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Structure or culture: the great reform conundrum

Chris Painter, Emeritus Professor of Public Policy and Management at Birmingham City University, examines the tensions between structural and cultural change in public services, arguing that the latter is potentially as problematic as the former.

The temptation for ministers to leave their mark on public services by embarking on structural reform often proves irresistible.
The coalition’s re-organisation of healthcare, pivotal to which were the clinical commissioning groups, is a classic example. Continued academisation of school education, along with the ‘free’ school experiment, is another case in point. Rationalisation of the 43 police forces in England and Wales is a structural option also now re-entering the political arena. 

Yet evidence for the efficacy of this structural fixation is tenuous at best. It is questionable whether the endless cycle of organisational upheavals in recent decades, not least in the NHS, has added value to the quality of service delivery. Any improvements can readily be explained by other variables. The structural obsession may even have been counter-productive, captured in the intriguing concept of ‘re-disorganisation’!

Shifting the focus

Of late we have seen the emphasis moving in favour of cultural as distinct from structural change. The former signifies ‘deep’ as opposed to ‘surface’ organisational change. The latter seems in retrospect all too often merely to have re-arranged the deckchairs on the Titanic!

Cultural change, by contrast, addresses underlying organisational values, attitudes and behaviours. It reaches the root causes of dysfunctional performance. The sense of crisis overtaking so many institutions since 2007 is the catalyst engendering fundamental soul-searching. Or, so it may appear.

This applies as much to the corporate sector as it does to public service organisations, notwithstanding the lip-service paid to social responsibility. The financial crash thus focused attention on the underlying ethos of the banking industry. The new Bank of England governor, Mark Carney, highlighted the critical importance of changing the culture of Britain’s high street banks if they are to re-connect with the interests of the wider economy and society at large.

In practice, structural re-configuration continued to take precedence, seen in endeavours to create a ‘firewall’ between investment and retail banking. That pre-occupation has spread to the energy sector, the industry’s structure now subject to a major investigation by the Competition and Markets Authority.  

In the public service context, both healthcare and policing are topical examples of debates around the necessity for cultural change.

Cultural change in the NHS

This moved centre stage following the final report of the Public Inquiry into the now to be dissolved Mid Staffordshire NHS Foundation Trust, chaired by Robert Francis QC and published in February 2013. The problems at the offending trust were attributed to the managerial cult of quantitative targets, with avoidance of financial failure prioritised over risks to patient care. An institutional culture giving precedence instead to transparency and openness – and the kind of senior leadership that implied – would serve patients much better. 

The ensuing review from Professor Don Berwick (pictured), an internationally renowned US expert on patient safety, commissioned by the prime minister and published in August 2013, was even more radical in tone. It called for abandonment of a blame culture based on fear in favour of one of support, placing trust in the professional pride and goodwill of healthcare staff. That of itself would contribute much to the greater transparency called for by the Francis report, facilitating institutional learning and improvement. 

The health secretary’s final response to Francis in November 2013 included a statutory duty of candour for healthcare providers, at a threshold in terms of the seriousness of the cases involved then yet to be determined. But there was concern that the proposal to subject health professionals in England to a new criminal offence of wilful neglect or ill-treatment of patients would hinder the desired transparent organisational culture. Recent reinvigoration of the Care Quality Commission inspection regime, remodelled along the lines of Ofsted in education, signified moreover a ‘top-down’ approach to healthcare performance management that is the very antithesis of the professional trust advocated by the Berwick review.

Cultural change in the police service

In the case of policing, renewed debate about ethics and values followed less from one cathartic occurrence. It was the cumulative effect of a series of revelations casting doubt on the standards observed by law enforcement officers – not least in relation to the fall-out from the Hillsborough football disaster; the vigour with which allegations of media phone hacking/intercepted communications were handled; and most recently with regard to the Andrew Mitchell affair. Posing an even greater challenge were allegations of corrupt activity during investigation of Stephen Lawrence’s murder, as well as police infiltration of his family’s subsequent campaign for justice, concerns reinforced by the independent review conducted by Mark Ellison QC whose findings were unveiled in March.

Staff associations, as well as the 43 police forces in England and Wales themselves, became caught up in controversy over fitness for purpose. This was amplified by the final report of the Independent Review of the Police Federation published in January, chaired by the former permanent secretary of the Home Office, Sir David Normington.

The coalition’s broader police reform agenda consequently did not dampen demands for a full-blown royal commission on policing. But the call for a ‘new professionalism’ to underpin institutional culture has been at the forefront of this debate; hence a new College of Policing, announced by the Home Secretary in 2011, drawing on the legacy of the National Policing Improvement Agency. Not only was it to provide a professional body for policing, with a mandate to set consistent standards, it would also lead the way in developing an evidence-based approach to police practice. In October 2013 the College published a much awaited code of ethics for policing in England and Wales, a declaration of principles of behaviour to be adhered to in the future.

There is, however, one delicious irony. The coalition government’s changes to police governance, taking effect with the election of police and crime commissioners (PCCs) in 2012, were designed to strengthen public accountability. Yet, apart from the historically low turnouts, these new political office-holders became associated with behaviour leaving much to be desired: appointments made by them strongly influenced by personal contacts; deteriorating relationships in some cases with their chief constables; and weak scrutiny provided by local crime and police panels. Doubt has even been expressed about whether the PCC experiment will survive the next set of elections scheduled for May 2016! It takes us right back to the seven principles of public life first enunciated by Nolan as long ago as 1995.

Rediscovering a public service ethos

Institutional failures appear paradoxically to have multiplied since the Committee on Standards in Public Life first made its presence felt in the mid-1990s, with public trust as a prime casualty. Paul Spicker, in the January 2014 edition of the Public Money & Management journal, maintains that the whole Nolan framework may be misconceived. Statements of broad principle will always be incomplete and pose difficulties when it comes to concrete application. As such, a compliance rule-based approach is no substitute for embedded institutional values, especially bearing in mind the ethical dilemmas faced by public servants.

In the same journal, in November 2013, Jane Boadbent identified the need for reclamation of the very idea of  ‘public service’, compromised by increasing reliance on transactional rather than relational approaches to service delivery. The former hinges on performance targets and related incentive structures. A recent example was the revelation that Home Office immigration staff have been set a target of winning 70% of tribunal appeal cases brought by asylum seekers, putting in jeopardy the fairness of proceedings. The relational model by contrast brings us full circle to the paradigm of professional trust advocated in the Berwick review. 

No panacea

Nonetheless, cultural reform can be even more problematic than structural change. That must be true by definition when it involves fundamental behavioural rather than merely surface change. By its very nature it entails the long haul. And if change management is a more contested and negotiable process than top-down linear models imply, how much more will this apply if the intention is to change deep-rooted values and attitudes?! Indeed, reform pressures are often absorbed in a manner consistent with established institutional practices, a phenomenon known as path-dependency. Frontline staff will also filter changes through the prism of
long-standing mindsets.

In the realm of policing there are many documented examples of less than fully successful attempts to change organisational culture going back decades, not least within the Metropolitan Police. Reconstituting professional identities, especially in contexts where there are entrenched occupational cultures, can be a particularly daunting challenge. Then there is the not inconsequential issue of what form cultural change should take given the likelihood of conflicting objectives. In the NHS this typically involves tensions between care quality and financial performance. Reconciling the two is no mean juggling act!

Elementary ground rules

In the light of the above we can at least set out some basic parameters: prosaic truths that minimise the risk of public service reforms leading to perverse effects or even proving counter-productive, yet all too often disregarded during the conception of political ‘modernisation’ projects.

Innovation of course must play its part when budgetary retrenchment is likely to prevail for some time into the future. More from
less has become a familiar mantra! But that also means bearing in mind what is feasible in the context of such fiscal expectations. Realistic timescales have to be set for meaningful changes. Clarity of objectives helps – or articulating acceptable trade-offs between competing values. And above all, give previous reforms a chance to become embedded before the next upheaval sweeps in!


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