The iceberg theory of NHS culture

The Big Society is upsetting Big Medicine. The BMA and the Royal College of Practitioners have registered their displeasure at the extent of the government's NHS reform agenda. The same results could have been achieved with a small change in the current structure, they say. More ‘extreme concerns’ surround the prospect of greater commercial competition between the NHS and private companies. Responding in January, the Prime Minister demanded that fundamental changes are needed in the NHS and a ‘quiet life’ was no longer an option.

The government is quick to emphasize that the reforms are not about improving process outcomes or saving money. The purpose is better clinical outcomes, a healthier nation. While most medical professionals would agree with these aspirations, they might wish to challenge the notion that their professional life is a quiet one. Endless reorganization and restructuring of the NHS has reduced staff morale, with many clinicians unhappy that they are busy reinventing services that already work instead of treating patients.

As ever, the appetite to reconstruct the NHS is hungrier among people who observe the NHS, manage it, or comment upon it than among those who work in clinical disciplines. This polarization of opinion about the health reforms will mean that their implementation will be more difficult, conflict inevitable.

Governments have a short lifespan, and a desire to press ahead with their agenda overrides the concerns of professional trade unions or societies. This isn't to say that reform is necessarily bad but without sufficient support – or ‘buy-in’ in management speak – from the medical profession, reform is unlikely to succeed. At a very basic level, the BMA and the RCGP know that they will outlast any government and the next one might be more sympathetic to their concerns.

The Government's health reforms will attempt to change the culture of the NHS, and as Jeffrey Braithwaite argues, ‘cultural change involves concerted effort, usually over lengthy periods’ ( JRSM 2011;104:85–7). Cultural renewal not only involves observable workplace behaviours, practices and discourses that are visible above the waterline in the iceberg model of culture. Below the waterline lie a greater mass of beliefs, attitudes, values and philosophies that are often taken for granted. The tip of the iceberg is ‘the way we do things around here’. The depths obscure the reasons why we do things, and are usually unplumbed.

Braithwaite uses former Prime Minister Tony Blair's approach to brokering the Good Friday Agreement in Northern Ireland as a possible model for culture change in the NHS. Where the analogy might struggle in trying to adapt Blair's 10-point plan for negotiating is in the requirement for external assistance. The NHS conflict, unlike the Northern Ireland conflict, has no room for external assistance. Patients are the only logical go-between but when has either government or medical profession been serious about listening to what patients want?