Culture change can have a drastic impact on quality and finance

Hospital corridor

Cultural rather than structural shifts are essential to facilitating better decision-making and enabling the right relationships, behaviours and environments in which decisions on quality and finance are made, according to new research.

Decisions of value, published on Thursday (16 October), identifies different factors that support good decision-making, focusing on the judgments made every day between clinicians and managers. The impact of cultural rather than structural factors, and the interaction between people rather than rules and standards, were identified among key challenges.


Launched jointly with the Academy of Medical Royal Colleges(AoMRC), the report presents insights into how people interact in the NHS and the crucial factors affecting how they operate within a particular context. 

It finds that strong clinical and financial engagement improve decision-making and strengthen the value underpinning decisions made. The report also concludes that information and values can be used to drive decisions, though support is important to help decision-makers feel comfortable with using them.

Balancing act

The research is a product of the Decisions of Value project led by AoMRC and the NHS Confederation. The organisations have spent six months studying what influences decisions on quality and finance. 

‘Decisions of value’, meaning those that balance quality, financial and operational considerations, aims to support and empower those working in the NHS to find solutions to the question, how best to balance the priorities of quality improvement and financial sustainability.

The report brings together a large amount of research to show how decisions impact on the value delivered and how this extends beyond Whitehall to the front line.

It comes as the Secretary of State today made a speech on how improving the safety and quality of care will reduce avoidable costs for the NHS. "We welcome the Secretary of State's focus on this issue today and the sponsorship by the Department of Health of this work. Often we see political focus on performance targets and structures and an approach based on cultural factors is very timely," NHS Confederation chief executive Rob Webster said. 

Culture vs strategy

“This is an important report that demonstrates again that 'culture eats strategy for breakfast'", said Rob Webster, chief executive of the NHS Confederation.

"The importance of the relationship between clinicians and managers when making decisions is critical to the future of the NHS and this report gives full support to how patient experience and safety should not be discussed separately to finances. 

He added: "This research project aims to improve the quality of care and reflects the importance of cultural factors for organisations that are working to keep their budgets balanced. This links closely with our combined asks in the 2015 Challenge Manifesto about creating a new culture in the NHS, where patients are fully engaged and staff are empowered to make decisions within a tough environment.

'Required reading'

“Alongside this, we need to bring more data and information into decision-making, to reach intelligent decisions grounded in evidence. This is key to getting more value from the resources we have. Clinical and financial staff must work better together, so that every decision is focused on value rather than costs or quality in isolation. This report should be required reading for every board in the NHS.”

Professor Terence Stephenson, chair of the Academy of Medical Royal Colleges, said: “The Decision of value report shows the importance of having, above all else, the right culture in place which can deliver high quality and a balanced budget. It rightly outlines the importance of clinician involvement in decision making, providing the right environment for staff and robust data upon which to make the right decision.”

“Also, as the Secretary of State has rightly pointed out today, to ensure patient safety managers and clinicians must have productive and constructive relationships in order to make sound joint decisions about finances and quality. I look forward to working with partners cross the NHS to help implement the guidance and advice as outlined in the Decisions of value report.”

Crucial factors

The report highlights six important factors in the study, based on detailed exploration with staff across the NHS:

Find out more

Download the report and view the accompanying infographic.

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