therapist or carer, leads to better treatment and improved outcomes, and a virtuous circle of improved organisational effectiveness and productivity.
The authors are not so naïve as to think that this is an easy process. Although they agree with the Harvard philosopher Michael Sandel’s  observation that compassion like a muscle and gets stronger with exercise, they nonetheless draw attention to a number of phenomena which impede the virtuous cycle that they hope for. They point out that the encounter with ill-health can provoke mixed feelings of anxiety, guilt and inadequacy that the standard of care can ever be good enough, or equally it can encourage over-identification with the sick person. Although the practice of kindness is predicated in relating to the ‘other’ as though they are kith and kin, it is sometimes difficult to do so if the experience of extreme illness can make patients truculent, rude or unpleasant in other ways. For Ballatt and Campling the hospital is a theatre of both love and hate and will call out both strong and mixed feelings in medical staff. They also draw attention to the pressures of being a member of a group, and how this can provoke anxiety and irrational behaviour in group members, such as the tendency to deny poor practice or other unwelcome evidence that is contrary to what the group is trying to achieve, as well as collusion and competitiveness with other groups. The authors recommend reflective discussions as a means of establishing affiliative relations between colleagues using the same principles that establish generative relations between patients and carers. They argue that the most important skill an NHS chief executive can demonstrate is the ability to master their own anxiety and work skilfully with the anxiety of others.
Ballatt and Campling point to other inhibitors of caring approaches. They argue that the industrialisation of medicine, regimes of benchmarking and standardising, have led to the spread of mediocrity. Requiring rigid adherence to standardised tools does not always recognise expertise which has already developed beyond the rules. What I understand the authors to be pointing to is the importance of locally formed expert judgment for which standardised procedures are no complete substitute. Additionally, Ballatt and Campling argue that the way that the marketization process has led to a commodifying of the spirit of voluntarism which until recently has pervaded medicine as a vocation. The give as an example the way that the new GP contracts have obliged them to count all the hours that they work as units of pay, whereas previously they would have worked for free. Despite the fact that their pay has increased, so too has their dissatisfaction at having to itemise and claim for every minute they are working to justify their claim. In addition the move to inspection, intense monitoring and ‘naming and shaming’ supposedly poorly performing hospitals leads to a culture of suspicion which has a tendency to set up defensive relations between care staff and the public they serve. The authors also consider that the purchaser/provider split in health care has been both expensive and wasteful.
Intelligent Kindness is a thoughtful and provoking book which brings politics and what it means to be human back into discussions of organisational change. It reintroduces both globally political and locally practical themes and shows how fraught professional caring can be because it brings professionals face to face with the extremes of what it means to suffer, as patient and as carer: hospitals can be fora for the playing out of very strong and mixed emotions. The authors demonstrate how ‘reform’ is never a technical and neutral word and it can be used equally easily by politicians and managers to bring about diametrically opposite changes. They argue that latterly changes to the health service have reflected a particular ideology and have resulted in instrumentalising relationships between people.
That the cleavage of left and right, individualism and solidarity, pro and asocial behaviour shows up at the heart of one of Britain’s principal institutions can be no surprise. Questions of what it means to change the NHS also involve questions about what it means to be British, since the institution forms one very central way of collective belonging and identity: it forms part of what Norbert Elias referred to as the ‘we layer’ of the British personality structure. Culture, even approached from within one institution, is also an expression of who we are and who we would like to become.
Nonetheless, as important as their contribution is in identifying some of the processes which militate against mutual recognition, to a degree, Ballatt and Campling could also be critiqued for idealising intelligent kindness and the extent to which it can contribute to a ‘virtuous circle’ in health care. They are setting out an alternative equilibrium model based on the idea of stabilising and integrating ‘for the good’ where organizational culture is manipulable. From a complex responsive processes perspective, whatever we take organizational culture to be, the habitus, will always be both stable and unstable at the same time as staff navigate the contradictory processes of finding the ‘I’ in the ‘we’. As an example and for a thorough treatment of the importance of both trust and mistrust in organisations and their relationships with stability and instability read Ralph Stacey’s previous post here. In drawing attention to the neglected pole of competition/co-operation they have to an extent lost the paradox between the two, and may be in danger of over-claiming, particularly when they start to argue that their understanding of intelligent kindness can be equally efficient and effective. Efficiency and effectiveness are much more problematic terms if one assumes that the interactions between human beings are non-linear: creativity and learning may only be possible in situations where there is a certain amount of redundancy of both time or resources.
Another way of understanding the march towards individualisation which we experience in contemporary society is that it arises partly as a reaction to the perceived inflexibility of state bureaucracies: inflexibility can also be a way of stifling caring. Moreover, a caring response, which can only be expressed in close proximity between human beings, has to go through processes of abstraction in order to become institutionalised and there will always and inevitably be occasions where patients will feel misrecognised. The authors recognise that regimes of inspection are predicated on important questions of quality. Moreover raising questions of quality can also challenge existing patterns of power relations which might privilege redoubts of poor practice . There is much to be debated about the nature of quality regimes and the consequences of exercising disciplinary power, but managers and clinicians will always need to exercise such power in order for the NHS to cohere. This question of power and the every day politics of achieving things together is underdeveloped in the book from a complex responsive processes perspective, particularly if one considers the authors’ appeal for power to be more ‘distributed’. Unequal power relationships between different groups of medical professionals, doctors and nurses for example, predate NHS ‘reform’, and both official and unofficial hierarchies persist.
However, Ballatt and Campling have opened up some important questions concerning global and local themes in organizational change processes, which will always involve ideology, power, politics, unintended consequences, anxiety and strong affect. They also point to the perverse effects of targets, inspection and rounds of reorganisation based on market principles.
 Schein, E. (2010) Organizational Culture and Leadership, London: Wiley, 4th Edition.
 Ballatt, J. and Campling, P. (2011) Intelligent Kindness: Reforming the Culture of Healthcare, London: Royal College of Psychiatrists Publications.
 Phillips, A. and Taylor, B. (2009) On Kindness, London: Penguin.
 Sandel, M. (2012) What Money Can’t Buy: the Moral Limits to Markets, London: Allen Lane.
 Elias, N. (1997) The Germans: Power Struggles and the Development of Habitus in the Nineteenth and Twentieth Centuries, Cambridge: Polity Press.
I believe the organization as a complex system must be analized as one and the culture is a result, so we must check the composition of this result some points we can change and others do not.
A fascinating post Chris. As an NHS ‘insider’ I can see that the introduction of competition was a political (and even social) response to a financial black hole which consumed more and more scarce resources, protected from scrutiny by a veil of solidarity and social goodness. The disciplines of competition have had some benefits but also many failures – Mid-Staffs being the seminal example. The pendulum is currently being pulled by both ends of Ballat and Campling’s spectrum – an interesting tension which is going to change the face of care. It is paradoxical that in order to maintain the collective nature of the NHS, patients are going to have to take more responsibility for their own care which will increasingly be ‘co-produced’. This reflects social trends. I think the tension with systems such as the NHS is when they are out of sync with wider social and political trends rather than which end of the ideological pole they rest at any one time. With a complex system like the NHS, which was at one time protected from the financial consequences of its behaviours, change is always behind the curve.
So often I see the NHS described as an entity. In our minds perhaps, but if it is to be viewed as a complex system do we need to acknowledge that with scale comes lack of homogeneity?
It is perhaps our lack of ‘tools’ to harness heterogeneity that is at fault. Attempts to codify and standardise provide a froth of control for political purposes but will always be a poor approximation of the complexity beneath. Our attributions (meaning making) also confound: so often we look for external causation (other than ourselves) with too much belief in espousing our capacity to ‘fix’ things.
Progress might be made if we could move towards a looser systemic frame and more localisation and more acceptance that expertise is both scarce and lags behind demand.
If so, then the education of the patient is paramount, and the place for market economics highly dubious if our ethical position is for the greater good.
It’s worth noting how ahistorical gecko1000’s description is. The so-called “black hole” was indeed the rationale put forward for the introduction of competition – but it needs to be acknowledged that “competition” has only cost money, not saved it. Indeed, most of the black hole is a result of the introduction of “competition” and also of extremely ill-judged introduction of methods of cost accounting and control. This is a matter of historical record, by the way, you can look up the figures and match them to the timeline…
Thank you Chris for your very thoughtful – and helpfully challenging – thoughts and comments about our book. It’s refreshing not to meet a binary ‘it’s right or wrong’/meets my experience/doesn’t response and to be prompted to think further. It’s also extremely cheering to encounter a recognition of the political and complex (perhaps not quite in your terms!) aspects of our examination of these issues.
I really enjoyed the book John and hope it has provoked some necessary reflection within the NHS hierarchy.
Thanks Chris. Quite a lot of interest and invitations – not quite so sure how much reflection/digestion.
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nice blog chris… elias was right to point out how we are conditioned to behave in certain situations and it is little surprise to me that people find it very difficult to examine power and political relations in institutional settings, particularly when to do so would be so at odds with what most would deem acceptable. If this is so, are you not in danger of idealising the potential of a manager to be able to recognise this and then in an imaginative and reflective way, facilitate or help people to overcome this? Who would these people be, who were able to deliver in this way, given this social reality?
I’ve just been in an organisation that espouses a good deal alternative and open forms of management/structure etc, yet when things got bad, they opted for a formal process of conflict resolution, despite there preference for something more meaningful and real…
I agree that it can be difficult for managers, but I am not sure I am idealising their ability to engage with these situations. You are right if you are implying that it would take quite a good deal of self-knowledge to do it well.
Reblogged this on Social & Health Practice Ottawa.