'Academic warns 'toxic' NHS needs major overhaul if lessons are to be learnt from Lucy Letby case'
'A former NHS employee turned academic has spoken out about how the NHS is "toxic" and plagued by a "culture of fear" with staff "lacking a voice", in the aftermath of the Lucy Letby case. Dr Rachael Pope shared her disturbing research findings with CheshireLive after hearing editor-in-chief Marc Waddington discussing media coverage of the Letby case on The Media Show on BBC Radio 4...' Ockendon Report 30 March 2022 – Shrewsbury and Telford NHS Trust – Review of maternity services5/1/2022 Yet again I despair. Yet more tragedy and harm to babies and families in the NHS. The words failure and failed are repeated many times throughout the report. The failures are described as ‘systemic’.
‘The Shrewsbury and Telford Hospital NHS Trust is about an NHS maternity service that failed. It failed to investigate, failed to learn and failed to improve and therefore often failed to safeguard mothers and their babies at one of the most important times in their lives.’ (p.i). There is evidence of bullying and dysfunctional behaviours and a culture of fear; the fear of speaking out. There were failures in ‘governance and leadership’ (p.x). ‘The Trust consistently demonstrated negative behaviours and practices, resulting in many staff learning to accept poor standards as it became the cultural norm; this constitutes organisational abuse’ (p.66). ‘…staff members described a ‘clique’ on the labour ward at the Trust with a culture of undermining and bullying…Many staff members told the review team of the fear of speaking out within maternity services. This included those who are currently working in maternity services at the Trust.’ (p.184). ‘It is imperative to ensure the ‘culture’ within all healthcare settings is one that promotes openness, transparency and the psychological safety to escalate concerns. Yet the review team found evidence of disempowerment, with staff encouraged not to complain or raise awareness of poor practice within both personal and professional capacities.’ (p.66) Sadly none of these behaviours are new to the NHS and as many commentators have identified many other reports have highlighted failures and cultural problems – e.g. Gosport, Mid Staffs, Bristol Royal Infirmary, Alder Hey, Morecombe Bay, East Kent, Nottingham and the contaminated blood scandal with the current inquiry underway. Stephen Glover writes in the Daily Mail that ‘Until we admit that there is something rotten at [the] heart of the NHS, these scandals will never stop’. ‘The evidence is overwhelming. It is also deeply shaming.’ (31 Mar 22). ‘This is possibly the biggest scandal of all — the pretence by politicians of all parties that 'our cherished NHS' offers unparalleled service’. ‘…with the NHS we are all-forgiving. We are in the grip of a collective delusion. A fantasy, even...many of us — believe that the NHS is wonderful and unique. It is the envy of the world (it's not, of course). We close our eyes and block our ears.’ Canon Angela Tilby on Thought for the Day (31 Mar 22) also made reference to the multiple reports detailing ‘…there is something wrong with the culture of our much loved NHS’. ‘Two years ago we were clapping for carers at the start of the Covid crisis, yet I remember wondering then , even as I joined in whether we weren’t engaged in some curious ritual in which we were suppliants bringing our tribute of praise and prayer, as to a deity. It’s been said before that the NHS is the nearest thing we have to a national religion. Perhaps we haven’t recognised how that distorts our relationship with it’ Allison Pearson in the Telegraph writes that the maternity report ‘proves the NHS is not a national treasure – it’s a national disgrace…Contrary to its humanitarian branding, the NHS is a Stalinist organisation with a culture of institutionalised bullying’. There is an ‘abusive, co-dependent relationship with the bullying, sometimes downright dangerous NHS’ (29 Mar 22). Very sadly, I agree with Stephen there is something rotten about the NHS, with Angela that we suffer from a distorted societal relationship, and Allison is correct, there is a ‘culture of institutionalised bullying’. The NHS does have Stalinist characteristics. I believe we are suffering from a collective societal delusion that results in some very dysfunctional and destructive behaviour which blocks improvement. Stephen Glover asks ‘…will we ever wake up? He believes the NHS is regarded as untouchable. In 2015 in my PhD thesis (p.219) I wrote the following: ‘Currently, the researcher has little optimism regarding the possibilities of bringing about change; such is the engrained nature of the problems over many years and the overall political control. The NHS may just continue to crash from one disaster to another. Tragically, it may be that the NHS will require further disasters to shock it into more serious focused action. “A common form of shock is media exposure. Significant negative exposure creates a socially undesirable image, often galvanising change” (Ashforth and Anand, 2003, p.38). It requires a significant organisational effort to remove normalised corruption.’…The NHS does seem to be very “deaf” and extremely resistant to cultural change.’ One participant said the NHS “Needs a complete wipe-out. Take everybody out and put them back in again. Retrain the managers. Need to have people in the caring system who care. Taking the bureaucracy out of the care system. It is plagued by bureaucracy...Whole of system is flawed. Lost in politics”. Another said it “Would have to be something gigantic...to break the culture”. Another said “I think to eradicate this endemic culture in the NHS is a fantasy! It will never happen until another generation!”’ In contrast, relating to the BRI inquiry and what they saw as “Kennedy’s fundamental errors” a further person had a very different view. “That cultures take a long time to change - they don't; true leaders can change them overnight. Evidence of it every day”. Sadly, the NHS has had multiple shocks from the media, but it has not responded appropriately. I wonder how many times the NHS has to be shamed before it takes the issue of positive cultural change seriously. Let’s hope that the person who had optimism and hope about the possibility of change taking place is right. I ever have to hope! 5 December 2020
NHS ‘cover-up culture’: Elizabeth Dixon deserved better Everywhere we look there seems to be evidence of dishonesty. We have the recent reports about the secretive and dishonest responses of the Catholic and Anglian churches as described in my last blog. Hiding the ‘dirty linen’ of child abuse. This week at the Grenfell Inquiry we heard about the dishonesty in the organisations supplying insulation. Now we have the report by Dr Bill Kirkup 'The Life and Death of Elizabeth Dixon: A Catalyst for Change'. This clearly identifies the existence of yet another NHS cover-up ‘…propped up by denial and deception’. 'Elizabeth’s profound disability and death could have been avoided had basic clinical principles been followed. There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later. Instead, a cover up began on the day that she died, propped up by denial and deception, which has proved extremely hard to dislodge over the years. The fabrication became so embedded that it has taken a sustained effort, correlating documents from many sources and interviewing key participants, to demolish it…some individuals have been persistently dishonest, both by omission and by commission, and that this extended to formal statements to police and regulatory bodies. Had police examined the events after Elizabeth’s death this must have become evident, but they closed their investigation without doing so. This represents a clear failing in the police investigation which should now be the subject of a statutory referral to the Independent Office of Police Conduct.’ (p.vii). The parents Anne and Graeme Dixon have had to fight for the truth about Elizabeth’s death for 20 years. No parent or person should have to fight like that to get to the truth. It is shocking and shameful. In the NHS there are many cover-ups. Dishonesty seems to be engrained and instinctive; the automatic response. This toxic culture is clearly detailed in John England’s book ‘NHS Dirty Secrets’. He describes the cover-up culture as pervasive, virulent and institutionalised. ‘NHS managers want to see no evil and hear no evil as per the institutionalised concealment and cover-up culture of the NHS’ (pp.100-101). A ‘Triad of Factors’ constitute and maintain this culture; propaganda, maskirovka (masking), and bullying. There is ‘frothy propaganda’. He writes ‘The cover-up culture is the endemic response to hiding the truth about any issue that would reflect badly on the various NHS managers and officials in the NHS hierarchy, all the way up to the higher echelons of government. Hiding the truth about an issue can take the form of concealment, diversion, disguise, deflection, denial, and broadcasting false information’ (p.337). Anyone who wants to understand the dysfunctional behaviours they see and experience in the NHS, should read this book. John is very clear that we cannot have a patient safety culture in the presence of the engrained, dishonest cover-up culture. For the sake of the Elizabeth Dixons of this world change has got to come. We need a ‘safety culture’ where learning is valued. Elizabeth and her family deserved better. 14 November 2020
A lecturer on discourse analysis made a statement at a seminar that “organisations always protect themselves”, citing the book ‘How institutions think’ by the anthropologist Mary Douglas (1986). This statement and book resulted in a significant shift in my thinking and brought clarity and a new direction to my research in the NHS. Douglas considers that institutions promote their ‘...righteous image’ (p.112), and ‘...endow themselves with rightness’ (p.92). They ‘…have the pathetic megalomania of the computer whose whole vision of the world is its own programme’ (p.92) and ‘...create shadowed places in which nothing can be seen and no questions asked’ (p.69). Andrew Brown interprets the ‘shadowed places’ as relating to the pervasiveness of rationalisations. He argues that groups and organisations, ‘...literally have needs for self-esteem that are regulated narcissistically’ (1997, p.649). ‘Just as individuals seek to regulate their self-esteem through such ego-defense mechanisms as denial, rationalization, attributional egotism, sense of entitlement, and ego aggrandizement, which ameliorate anxiety, so too do groups and organizations’ (p.643). The report published in 2009 on the Irish Catholic Church child abuse scandal identifies such ego-defensive mechanisms. The conclusions stated that ‘The desire to protect the reputation of the congregation and institution was paramount’ (Commission to inquire into child abuse, 2009, p.454). In October 2020 the Anglican Church in England and Wales also came under the microscope as part of the Alexis Jay Independent Inquiry Child Sexual Abuse. ‘The culture of the Church of England facilitated it becoming a place where abusers could hide…alleged perpetrators were treated more supportively than victims…the Church’s neglect of the physical, emotional and spiritual well-being of children and young people in favour of protecting its reputation was in conflict with its mission of love and care for the innocent and the vulnerable.’ (The Anglican Church: Safeguarding in the Church of England and the Church in Wales, October 2020, p.vi). Again we see that desire to protect the reputation and self-image. On 10 November 2020 we return to the Catholic Church, but this time for England and Wales with another report with very similar criticisms (The Roman Catholic Church: Safeguarding in the Roman Catholic Church in England and Wales 2020). ‘…faith organisations are marked out from most other institutions by their explicit moral purpose. The Roman Catholic Church is no different. In the context of the sexual abuse of children, that moral purpose was betrayed over decades by those in the Church who perpetrated this abuse and those who turned a blind eye to it.’ Again the Church failed to protect the physical, emotional and spiritual well-being of children and young people ‘…in favour of protecting its reputation’ (p.6). Two authors shed a little light on this overriding obsession with protecting the organisational reputation and image. According to Ricardo Blaug in ‘How power corrupts’, with increased status there is a blurring of the boundary between the person and the organisation and an increased defensiveness. “Increasingly, you identify with the organisation; you bring it into yourself and meld its interests with your own. Slowly but surely, you are becoming a centaur: part individual, part organisation. Any slight against the organisation is now one against your very self” (2014, p.94). Howard Schwartz writes ‘...to the extent that the individual’s identity is an organizational identity, threats to the organization are experienced as threats to the individual. Thus, defense of the organization becomes self-defense...it is not only real threats to the organization that are seen as reprehensible acts of aggression. It can even be mere threats to the image of the organization as perfect.’ (1987, pp.333-334). The NHS is a very defensive organisation with its constant desire for ‘good news’ and the burial and hiding of the ‘bad’; the ‘cover-up culture’ as described by John England in his book ‘NHS dirty secrets’. The child abuse reports provide interesting comparative material regarding behaviour and responses to concerns and complaints. The Churches and the NHS all have an overwhelming and paramount concern for protecting the reputation and external image. This seems to be put before every other moral concern. All are supposed to have an ‘explicit moral purpose’. All have failed to live up to that positive purpose. It seems the lecturer was right. “Organisations [do indeed] always protect themselves”. 9 November 2020
Thank you to Dr Mark Hughes @OCReviewDesk for his review of my article on Organisational Silence in the NHS. 'Organizational silence is not acknowledged enough in #orgchg theories and practice. In this video https://youtu.be/NyD7CJo3GTc I showcase Rachael's @nhsculture_pope fascinating research-informed account of organizational silence in the #NHS.' Organizational Silence in the NHS: ‘Hear no, See no, Speak no’ (2019). Organizational Silence in the NHS: ‘Hear no, See no, Speak no’. Journal of Change Management: Vol. 19, No. 1, pp. 45-66. tandfonline.com 9 August 2020
Systemic injustice – (3) Reframing of reality My doctorate research identified the denial, reframing and redefining of reality present in the NHS. This behaviour is very pervasive and destructive to patients, their relatives and staff. Institutions are places where wrongdoing and perversity can flourish. ‘The NHS: Sticking fingers in its ears, humming loudly’ ‘Organizational Silence in the NHS: ‘Hear no, see no, speak no’’ I particularly appreciate Chapters 20-23 in Tom Bell’s book ‘Lions, Liars, Donkeys and Penguins: The killing of Alison’. There are many words and phrases in these chapters that describe different aspects of this reframing and distortion of reality. The widespread pretence that things are what they are not. Here are some of those interesting words/phrases Tom uses: Post-honesty, fake news, finely polished bullshit, propaganda, cover-up, constant unchallenged stream of unicorn fluff, dark art of spin, illusionists guide to life, feigning authenticity in the pursuit of self-interest, insincerity, rose-tinted messages of success, a spin doctors dream, distraction from reality, rose-tinted positivism, rebranding, misdirection and spin, duplicitous utterances, bury bad news, mental acrobatics, self-delusion, manipulation of data, gaming of numbers, reinterpreting NHS data, manage performance data, turn a blind eye, scrutiny was resented, polished positive messages, ramblings of the positivity gurus and bullshit merchants, deceptive behaviours and the subsequent doublespeak, duplicity masquerading as noble intent, drawbridges of denial, hiding of incompetence and charades of false contrition when things go awry… I totally agree with his conclusions and share his deep concern about the state of our institutions in the UK. ‘To me it seems the collusive self-preserving harm accommodating culture that infected the NHS…is still thriving today’ (p.216)’ ‘The real crime within public sector circles is seldom the act, it is being found out. Possessing and displaying humanity, humility and morality has become a disadvantage, a weakness and hindrance to career progression, not qualities to be cherished or encouraged’ (p.219) ‘Patients continue to be needlessly harmed, lives unnecessarily lost, and justice denied to the victims and their families of a self-serving bureaucracy that seems incapable of acknowledging or learning from its mistakes, unable to empathise with those it fails and unwilling to challenge and hold accountable’ (p.216-217) These chapters in Tom’s book clearly expose the underpinning rottenness, dishonesty and perversity in the NHS, and the resulting ‘systemic injustice’. The NHS does indeed seem to be a place where you have to ‘park your humanity and morals in defence of the indefensible’ (p.220). When an organisation becomes dominated and controlled by such behaviours it becomes very callous and dangerous. ‘The absence of a moral compass is [most definitely] costing lives’ (p.226) and causes much damage to anyone who dares to ‘shine a light’ upon the ‘dirty linen’. The NHS is a very ‘dark’ institution in the way it conducts its business. A major ‘clean up’ is required for the sake of us all. Brackets [] added by RP 4 August 2020
I have just finished reading Tom Bells book ‘Lions, liars, donkeys, and penguins: The killing of Alison’. It is essential reading for anyone who wants to understand more about how some of our institutions behave when challenged. The book identifies the dysfunction, perversity and rottenness that is present within the NHS, CPS and the police. Churches are also criticised. All not wanting to acknowledge their ‘dirty linen’ and failures. ‘Moving someone who likes having sex with patients into an administrative role seems a bit like giving Peter Sutcliffe an office job to keep him off the road and out of trouble. I would later find out to my cost, it’s not harming patients that gets you hounded out of the NHS, it’s telling the truth (p.107). Chapter 18 particularly details how people are up against the might of institutions. Blocks are put in the way of individuals at every turn. Deflection and disregard, and a very unequal fight. ‘When something goes wrong in the NHS, in public sector health and care services, the long-term impact of the damage to patients and their families is enormous, in many cases irreparable. But any initial harm done is often merely the start of a lengthy list of hurt, pain and unnecessary scarring inflicted on patients, where they are still alive, their families, friends and carers.’ (p.175). ‘People dealing with such intense and often unexpected grief should not have to navigate the internal machinations and politics of bumbling duplicitous public sector bodies.‘ (p.184). What happened to Alison is appalling and shocking. The situation clearly identifies the pervasiveness of dishonesty and ‘systemic injustice’ in our society. 22 July 2020
I have heard two interesting terms used recently. The first is ‘institutional paranoia’. This term was used in the context of the judgement on the Post Office in a civil litigation case. ‘A theme contained within some of the internal documents is an extreme sensitivity (seeming to verge, on occasion, to institutional paranoia) concerning any information that may throw doubt on the reputation of Horizon, or expose it to further scrutiny’ Postmasters (women and men) were treated appallingly and very unjustly. Some went to jail when they had done nothing wrong. Others lost their money, careers and livelihoods. Lives were destroyed. They have had to fight for justice for many years. The NHS also suffers from ‘institutional paranoia’ with its extreme sensitivity to any challenge of its reputation. It is exquisitely sensitive to any criticism and exceedingly defensive. The other term is ‘systemic injustice’. The ‘institutional paranoia’ with the obsession with image and reputation drives and underpins the resulting ‘systemic injustice’. ‘Systemic injustice’ was a term used by David Davis MP on Radio 4 when he was interviewed recently, referring to problems within the police service, but also to other institutions where justice was not forthcoming. There seem to be many situations of ‘systemic injustice’ in the UK. The behaviour is the same. People are harmed, not listened to and feedback, criticism and truth are rejected e.g. Hillsborough, Windrush, The Post Office, Tainted Blood scandal, Stephen Lawrence, Alison Bell, 1950s women, Gosport, Mid Staffs, Southern Health and many other NHS organisational examples. The latest Cumberlege report (8 July 2020) yet again identifies the many cases of harm where patients have not been listened to, and treated unjustly, in the NHS and the wider system. ‘We have found that the healthcare system – in which I include the NHS, private providers, the regulators and professional bodies, pharmaceutical and device manufacturers, and policymakers – is disjointed, siloed, unresponsive and defensive. It does not adequately recognise that patients are its raison d’etre. It has failed to listen to their concerns and when, belatedly, it has decided to act it has too often moved glacially. Indeed, over these two years we have found ourselves in the position of recommending, encouraging and urging the system to take action that should have been taken long ago.’ (pp.i-ii). ‘We heard about a system that…lacks the leadership to deliver coherent and fully integrated patient safety policy directives and standards. Mistakes are perpetuated through a culture of denial, a resistance to no-blame learning, and an absence of overall effective accountability.’ (p.7). Interview with Baroness Cumberlege Woman’s Hour 11 July 2020 1-23 mins. In all these situations and cases people have had to fight, and fight hard, for their voices to be heard and for justice, often for many years. Many are still fighting. There seems to be a toleration of wrongdoing and injustice at the core of our institutions and our government. That should not be. 16 April 2020
There is The Beast, a very large beast; the “envy of the world”. The home of secrets. The People of The Beast worship The Image. The Image is called The Perfection or The Righteous Image. The Controllers protect The Perfection. All is well here. A Voice suggests an improvement. The Beast shifts uncomfortably, eyes moving and watching, grumbling in its throat. Watching The Voice. The Beast slightly turns its back, continuing to watch. There was the smallest suggestion that all is not well. Voices dare to raise concerns: patient care, health & safety, staff welfare. The Beast doesn’t listen at first, but as The Voices get louder, growls and spits warningly. “The answers are in the room, but they do not want them”. The Voices go quieter and then are silent. The Voices are learning to be quiet; it’s what happens here. Nothing will change, so there is no point. The Controllers control The Voices. Other Voices use the words, bullying, harassment, abuse, incivility, aggression, intimidation, negative behaviour. Action is required. The Beast is enraged. This threatens the very heart of The Beast. Its thinking, feeling, the very fibre and spirit of its being. The guts of The Beast. How can it exist without the tool of intimidation? How can it keep control? It enjoys it. Satisfies its needs. The Beast is scared. Scared of The Truth. Scared of secrets being exposed. Dirty Linen must not be washed. Scared of the myth of perfection being shattered. The Beast breathes fire, lashing out menacingly. The Voices cower, fear rising. The Voices go silent and some leave The Beast. They must learn to be quiet, and not challenge. Obedience, conformity, and silence are the hallmarks of The Perfect Employee. They will do well. Insubordination is not tolerated. The Constitution of The Beast states that The Voices must be positive. No ‘bad news’ or criticism to dent the shiny image. The Beast is “unimpeachable”. “…you cannot, cannot criticise”. The Beast settles back comfortably, happily smiling its perfect smile to The Outside World. Its back is completely turned. The Perfection, The Righteous Image is worshipped. All is well here. The secrets are kept. The Controllers protect and control. There must be no challenge to The Perfection. No challenge to the Righteous Image. Rachael Pope 16 February 2020 |