11.1. While I have toyed with an extensive analysis of what we mean by culture, a short definition is "a combination of behaviours which are repeated". Boxall and Purcell describe organisational culture as: ".... a system of shared values and beliefs about what is important, what behaviours are important and about feelings and relationships internally and externally." 
11.2. An article in the BMJ was drawn to my attention which seeks to tease out what culture means and how this relates to service performance, quality, safety and improvement. Its key messages remind us that:
- Organisational culture represents the shared ways of thinking, feeling, and behaving in healthcare organisations.
- Healthcare organisations are best viewed as comprising multiple subcultures, which may be driving forces for change or may undermine quality improvement initiatives
- A growing body of evidence links cultures and quality, but we need a more nuanced and sophisticated understanding of cultural dynamics
- Although culture is often identified as the primary culprit in healthcare scandals, with cultural reform required to remedy failings, such simplistic diagnoses and prescriptions can lack depth and specificity
Many Different Cultures
11.3. Sir Robert Francis notes that:
"There can also be various cultures within the same organisation. Different teams, different departments, and different hospital sites can all 'feel' different. A whistleblower interviewee described the contrast between teams in the same organisation, where one had good leadership that allowed people to address mistakes directly and question one another, and the other had a command and control style with 'an individualistic dynamic and a blame culture'."
11.4. In his discussion of the definition and exploration of culture in a healthcare context in the Mid Staffordshire NHS Foundation Trust Public Inquiry Report, Sir Robert reports that:
20.5: "Professor Charles Vincent sums up culture as meaning "how we do things round here", "here" being anything from a small group or team, to a whole organisation, a profession or a health system….."
20.6: "As Professor Vincent points out, an organisation may aspire to a common culture throughout, but in practice, in anything as complex and large as the NHS, culture can vary from organisation to organisation and from department to department." 
11.5. Again, this analysis has a strong resonance with the findings in this review, especially the idea that many different cultures may exist in one organisation, as this respondent told us from a rural area:
"I do also acknowledge that the size of the NHS makes it an unwieldy organisation and there is no doubt in my mind a pack/gang mentality can be easily formed in any department, staff grouping, committee etc. and that is what I felt I was up against."
11.6. Of course, there can be cultures that contribute to or create a set of circumstances (positive or negative) and cultures which address or fail to address these circumstances. It is multi-faceted.
11.7. Sir Robert refers to this observation:
"There exists a culture of bullying within the organisation that was largely covered up. For every case that comes to light, there is an iceberg of events that are simply not reported."
11.8. It is possible that what is reported in this report is the tip of a larger iceberg in NHSH. Only further exploration will elicit whether that is so.