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Medical leaders need help tackling 'diva' staff culture

Constructive working culture linked to better patient outcomes

Adrian O'Dowd

Wednesday, 14 August 2019

Clinical leaders need support in dealing with “problematic subcultures” within NHS organisation such as groups of “divas” within the workforce, according to the regulator the General Medical Council (GMC).

The regulator has today published its How doctors in senior leadership roles establish and maintain a positive patient-centred culture report which looks at what good leadership should be like and how it helps create better care for patients.


Research commissioned by the GMC and led by Suzanne Shale, a medical ethics consultant, involved in-depth interviews with 27 participants in senior leadership positions throughout the NHS, and focused on:

  • how medical leaders conceptualise and promote a positive culture
  • how they identify its presence or absence
  • how they approach the task of building or sustaining a positive culture in their workplaces.

Participants revealed that the most demanding, but often unsupported, step into senior leadership was the first one beyond the level of consultant.

They said leaders drew on their own knowledge and experience to shape interactions with colleagues, and developing leadership skills was often a matter of trial and error.

Comments from the interviews revealed that although they were positively-engaged leaders from diverse backgrounds, they were often unprepared and unsupported for the challenges of leadership during the early stages of their management careers.

Particular challenges included balancing competing priorities and demands, focusing on people and culture rather than tasks, and recognising and tackling problematic subcultures.

Five “notable clinical subcultures”, that could be harmful if allowed to develop, were identified as:

  • "diva" subcultures – powerful and successful professionals not held to account for inappropriate behaviour, who, if left unchecked, became viewed as untouchable with colleagues accommodating and working around them
  • factional subcultures – which arose when disagreement became endemic, and the team started to organise itself around continuing conflict with those in dispute seeking loyalty from colleagues
  • patronage subcultures – which arose around influential leaders who had social capital in the form of specialist knowledge, professional connections, high status, respect and access to resources
  • embattled subcultures – where resource had been inadequate, and unequal to demand, practitioners eventually became overwhelmed, leading to signs of chronic stress such as short temper, anxiety and burnout
  • insular subcultures – where some units became isolated from the cultural mainstream of a larger organisation, resulting in professional practice or standards of care that deviated from what was expected.

The report highlighted how damaging subcultures were a challenge to an organisation’s senior leaders, and once they became established, significant time and resources were required to turn them around.

Dame Clare Marx, GMC chair, said: “Positive workplace cultures are important in all sectors, but in healthcare they are especially crucial as they impact on patients as well as staff. Safe and high-quality care depends on a team working well, and that depends on them being led effectively.


“We cannot just assume that doctors in senior leadership roles will automatically be good leaders. Leaders are developed, not born, and doctors who choose to take on these roles deserve to have all the necessary support and resources to help them succeed.”

Suzanne Shale said: “The evidence we already have suggests there is a clear association between constructive working cultures and measurably better outcomes for patients. Senior leaders are vital in developing those cultures, and many fulfil that role to a very high standard despite the pressures they face.”

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