How do you change the culture of an organization or society? I ask because of Robert Francis's claim that "a fundamental culture change is needed" in the NHS.

This runs into the problem described by Phil Hammond in the Times - that the Kennedy report into excessive deaths of babies at Bristol Royal Infirmary 12 years ago made similar recommendations to Francis, which do not seem to have been heeded. Merely recommending change, therefore, is not sufficient says Hammond:

We've learnt that large, distant regulators and centralized management don't work..Time for a bottom-up revolution rather than more top-down pressure.

You might think I'd agree. But I'm not sure. Mere institutional change on its own isn't sufficient to change things for the better, as Acemoglu and Robinson say in Why Nations Fail:

There should be no presumption that any critical juncture will lead to a successful political revolution or to change for the better. History is full of examples of revolutions and radical movements replacing one tyranny with another (p111).

For example, the collapse of Tsarism didn't end Russians' desire for a strong leader, and after decolonization African leaders merely continued the exploitative practices of their colonial predecessors.

There's a reason for this. Institutions shape culture, and the imprint of institutions lasts after the institutions themselves disappear.

This problem afflicts individual organizations as well as societies. Jeffrey Nielsen has described how hierarchical organizations breed "rank-based thinking" and demotivated employees; in saying this, he's channelling Tocqueville, who argued that democracy's great virtue was that it "spreads throughout the body social a restless activity, a superabundant force, and energy never found elsewhere."

Now, if a man has been hit by a bus you cannot restore him to health merely by reversing the bus. Institutional change doesn't immediately create the sort of energy which motivates individual workers to challenge bad practice. Francis calls for "openness, transparency and candour throughout the system". But it doesn't follow that open structures will create an open culture. Nurses and junior doctors who have become used to not challenging managers and consultants might remain deferential.

Bosses are fond of the cliche "my door is always open." But they don't get a heavy footfall.

Marx was, arguably, awake to this problem. A precondition for successful revolution, he thought, was a change in working class "culture":

Where the working class is not yet far enough advanced in its organisation to undertake a decisive campaign against the collective power, i.e., the political power of the ruling classes, it must at any rate be trained for this by continual agitation against and a hostile attitude towards the policy of the ruling classes.

Herein, though, lies the problem. Insofar as institutions shape culture, the scope for cultural change is limited. At yet without cultural change, institutional change won't yield the results people hope for.

The question for anyone hoping to change the culture of an organization is the same it has been for Marxists for decades: is this an insuperable impasse or not?