NHS toxic culture – understanding the symptoms and causes

How to spot a toxic workplace

Type “NHS toxic culture” into your web browser and wait for a deluge of reports about organisations in trouble with their people.  I have seen adverse media coverage of two NHS Trusts, the Houses of Parliament, Amazon, Sainsburys, Hampshire Constabulary and Durham University.  It seems no organisation is immune.

The latest media observations are aimed at the people leading NHS Test and Trace, who are coming under increased scrutiny for spending billions of pounds in an attempt to deliver crucial public health services through allegedly dysfunctional organisations and demotivated staff.

What is toxic culture and what does it mean for an NHS organisation to have a toxic workplace?  Is there more to this than a catchy label and a snappy soundbite?  What are the symptoms of a toxic culture, and what factors cause these problems?  More importantly, what can leaders do about developing better culture in their organisations?

The symptoms in organisations with poor culture are normally pretty obvious.  High and unplanned staff turnover is often an indicator of poor workplace relationships.  Frequent absenteeism, poor staff morale and people working without enthusiasm are usually easy to spot when you walk around your organisation.

Rapid changes in key leadership roles, survey data that say people plan to leave soon and feedback that says people are unclear about how their work matters are also common indicators that the culture is not right.  Add in any signs that people are suffering from stress, raising grievances or whistleblowing about alleged malpractice and the alert leader will soon have a worryingly rich picture that something is seriously wrong.

In recent years I’ve become more and more interested in the concept of toxic workplace culture and, in particular what causes it to take hold and flourish in some places. I know what it feels like to work in one, and I know what works, and doesn’t work, in trying to change culture for the better.  I have been responsible for leading the turnaround of three different organisations that were characterised by poor performance and, in all these cases, the toxic culture was a key issue at the heart of the problems.

The literature on toxic workplaces seems to emphasise the importance of toxic leadership, which I agree is an essential ingredient. However, having reflected on my personal experience, I think there are other important issues to consider.  I believe that toxic culture is created and allowed to persist in organisations and that the following factors are often at the root of the problem.

  • Toxic leadership. This is all about the behaviour of senior leaders and its impact on the organisation. Bullying behaviour is a classic ingredient of a toxic workplace, but I would also add inappropriate and unprofessional behaviour. In particular, in my experience, lack of clear boundaries between leaders and their people can be a serious issue in the workplace. This can include leaders treating their subordinates as friends, clearly having favourites and, in the most extreme situations, becoming involved in romantic relationships with people they manage.
  • A disconnect between the stated values of an organisation and the behaviour of senior leaders. This can cause a lot of cynicism in the workforce. A classic example here would be an organisation professing to put the needs and wishes of service users first, but leaders demonstrating by their behaviour that money is more important. What the boss says and does is really important, and people quickly learn to concentrate on the real priorities!
  • We know that charismatic leaders can cast a shadow over their organisation. For the best kind of leader this can be inspiring and empowering for their people.  But poor leaders cast a more worrying shadow, especially if their subordinates emulate their boss to fit in to the culture of the team, to look good in the boss’s eyes and to focus their efforts on what they think is important to the boss.
  • Toxic workplaces also flourish in “closed communities”. By this I mean organisations that don’t open themselves up to hiring external talent, that routinely promote from within to senior positions and that appoint few leaders from outside. This can result in an organisation which lacks external reference points around good practice and professional behaviour. Organisations have a strong immune system and the protective culture in such organisations can actively resist newcomers, and can quickly lead new people to feel isolated and powerless to change things.

In top teams in these organisations, an “echo chamber” can develop that reinforces long held views, that resists innovative thinking and that perpetuates “the way we’ve always done things around here”. And in these circumstances bad behaviour and ways of working that would not be accepted elsewhere are accepted here because it’s the norm. And it’s not just new people that organisations resist. A characteristic that is often linked to the previous one is when an organisation puts up barriers and doesn’t welcome an exchange of ideas with the external environment. Healthy organisations have very permeable boundaries and their leaders have a lot of external contacts and encourage the sharing of ideas. Toxic workplaces tend to be the opposite.

NHS toxic culture challenges

Toxic workplaces are also characterised by a serious disconnect between senior leaders and the front-line. Obviously, senior leaders cannot be everywhere, all of the time. But leaders who are not visible and do not make enough effort to get to know their front-line staff, or to understand their experience, will always struggle to close that gap with their people. And if people think that their leaders are unapproachable, they will not approach them. So, the voices of your people, the people they serve and their families are unlikely to be heard

Managing a large organisation in health or social care is complicated and it places serious demands on the best leaders. Success at this level needs a remarkably wide range of competencies, including emotional intelligence as well as business skills. By the time senior leaders make it to the top of their organisation they’ve often shown considerable talent, hard work and effective performance. But few of us are perfect, even at that level, and it is essential to remain open to opportunities to learn. I have known toxic workplaces that have resulted from senior leaders simply not being competent enough to do their job, or not being open enough to accept that they need to improve.

A final point which I haven’t seen discussed much in the literature is the impact of rapid growth on culture. Where organisations grow quickly, particularly through mergers and acquisitions, it can be difficult to maintain a strong and positive culture. Integrating cultures where organisations come together requires a great deal of thought and time. Even organisations with very good cultures can lose their way if they grow too quickly and without sufficient thought.

I have no direct experience of the difficulties that the leadership of NHS Test and Trace is experiencing. But I would be surprised if they are not struggling with the challenges of harnessing the different cultures in the public and private sector teams that are working together to deliver the programme.  The political pressure the organisation is under, and the public scrutiny of the work that Test and Trace people are doing is immense.  And this means that the challenge for effective senior leadership is huge.  Fixing the “NHS toxic culture” must be a top priority.


If you want to learn more about NHS toxic culture and Verita’s approach to helping organisations with culture issues, please book a free consultation or contact Ed Marsden on 020 7494 5670 or [email protected].


1 thought on “NHS toxic culture – understanding the symptoms and causes”

  1. Hi.
    I work in the NHS. I believe that our department is a toxic work place.
    Reading some of your article has confirmed this for me.
    Years of trying to make sence of it all, asking myself the questions, ‘ is it me!’
    I know root cause, but what can we do, where do we go?
    Nothing ever changes dispite the obvious.

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