The NHS cannot build a successful future on a platform of fear and blame. If we are to embrace the future of healthcare and the NHS, we need to have a motivated and empowered workforce to create it. But the NHS risks being held back by a culture creating rigid decision making entombed in stress and anxiety.
Table of Contents
Blame and A Scandalous Culture in the NHS.
Whenever an NHS scandal pops up, the media jump straight into a frenzy of who to blame. With NHS leaders repeatedly put under the spotlight. It makes for a compelling story. But it also reinforces a blame game going on within NHS Trusts. A scandal does not have to happen, only the fear that one might happen is enough to shape decision making.
A failure to listen to patients and a corrosive blame culture have been continuous themes across the NHS over many years. Whilst problematic cultures in NHS Trusts have been repeatedly cited as contributing to failures in patient safety and care.
Bullying is not just where the scandals occur, it is everywhere with 22–28% of staff reported harassment, bullying or abuse from other staff in just the last 12 months. (NHS England) Alarmingly, black and minority ethnic (BME) staff are more likely to experience bullying and harassment in over 90% of trusts. This years record number of staff dismissals for ‘poor performance’ can only add fuel to the fire.
Unfortunately, the NHS’s loudly declared ‘zero tolerance approach to bullying’, means that when people report bullying, the systems and organisations seek to deny its existence at every stage. “It can’t possibly happen here as we have a zero tolerance approach” is the organisational corporate gaslighting many people have experienced when they have raised concerns. With the organisation implying that their experiences must be somehow their fault.
A Blame Culture That Risks the Future of the NHS.
This is not just a problem now, but risks the future of the NHS. The 3 Big shifts and changes in the NHS 10 Year Plan will not happen if people are being punished for trying new things and making mistakes. The Experience Curve means that initially lower performance when learning brand new and different tasks is pretty much inevitable.
Whilst funding and power will remain siloed in the safety of existing organisational structures. With the Sword of Damocles held high over any new service.
- Digital transformation will not happen if people cling to safe options because innovation feels dangerous. Whilst small innovative providers are squeezed out in favour of large corporate giants such as Microsoft and Palantir.
- Neighbourhood health will not work across organisational boundaries if staff are afraid to think, act, and adapt in complex community settings or respond to diverse patient needs.
- Prevention will not succeed if everything must be policed, audited, and controlled because trust has collapsed. People do not change their lives to satisfy bureaucratic checklists.
If we truly want to devolve power and resources to the places that matter, we must trust staff and communities to use them well. That requires resisting the seductive simplicity of blame.
How Blame Fuels Bureaucracy
I was prompted to write this after reading another thoughtful piece by Liam Cahill, this time on bureaucracy and leadership. He describes how NHS bureaucracy is often fuelled not by bad intent, but by fear. Fear the leaders have of being publicly blamed and shamed when things go wrong. For example, by being named and shamed in the Daily Mail, for all their colleagues, friends and family to see. It is no wonder this makes NHS leaders act in fear.
I really chime with Liam’s connection between bureaucracy and fear I’ve previously called this ‘blameocracy’. Whilst In a previous article, I identified a recurring psychology in NHS leadership: when leaders are confronted with fear and uncertainty, they often retreat into power and control. This is not because they want to dominate, but because the system conditions them to control out of anxiety.
And to be clear, that fear is not irrational. In the NHS, when something goes wrong, blame reliably follows. Indeed the entire hospital ranking system was officially and explicitly designed as a process for ‘zero tolerance for failure’ (NHS England). It is quite astonishing that the same organisation can simultaneously promote a ‘zero tolerance to bullying’ and a ‘zero tolerance to failure’ approach at the same time. Even though each approach on it’s own aims to be well intentioned.
A Blame Culture That Is Right In Front Of Us
All too often the culture of fear is hiding in plain site at a much less grand scale. Through playing out of every day mundane management processes, designed to demonstrate power whilst devolve accountability to individuals and parcel out blame.
Many performance meetings are little more than ritualised name and blame sessions. Performance dashboards are reviewed, red and amber boxes are scanned, responsibility is assigned, and punishment is delivered. Usually in the form of action plans, deadlines, and increased scrutiny.
It doesn’t have to be this way. Much of this could be done privately. A face-to-face conversation grounded in support, coaching, and the simple question: “How can I help?”
But that is rarely what happens.
Instead, leaders feel compelled to demonstrate authority. Scapegoats must be found. Blame must be attributed. The status quo must be protected. Bums must be covered.
It would be hard to design a more effective process for destroying psychological safety.
Why We All Participate in the Blame Game
We need to be honest about something uncomfortable.
We are all culpable.
Who among us has not felt a quiet sense of relief when the blame lands on someone else? In our own very real version of The Traitors, this is deeply human. It is instinctive. We see it across organisations, countries, and cultures.
When something goes wrong, there is a hunt. A scapegoat is found. Punishment is delivered. The system remains intact.
It is one of the most consistent findings in psychology we instinctly have a ‘self serving bias’: where individuals attribute their successes to internal factors (ability, effort) and their failures to external, situational factors (luck, others) to protect their own sense of self-esteem.
This is the dark side of human behaviour. And the NHS is not immune to it. I think it is in fact it amplifies it as the moral and emotional imperative to ‘only do good’ is so high.
Because it is so deeply woven into our psychology (and i think this is crucial) it even affects how we see and perceive the world. (Motivated self cognition, Kunda 1990) Therefore, we should not pretend we can simply come up with policies and rules that will stop bullying or bias. Instead we have to recognise we are biased whatever the policies or values documents say.
Why Projects Fail and Why We Blame the Wrong Thing
Going back to practice: In my experience (and aligning with evidence by the Project Management Institute) ,projects rarely fail because of a bad project manager.
They fail because of unrealistic demands, systemic constraints, poor organisational design, conflicting priorities, unclear roles, lack of time, lack of resources, loss of key staff, or weak engagement.
These are system failures.
Yet when things go wrong, we blame individuals. Not the system that placed them there. Not the structures that constrained them. Not the under investment of time and capacity.
When someone is genuinely underperforming, more often than not it reflects issues with wellbeing, frequently outside of work. None of us are immune to life. Once you manage a team of a dozen people or more, I’ve found it is almost guaranteed that one or two of them are navigating serious personal challenges at any given time.
Blame and punishment are the worst possible responses in those circumstances.
And if someone truly lacks the skills required, that too is a system failure. The system put them there and failed to develop them.
How Can We Defeat The Blame Game
What High Reliability Systems Do Differently
In the Toyota Production System, there is a system of error proofing called ‘poka yoka’ . When a part does not fit or a process fails, the response is not to punish the worker. The system is redesigned so the failure cannot recur.
The NHS often does the opposite.
We sacrifice individuals to protect broken systems.
That should trouble us deeply.
Psychological Safety Cannot Exist in a Threatening System
The reason people fear blame and scapegoating is simple. The system is a threat to them. They have seen it happen to others, and so they retreat to the safe predictability of process. This is why bureaucracy thrives, while people feel unwilling or unable to speak up.
If we want psychological safety and reduce the buruecracy we must redesign the system so it does not focus on individual blame. There is no other route.
Value statements alone will not fix this. Evidence consistently shows that culture does not change through slogans and value statements. As i mentioned earlier, it is perception that matters.
The Genuine Power Of Team Leaders
In a Harvard Business Review study, Professor Benjamin Laker found that 72 percent of culture initiatives had no meaningful impact on trust or engagement. But when senior leaders changed their own behaviour, without announcing a culture programme, the impact was 26% higher.
There is also substantial evidence base showing that the single biggest driver of employee engagement is the quality of the relationship with line managers. According to Gallup’s State of the Global Workplace research, as much as 70 % of the variance in employee engagement scores is attributable to team-level managers and how they engage with their teams
Culture is behaviour, not aspiration, not policies. It is what we do and how we work with one another.
Leadership, Politics, and the Spread of Blame
Yes, we need leadership from senior figures. We also need politicians to stop trust-bashing. Public criticism of NHS organisations, such as Wes Streeting blaming trusts for failing to reduce waiting lists, reinforces fear throughout the system.
But culture is not changed from the top alone.
Every manager in the NHS has a choice.
A choice to say: I will not feed the blame game in my team. I will fix systems rather than sacrifice people. I will not create fear in the name of control.
This is not about shielding malpractice, illegality, or deliberate harm. We should not be protecting bad actors from blame.
It is about protecting people who are trying to do the right thing in an impossibly constrained system.
A Practical Leadership Tool To Move Away From Blame and Bureaucracy
It is all very well for me to say managers need to stop blaming people. Especially in an institution that seems to be reward blame at every level. However, it IS possible. For example: David Marquet’s leadership ladder. is a powerful tool I’ve used to move away from a control culture to a more people focused ‘intent-based culture’. The idea is that you build people’s skills and confidence (and your own) to gradually manage them through the ladder. This is a learning process. It takes time.
Moving From Leading Through Process To Leading Through Relationships.
More fundamentally, if we want to reduce blame and bureaucracy, we have to move from relying on managing people and performance through process alone. It may be the ‘easy’ way. But the cost is that it creates a rigid, inhumane system that demotivates and deskills the workforce and leaves NHS organisations stuck in the past and unresponsive to the needs of both staff and patients.
Instead, we need to build up our skills to manage people through trust and relationships supported by the process. Building up the confidence, skills, and expertise of our staff so that they can thrive, be innovative and shape the future. It is not just an ethical choice, it is a practical choice to adapt to an ever changing, complex world.
We Need To Choose The Light Side of Management Over The Dark Side.
Leadership always involves a choice.
The dark side of management is familiar and seductive. It focuses on order and calls it fairness. It talks about variation and uses it to take power away. It talks about accountability and requires subservience. It hide behind process. Enforce rules to maintain control. Use compliance as a proxy for performance. Passes on responsibility without authority. When pressure rises, default to blame. It looks like order, but it breeds fear, disengagement, and, too often, bullying dressed up as governance.
That said the dark side has it’s place, but it should be used wisely, when there is clear confusion or chaos (e.g. when people go too far up the ladder of intent) or when someone has clearly acting in a way that is harmful.
The light side is often the harder route to learn.
It asks leaders to focus on people, not just process. To notice when blame is creeping in and actively defuse it. To shift attention from individual fault to how the system is shaping behaviour. To create conditions where people can do their best work, not just avoid punishment. The focus is on learning, building skills growing from failure and empowering people to work collectively to achieve their goals.
This is not a one-off decision. Like any discipline, it is a series of daily choices. To support rather than control. To challenge without humiliating. To nurture capability while redesigning the wider system so teams can succeed together.
When leaders say one thing and do another, credibility collapses. People stop trusting the intent and start working around the bureaucracy. If our processes drive individualised blame, they are undermining teamwork, not strengthening it.
Choosing the light side of management is more demanding. But it is the only path that leads to trust, learning, and sustained performance.
Conclusion: Choosing Courage Over Fear
If we give in to fear, we lock ourselves into the present. We defend what exists. We punish deviation. We suffocate learning. Whilst increasing process and bureaucracy stifles our present and our future.
If we want to make new things possible in the NHS, we must end the blame game together. We must recognise and organisation is about people working together through relationships with one another. Ultimately, the NHS is about people helping people. To do that, we need NHS staff to focus on helping each other.
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