If we think of an organisation as consisting of a structure, systems and a culture then most people would give structure the least importance, although structural reorganisation has preoccupied most of the attention of people in health and social care in the last 50 years. Structure is relatively unimportant, although it is important to remember the principle attributed to Gandhi that, “there is no structure that can make bad people behave well but the wrong structure can make good people behave badly.”

Of systems and culture most management experts would give higher priority to culture than to systems, because unless there is a collaborative culture, no matter how well designed will work well so culture is the key issue.

Of course health and social care is like any organisation, involving people committed to broad humanistic issues such as honesty, openness and respect.

A health service, as distinct from other organisations would also be committed to mitigating inequity or quality improvement and of course the various subsections within a health service such as an orthopaedic service or a cancer service or a paediatric department have their own culture.

A key concept for the future is the collaborative culture because that is the culture that allows networks to flourish and therefore systems objectives to be achieved.  The word collaborative is mentioned 55 times in the White Paper indicating that a transformation is taking place and there is no longer reliance on the market culture of competition that has prevailed for the last 30 years.

The second aspect of culture that is of clinical importance is the culture of stewardship. This was first developed by William Henry Douglas, a biologist in Buckinghamshire in the 19th century who wrote in 1833,

“If a shepherd put more than his allotted number of sheep on the common, overgrazing could result. For each additional animal, a shepherd could receive additional benefits, but the whole group shared damage to the commons. If all shepherds made this individually rational economic decision, the common could be depleted or even destroyed, to the detriment of all.”

The idea was further developed by Elinor Ostrom for which she was a joint recipient of the Nobel Prize of Economics in 2009 with Oliver Williamson and she wrote:

“If those using the resources are allowed to manage those common pooled resources themselves, then sustainability is possible. They become stewards.”

Furthermore their prize work destroyed the idea that the only option for running services were either bureaucracies or markets, and Williamson wrote:

“if the market is a marvel, then why do we need firms? But then the question can be turned around. If internal organisation enjoys advantages over markets, then why is not all production carried out in one big firm?”

What is needed is a system, an integrated system.

We have to create a culture of stewardship and this can be done in a number of ways for example by

  • getting the language right, using terms that support the culture and indeed trying to stop the terms that do not support the culture because language creates culture and indeed language creates social reality;
  • training, and there is a need to train large numbers of people in the new ways of thinking;
  • behaviours that express the culture and behaviours that are counter cultural also need to be defined the former being rewarded and the latter being sanctioned.

The work of Elinor Ostrom makes it absolutely clear that this is the most, most important organisational development that needs to take place to ensure the sustainability of universal healthcare.