A lasting legacy from Tony Blair? NHS culture change.

Abstract

He appeared to be talking off the cuff, but ever since he uttered the words, philosophers have been debating whether his language refers to some sort of deeper epistemological truth, a kind of new philosophy for the age. In other areas of life, serendipity appears everywhere: celebrated examples are Fleming’s discovery of Penicillium notatum on an overnight petri dish, and Penzias and Wilson’s accidental detection of the cosmic microwave background radiation from the noise emanating from their radiometer’s antennae. Tony Blair has done something similar in his new autobiography Tony Blair: a journey. Most of the 718-page monolith is relatively easily disposed of: it is his version of events during his prime ministership, 1997–2007, a lot of which we knew. Yet in an intriguing way it is compulsory reading as it gets into the mind of a key decisionmaker as he made the choices we agreed with or disputed, but regardless followed so closely. It is not nearly as self-serving, indulgent or religious as it could have been, or some have made out. That said, it has one section, buried in chapter 6, ‘Peace in Northern Ireland’, which may prove useful for improving the National Health Service (NHS) – or any large health organization. Following Blair’s account of the negotiations leading to the Good Friday Agreement by which the warring loyalist and republican parties, along with the British and Irish governments, came together to discuss the end of hostilities lies more than the germ of an idea about how to alter complex organizations. Blair presents 10 reasons why the agreement was successful, despite numerous setbacks and blind alleys. These principles are useful not only, as Blair intended, to be applied to other sticky political negotiations by those brokering peace among truculent, bellicose parties, but for longer-term cultural and organizational transformation. This type of change is badly needed in the NHS in substitution of, or as a replacement for, the structural change which is being sponsored by the Conservative–Liberal Democrat Coalition. Table 1 summarizes this proposal. Culture change involves concerted effort, usually over lengthy periods, to influence and shape behaviours and practices on the one hand, and attitudes and values on the other. It is readily conceptualized as an iceberg, with the visible portion, the organizational and clinical activities, above the waterline, and the invisible collective mental constructs, below. The idea is that both need re-orientation to render cultural renewal (Figure 1). Did Blair realize he had developed a yet-to-be tested but nevertheless promising new model for culture change across large complex systems? From a close reading of his book, it does not appear so. This is an unknown unknown: Blair did not say, and we are unable to confirm this. He looks to be genuine in his desire to leave recommendations for DECLARATIONS