This section on the NHS Culture website provides details and quotes from the latest reports/literature which identify cultural problems in the NHS.
Dr Bill Kirkup - October 2022 Reading the signals Maternity and neonatal services in East Kent – the Report of the Independent Investigation 'Culture of denial and resistance to change' (p.88). '...failed to ensure the safety of women and babies, leading to repeated suboptimal care and poor outcomes – in many cases disastrous...an unacceptable lack of compassion and kindness' (p.157). Tim Knox - Civitas - April 2022 International Health Care Outcomes Index 2022 See Nuffield Trust Blog by Mark Dayan also 'Tim Knox said: “This index compares our health care outcomes with those in similar countries. It’s impartial and based on an established methodology and comparable data that is available to anyone, anywhere. “If what matters most to patients is the outcome of the treatment that they will receive, then these findings should be of concern to all, not least as the least well-off are those who have no alternative to the NHS. “Our uncritical worship of the NHS means that it is difficult to ask questions of our health service and how it ranks against those of other nations. This index is meant to challenge our preconceptions.” Ockendon Report - March 2022 ‘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) ‘Other staff members described a ‘clique’ on the labour ward at the Trust with a culture of undermining and bullying. Some staff members described that this had negatively and seriously affected their mental health. Other staff members described that the behaviour experienced on the labour ward was so bad that they had difficulty finishing their shifts and cried secretly whilst in work. These staff declined for their direct quotes to be used, because they were fearful of being identified. 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) Health and Social Care Committee - 8 June 2021 'Workforce burnout and resilience in the NHS and social care' 'Burnout is a widespread reality in today’s NHS and has negative consequences for the mental health of individual staff, impacting on their colleagues and the patients and service users they care for. There are many causes of burnout, but chronic excessive workload is a key driver and must be tackled as a priority. This will not happen until the service has the right number of people, with the right mix of skills across both the NHS and care system.' 'It is imperative staff have the opportunity and the confidence to speak up. However, this needs to be matched with a culture in which organisations demonstrate that they are not just listening to, but also acting on, staff feedback.' Dr Bill Kirkup - 26 November 2020 'The Life and Death of Elizabeth Dixon: A Catalyst for Change' Report of the Independent Investigation' '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. The most troubling aspect of compiling this report has been the clear evidence that 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. Elizabeth’s parents, Anne and Graeme Dixon, have been denied confirmation for too long of the truths that they increasingly came to recognise about the loss of their daughter. The obvious but unimaginable distress that has been caused them is profoundly regrettable' (p.vii). Baroness Cumberlege - 8 July 2020 'First do no harm: The report of the Independent Medicines and Medical Devices Safety Review' '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) Press Conference Speech 8 July 2020 Michael West – The Kings Fund – 19 February 2020 ‘What does the 2019 NHS Staff Survey truly tell us about how staff needs are being met?’ ‘To start, we must be honest. The 2019 NHS Staff Survey results shows that though staff experience overall has improved slightly on many measures it has simply not changed substantially. Over the past five years there has been little meaningful change. Second, we must understand the basic core needs of NHS staff at work and ensure that we are meeting them for the sake of staff wellbeing and the ability to provide compassionate, high quality care. They are the needs for autonomy and control (in practice, voice and influence) in a fair culture; a sense of belonging and community in a supportive team and compassionate culture; and feeling of competence and effectiveness rather than a sense of moral distress that an excessive workload leads to compromising quality care.’ The Rt Revd Graham James - 4 February 2020 ‘Report of the Independent Inquiry into the Issues raised by Paterson’ ‘An opening statement by the Chair of the Paterson Inquiry The Rt Revd Graham James This report is not simply a story about a rogue surgeon. It would be tragic enough if that was the case, given the thousands of people whom Ian Paterson treated. But it is far worse. It is the story of a healthcare system which proved itself dysfunctional at almost every level when it came to keeping patients safe, and where those who were the victims of Paterson’s malpractice were let down time and time again. They were initially let down by a consultant surgeon who performed inappropriate or unnecessary procedures and operations. They were then let down both by an NHS trust and an independent healthcare provider who failed to supervise him appropriately and did not respond correctly to well-evidenced complaints about his practice. Once action was finally taken, patients were again let down by wholly inadequate recall procedures in both the NHS and the private sector. The recall of patients did not put their safety and care first, which led many of them to consider the Heart of England NHS Foundation Trust and Spire were primarily concerned for their own reputation. Patients were further let down when they complained to regulators and believed themselves frequently treated with disdain. They then felt let down by the Medical Defence Union which used its discretion to avoid giving compensation to Paterson patients once it was clear his malpractice was criminal. Only by taking their cases to sympathetic lawyers did some patients find themselves heard. By that stage many others found their exhaustion was too great and their sense of rejection so complete that they scarcely had the emotional or physical strength to fight any further. Even today, many patients, especially those treated within Spire hospitals, have no individual care plan. Thousands of people are still living with the consequences of what happened… This report is primarily about poor behaviour and a culture of avoidance and denial. These are not necessarily improved by additional regulation (p.6)… This capacity for wilful blindness is illustrated by the way in which Paterson’s behaviour and aberrant clinical practice was excused or even favoured. Many simply avoided or worked round him. Some could have known, while others should have known, and a few must have known. At the very least a great deal more curiosity was needed, and a broader sense of responsibility for safety in the wider healthcare system by both clinicians and managers alike. However, some seem to have been inhibited from complaining because they had seen colleagues appearing to get nowhere by doing so (and in some cases finding themselves under investigation). A few of Paterson’s more junior colleagues commented that the unusual character of his surgical practice (compared with other breast surgeons) was well known. To a surprising degree he was “hiding in plain sight”. (p.7)’ Patient Safety Learning - 2019 (added to website January 2020) ‘The patient safe future: A blue-print for action’ ‘Patient safety is a major and persistent problem Every year, avoidable harm leads to the deaths of thousands of patients, each an unnecessary tragedy. Unsafe care also causes the long-term suffering of tens of thousands and costs the health service billions of pounds… Systemic causes of unsafe care We believe that patient safety fails for one or more of the following systemic causes: • Patient safety is not regarded as a core purpose by leaders • Organisations do not take ‘all reasonable and practical steps’ to improve safety. • We don't have standards for patient safety in the way that we do for other safety issues, and those that we do have are insufficient and inconsistent. • We focus too much on responding to, and mitigating the risk of, harm. We don’t pay enough attention and take action to design healthcare to be safe for patients and for the staff who work within it. • We don’t learn well enough, share or act on that learning for patient safety. • Staff working in healthcare are not ‘suitably qualified and experienced’ for patient safety and are not properly supported by leaders and specialists in safety design and human factors. • Patients are not sufficiently engaged in their safety during care and after harm; patients need to be part of the team. • We don’t have good ways of measuring and performance managing whether we are providing safe care. • A culture of blame and fear undermines our ambitions to design and deliver safer care. Foundations of patient safety Patient safety is a system-wide challenge. We list below six evidence-based foundations for action to address the causes of unsafe care: 1 Shared learning for patient safety 2 Leadership for patient safety 3 Professionalising patient safety 4 Patient engagement for patient safety 5 Data and insight for patient safety 6 Just Culture These foundations form the basis of our Blueprint for Action.’ (p.6-7) Tom Kark QC and Jane Russell (Barrister) – November 2018 (added to website 3 October 2019) ‘A review of the Fit and Proper Person Test’ ‘The quality of management within the NHS is an issue of considerable national importance. The behaviour and ethos of staff within our hospitals are often heavily influenced by the behaviour and ethos of the directors on the Trust Board and especially those of the Chief Executive and the Chair.’ (p.3) ‘No hospital can run well with poorly led medical staff who do not or cannot focus on the care of the patients as being their first concern’ (p.3) ‘One of the identified problems relating to management in relation to those two organisational failures [Mid Staffordshire and Winterbourne View] was the ability of poorly performing managers and directors to move from Trust to Trust, often following a settlement agreement and a pay-off’ (p.3) Care quality Commission – September 2018 (added to website 21 September 2019) ‘Sexual safety on mental health wards’ ‘The alleged incidents were mostly carried out by patients (95% of all reports). However, in 51 (5%) of the reports, it was alleged that a member of staff was the person who carried out the incident.’ (p.9).
For staff to make sure that appropriate boundaries are maintained, they must communicate clearly to patients what behaviours are not acceptable and how the ward responds to sexual safety incidents.’ (p.13). Dr Suzanne Shale – March 2019 ‘How doctors in senior leadership roles establish and maintain a positive patient-centred culture: Research Report for the General Medical Council’ ‘Leader attitudes towards unwelcome information Leaders recognised that leadership teams sometimes defended themselves from unwelcome information in the same way that they observed clinical groups doing. The consequences of leaders denying bad news have been widely remarked ever since the Bristol Royal Infirmary Inquiry, and have been reprised in several inquiries since. Senior leaders were conscious of having to guard against three problematic responses: discounting bad news, dismissing it, and being immobilised in the face of difficulty… Negative behaviours from the top Close to a quarter of the sample (seven out of twenty seven medical leaders) reported having experienced negative behaviours directed towards themselves or senior colleagues either from the very top of their own organisation, from NHS Improvement, or from NHS England. At worst these behaviours correspond with descriptors of workplace bullying (Einarsen et al., 2009) and at lower levels with workplace incivility (Estes and Wang, 2008). Within organisations, senior leaders reported what they experienced as humiliating ‘assurance’ behaviour and senior management meetings that were toxic’ (p.33) All Party Parliamentary Group for Whistleblowing - July 2019 ‘Whistleblowing: The Personal Cost of Doing the Right Thing and the Cost to Society of Ignoring it’ ‘Forward On 10th July 2018 we held our inaugural meeting, well attended by MP’s, whistleblower constituents, the press and civil society organisations. Gosport Memorial Hospital was in the news that day, how whistleblowers had been ignored or silenced and how if they had been heeded lives could have been saved.’ Royal College of Obstetricians and Gynaecologists - 15-17 January 2019 ‘Report: Review of Maternity Services at Cwm Taf Health Board.’ ‘Conclusions Clearly, the review of the process for handling and responding to complaints and concerns and governance is a priority; interviews and engagement with women and families revealed serious issues about the way that concerns and complaints were investigated and responded to. Issues included: Failure to respond to ‘on the spot’ concerns expressed and examples of dismissive attitudes regarding issues raised by women on the ward or during appointments, with many women not being listened to or taken seriously. Poor communication in follow up meetings to discuss concerns and failure to apologise Lack of comprehensive investigation resulting in incomplete responses to concerns and lack of access to all appropriate information, notes being unavailable, missing elements from the record or inaccuracies, missing reports from the clinicians involved. Focus on providing responses that were formulaic and seemed to be more interested in defending the reputation of individuals and the Health Board. Letters of response often provided a summary of what ‘should have happened’ but did not provide answers to all of the concerns raised. Responses received that did not demonstrate how learning had been translated into action to ensure that this did not happen again.’ Patient Experience Library – April 2019 ‘Public Administration and Constitutional Affairs Committee: Inquiry to explore the findings of "Ignoring the Alarms" by the Parliamentary and Health Services Ombudsman. Written evidence submitted by the Patient Experience Library, April 2019’ ‘Evidence shows that the failures of investigation and learning highlighted in Ignoring the Alarms are not unique to Averil Hart's case. Neither are they unique to eating disorder services. They are systemic, and extend right across the NHS. A common factor throughout is a failure to hear from patients and bereaved relatives, and to understand the patient experience.’ Care Quality Commission – March 2019 “Learning from deaths: A review of the first year of NHS trusts implementing the national guidance” “Open and learning culture In our State of Care 2017/18 report, we commented on the link between the culture and the performance of an organisation, and how leaders are integral to setting a good culture, with capable, high-quality leaders creating workplace cultures that are conducive to providing high quality care. A culture that is open and transparent, and in which staff feel able to speak up and speak out, was also previously noted as one of the most valuable aspects of driving improvement in trusts. Analysis of our interviews and focus groups with inspection staff for this review suggests that the existing culture of an organisation can be a key factor in trusts’ ability to implement the guidance on learning from deaths, with inspection staff observing a difference between an open, transparent no-blame culture that is focused on learning, and an inward-looking, fearful culture, which can manifest in defensiveness and blame. As highlighted in the section on engagement with families and carers, negative cultural factors can include a fear of litigation, public perception, or confrontation with families, and a failure to engage staff with the trust’s cultural values or empower them to raise concerns. This supports the findings of our review of Never Events, Opening the door to change, which found that organisational and individual cultural issues could prevent the effective implementation of safety guidance. In that review, we also heard from other industries that it is culture that drives the reporting of and learning from incidents. To truly learn from serious incidents in the NHS, there needs be a culture where staff, patients and leaders all feel able to speak up and work collaboratively to learn.” (p.14-15). Latest NHS Staff Survey (2018) published February 2019 “NHS Staff Survey 2018 National results briefing” “The following percentage of staff experienced at least one incident of bullying, harassment or abuse in the last 12 months: “28.3% …from patients / service users, their relatives or other members of the public (q13a | 2017: 28.1%) 13.2%…from managers (q13b | 2017: 12.8%) 19.1%…from other colleagues (q13c) •An increase of over 1 percentage point since 2017 (18%)” Patient Experience Library – January 2019 “Developing a patient safety strategy for the NHS Proposals for consultation December 2018: Response from the Patient Experience Library, January 2019” “The consultation proposals recognise the learning from "the Gosport Inquiry and other inquiries such as those at Mid Staffordshire NHS Foundation Trust, and University Hospitals of Morecambe Bay NHS Foundation Trust ". Those inquiries found unsafe cultures on wards, in boardrooms, and in organisational processes such as complaints handling and communications. They also found that when patients and relatives tried to speak up about safety concerns, they encountered dismissiveness, defensiveness and outright denial. It would be a mistake to think that such punitive action towards patients is confined to one or two rogue Trusts. Six headline-hitting inquiries in five years (from the Mid Staffs report in 2013, through Morecambe Bay, Southern Health, Hyponatraemia, and Gosport, to Shrewsbury and Telford in 2018) form a roll call of unjust treatment of patients, stretching across the NHS. It is no wonder that fear of retribution inhibits many patients from voicing concerns. A just safety culture for patients would not allow punitive responses to legitimate concerns. The "just safety culture" principle proposed in the consultation document must result in justice for all.” (p.2) Care Quality Commission – December 2018 “Opening the door to change NHS safety culture and the need for transformation” “There is a contradiction between how health care culturally thinks about patient safety and the experience of individual members of staff. Staff know that what they do carries risk, but the culture in which they work is one that considers itself as essentially safe. We have repeatedly highlighted in our inspection reports that staff are often unwilling or unable to raise safety concerns. Raising concerns challenges the cultural norms of the workplace and the dichotomy between the safety reality and the safety culture may be the reason why this has proved such an intractable problem. Just like the persistent number of Never Events, our observations of this problem in our inspections sends us a message about the underlying weaknesses in the safety culture of the NHS. The contradiction between culture and reality also leads to defensive behaviour when things do inevitably go wrong. Defensiveness weakens our ability to understand why safety problems have occurred and too often leads to individuals being blamed for real or perceived errors. The safety experts we spoke to from outside health care told us that this behaviour led to increased risk. They also highlighted how they had learnt that hierarchical cultures were inimical to safety and had to be eradicated. In the NHS this lesson has not been learned and rigid professional and managerial hierarchies remain widespread. We have been constantly impressed by the commitment we have found in staff across the NHS to patient safety. Our challenge is to turn this commitment into real change for the better. Fundamentally, the safety culture of the NHS has to radically transform if we are to reduce the toll of Never Events and the much greater number of other safety events. Cultural change is not easy; the other industries we spoke to told us it had taken them years to achieve. Many will find challenge to their cultural norms to be uncomfortable. We have made recommendations that will start the process of building an NHS that delivers the safest possible health care. But mechanistic implementation of the recommendations alone will not be enough to achieve the change that is needed. A new era of leadership, focused on safety culture, engaging staff and involving patients is essential.” (p.4) Parliamentary and Health Service Ombudsman – December 2018 “Blowing the whistle: an investigation into the Care Quality Commission’s regulation of the Fit and Proper Persons Requirement” “…we accept that Ms K will have the retrospective knowledge that the CQC did not handle these FPPR matters properly which she found ‘galling’. In particular, she told us that it was upsetting to see the Chief Executive welcomed back into the NHS, following incomplete consideration of FPPR, while she felt ‘blacklisted’ by the NHS. Therefore, whilst we cannot say that the outcome would have been different, we accept that Ms K felt that the Chief Executive should not have met FPPR criteria and the knowledge that the CQC has not handled these matters properly will confirm that for her. For these reasons we accept that the CQC’s actions caused Ms K distress, frustration and upset – the CQC’s actions would have exacerbated the distress she felt about her own situation and given rise to a loss of opportunity for a robust outcome. Further, Ms K lost confidence in the CQC’s ability to properly regulate FPPR. These are injustices to her.” (p.27) “…where maladministration or poor service has led to injustice or hardship, the public body responsible should take steps to provide an appropriate and proportionate remedy. They also say that public organisations should seek continuous improvement, and should use the lessons learnt from complaints to ensure that maladministration or poor service is not repeated” (p.28) National Guardian office – December 2018 “A review by the National Guardian of speaking up in an NHS trust” “The National Guardian’s Office has conducted a review of the speaking up processes, policies and culture at Royal Cornwall Hospitals NHS Trust, in response to information the office received that the trust’s response to the concerns raised by its workers was not in accordance with good practice.” “The review found evidence that the trust did not always respond to instances of its workers speaking up in accordance with its policies and procedures, or with good practice. Such responses contributed to a belief among some of the workers who spoke to our review that there was not a positive speaking up culture in the trust and that the issues that they raised were either poorly handled, or ignored by management” (p.3) Andrew Gent - Ashfold Consulting Limited - December 2018 “Bullying and harassment at the Lewisham and Greenwich NHS Trust: An Independent Inquiry Report” “Principal Key Findings Whilst bullying in the Trust is not described as institutionalised, it is however widespread in that it is evident across all sites, in all divisions, at all levels and perpetrated by managerial, non-managerial and clinical staff. To this extent, it is embedded in the culture of the organisation. The prevalence of overt bullying, both witnessed and reported, particularly at the most senior levels, coupled not only with a lack of visible action to address it, but a laissez faire attitude which appears to condone it, can be interpreted as a lack of willingness to recognise and tackle bullying behaviour. This apparent inaction has damaged the reputation and credibility of the executive leadership, as it existed at that time, both at a collective and, in some cases, individual level… (p.7). “Many examples were given of members of the senior leadership team demonstrating a leadership style that at best was described as ‘menacing, threatening and heavy handed’. These behaviours were regarded as part of the day to day persona of the individuals concerned often excused as “Oh well that’s how they are” or “they are really, really stressed” seemingly legitimising the behaviour, which became an accepted part of life for those more junior.” (p.47). Sir Anthony Hooper – 19 March 2015 “The handling by the General Medical Council of cases involving whistleblowers: Report by the Right Honourable Sir Anthony Hooper to the General Medical Council presented on the 19th March 2015” “16. There is considerable evidence that, in the workplace, persons who raise concerns about a danger, risk, malpractice or wrongdoing that affects others, may well suffer, or believe that they will suffer, reprisals at the hands of an employer or fellow workers.12 17. Employers and fellow workers may resort to reprisals against those who raise concerns in order to protect the reputation of the organisation or of a fellow (often senior) worker… 19. In the Introduction to his Report, Sir Robert paints a bleak picture: “The number of people who wrote to the Review who reported victimisation or fear of speaking up has no place in a well-run, humane and patient centred service. In our trust survey, over 30% of those who raised a concern felt unsafe afterwards. Of those who had not raised a concern, 18% expressed a lack of trust in the system as a reason, and 15% blamed fear of victimisation. This is unacceptable. Each time someone is deterred from speaking up, an opportunity to improve patient safety is missed.”” Care Quality Commission - 29 November 2018 “Shrewsbury and Telford Hospital NHS Trust Inspection Report” “Staff reported a culture of bullying and harassment and at times we found a culture of defensiveness from the executive team” (p.13) “The disjointed approach of the leadership team and ineffective systems mean that the trust did not maximise opportunities to learn and improve” (p.13) “Staff felt they were not listened to and were sometimes fearful to raise concerns or issues” (p.14). Sir Ron Kerr - 28 November 2018 “Empowering NHS leaders to lead” “The conditions in which leaders operate are stressful and difficult, with great responsibility and the highest stakes. Over time, this has led to a negative working culture in which both bullying and discrimination are prevalent and accepted. This must change and should be led from the top, with NHS leaders ensuring they model the highest standards of behaviour. The review recommends a number of actions to build a modern working culture in which all staff feel supported, valued and respected for what they do and can challenge without fear.” (p.12) “…the review also found strong evidence of a culture of “negative behaviours” - which often stemmed from the different relative priorities and pressures between regulators and organisations. The behaviours described fall below the standards of what is expected in a professional setting. Some leaders told us that they did not feel confident that speaking out about these behaviours would make a difference.” (p.14) Care Quality Commission – 28 November 2018 “Norfolk and Suffolk NHS Foundation Trust Inspection Report” “At our inspection of 2017, we had significant concerns about the safety, culture and leadership at the trust. We told the trust that they must urgently address concerns and meet regulation. At this inspection, we found that some of our significant concerns, some that we had raised with the trust in 2014, had not yet been fully addressed. We found that the board had not driven effective change at a pace and with sufficient traction to bring about improvements needed to resolve the failings in safety and to bring about sustained improvement. When we last inspected, we told the trust leadership that they did not demonstrate a safety narrative running through the organisation and that that they should ensure that learning was captured from incidents and concerns. At this inspection, we found that the safety culture has not yet fully developed. Managers did not ensure that learning from incidents was shared and embedded across the trust. Not all ward and community environments were safe... We found widespread low morale across services. This was attributed to a “do unto” attitude staff felt came from senior management and directors” (p.5). Dr Bill Kirkup - January 2018 “Report of the Liverpool Community Health Independent Review” The ‘…management of the organisation was excessively top-down, with a punitive and blame culture that spread throughout the organisation’. It was ‘...a dysfunctional organisation from the outset’ (p.4). The HR department was ‘…chaotic’ and there was ‘…documentary evidence of some appalling instances of staff treatment, including individuals who were suspended for prolonged periods with no apparent rationale or process for resolution’ (p.19). British Medical Association – October 2018 “Bullying and harassment: How to address it and create a supportive and inclusive culture” Surveying UK doctors “Two in five doctors say bullying and harassment are problems in their workplace. One in five say they have personally experienced it in the past year.” (p.1) Rachael Pope – Journal of Change Management – 5 September 2018 “Organizational Silence in the NHS: ‘Hear no, See no, Speak no’” “ABSTRACT There have been major health care failings in the UK National Health Service (NHS) over many years. The persistent dysfunctional organizational culture, an inability to learn and the need for change has been identified within literature. The concept of organizational silence forms one aspect of the proposed model of organizational dysfunction in the NHS. Forty-three interviews and six focus groups have been conducted to test the model. From generalized evidence, it is suggested that the NHS is systemically and institutionally deaf, bullying, defensive and dishonest. There appears to be a culture of fear, lack of voice and silence. The cost of suppression of voice, reluctance to voice and the resulting ‘sea of silence’ is immense. There is a resistance to ‘knowing’ and the NHS appears to be hiding and retreating from reality. There is an urgent need for action to be taken to address this dysfunctional culture. The NHS needs to embrace the identity of being a listening, learning and honest organization, with a culture of respect. It needs to choose to hear, see and speak for the benefit of patients and staff. There are implications for the wider UK society due to the apparent inability to learn and improve.” Hansard – 18 July 2018 “NHS Whistleblowers” “Dr Philippa Whitford (Central Ayrshire) (SNP) I beg to move, That this House has considered NHS whistleblowers and the Public Interest Disclosure Act 1998. It is an honour to serve under your chairmanship, Mr Davies. Gosport, Morecambe Bay, Mid Staffordshire and Bristol Royal Infirmary are NHS scandals that all have quite a few things in common: they went on for a long time and often whistleblowers who might have brought the issue to an end and saved lives were punished or ignored. They were certainly intimidated. The anaesthetist who raised the issue of baby cardiac surgery at Bristol Royal Infirmary ended up in Australia… In the investigation into Mid Staffordshire, which was the worst NHS scandal, Sir Robert Francis’s report spoke about developing a “freedom to speak up” culture, to make doing so normal. Sir Robert suggested only minor changes to the Public Interest Disclosure Act 1998 but, as I will come on to later, I think it needs major change because it underwrites everything else.” Care Quality commission - 13 July 2018 "Wirral University Teaching Hospital NHS Foundation Trust: Inspection Report" “There was not always a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Some staff informed us that they had witnessed or experienced bullying or harassment and we found that when concerns had been raised, they had not always been dealt with in a timely manner.” (p.3) Academy of Medical Royal Colleges and Faculties in Scotland – April 2018 “Review of Whistleblowing Allegation: Final Report - NHS Lothian - November 2017-March 2018” “Concerns were raised by some staff who felt bullied and harassed at two sites (SJH and RIE) which appears to have been exacerbated by the lack of robust management structures and governance at site level. NHS Lothian has had a previous review into its culture and, despite action being taken, we felt that this had not yet been fully embedded at all levels of the organisation. We were concerned by the experience of some staff who had raised concerns (out with whistleblowing); they felt that the response they received from their managers may discourage them from using the NHS Lothian processes for raising concerns. We met with staff who felt they had been admonished and blamed rather than supported.” “Priority recommendations – to commence within the next 6 months (i)… Culture 1.Develop a more transparent culture within NHS Lothian that enables staff at all levels to report concerns without fear of repercussions. Adopt and deliver zero tolerance of behaviour that could be construed as bullying and harassment. The relevant NHS Lothian policy should be reviewed in line with the revised PIN Policy and all staff required to demonstrate adherence. 2. Through existing programmes NHS Lothian should continue to facilitate sessions on culture and values, particularly for the site leadership teams, the site and capacity and senior nursing teams. At the centre of any OD programme there should be a focus on patient safety and quality of care to give staff confidence especially when systems are under pressure.” Gosport Independent Panel - 20 June 2018 “Gosport War Memorial Hospital: The Report of the Gosport Independent Panel” "Foreword by The Right Reverend James Jones KBE When I first came to Gosport and met those who had historical concerns about how their loved ones had been treated in the town’s War Memorial Hospital, there were eight families. Once the Independent Panel had been set up, we were soon in touch with over 100 families. The shocking outcome of the Panel’s work is that we have now been able to conclude that the lives of over 450 patients were shortened while in the hospital, and to demonstrate that those first families were right to persist in asking questions about how their loved ones had been treated. Over the many years during which the families have sought answers to their legitimate questions and concerns, they have been repeatedly frustrated by senior figures. In this Report, we seek to understand how and why this has happened. The obfuscation by those in authority has often made the relatives of those who died angry and disillusioned. The Panel itself felt some of that frustration directed towards ourselves at the beginning of our work. The families had already been let down so often that they saw no reason why they should trust a Panel set up by the Government, albeit an independent one. Some of the family members are the first to acknowledge that their quest for truth and accountability has had an adverse effect on their own lives. They know that the frustration and anger that they feel has sometimes consumed them. This in turn has no doubt made those in authority less inclined to build a bridge towards them and to investigate their concerns thoroughly. But what has to be recognised by those who head up our public institutions is how difficult it is for ordinary people to challenge the closing of ranks of those who hold power. It is a lonely place, seeking answers to questions that others wish you were not asking. That loneliness is heightened when you’re made to feel even by those close to you that it’s time to get over it and to move on. But it is impossible to move on if you feel that you have let down someone you love, and that you might have done more to protect them from the way they died. Many of the families to whom the Panel has listened feel a measure of guilt, albeit misplaced. The anger is also fuelled by a sense of betrayal. Handing over a loved one to a hospital, to doctors and nurses, is an act of trust and you take for granted that they will always do that which is best for the one you love. It represents a major crisis when you begin to doubt that the treatment they are being given is in their best interests. It further shatters your confidence when you summon up the courage to complain and then sense that you are being treated as some sort of ‘troublemaker’. Many of the family members from Gosport have a background in the services. They were brought up to believe that those in authority are there to serve and to protect the community. The relatives did not find it easy to question those in senior positions. It says something about the scale of the problem that, in the end, in spite of the culture of respecting authority, the families, as it were, broke ranks and challenged what they were being told about how their loved ones were treated and how they died." University of Bristol Norah Fry Centre for Disability Studies – 4 May 2018 “The Learning Disabilities Mortality Review (LeDeR) Programme” “The persistence of health inequalities between different population groups has been well documented, including the inequalities faced by people with learning disabilities. Today, people with learning disabilities die, on average, 15-20 years sooner than people in the general population, with some of those deaths identified as being potentially amenable to good quality healthcare.” (p.5) “National policy in relation to learning from deaths National policy in relation to learning from deaths has been strengthened following publication of the Care Quality Commission (CQC) report ‘Learning Candour and Accountability’ in 2016. The report describes what the CQC found when it reviewed how NHS Trusts identify, investigate and learn from the deaths of people under their care. The report authors indicated that there was a ‘common’ level of acceptance and sense of inevitability when people with learning disabilities or mental illness died, and that the lack of a single framework for NHS Trusts that sets out what they need to do to maximise the learning from deaths that may be the result of problems in care was problematic. The report concluded that learning from deaths was not being given enough consideration in the NHS and opportunities to improve care for future patients were being missed.” (p.10-11) HSJ & Unison – April 2018 “Violence against NHS staff: a special report by HSJ and Unison” “Introduction - It should go without saying that NHS staff should have the right to work without being assaulted. Unfortunately, physical attacks are an increasingly common occurrence in today’s overstretched and overstressed service.” Parliamentary and Health Service Ombudsman – March 2018 “Maintaining momentum: driving improvements in mental health care” “The complaints we have included in this report demonstrate how patient care and safety is jeopardised by these workforce challenges. They show clinical staff ill-equipped with the skills to manage potentially violent situations, being expected to work double shifts leading to exhaustion, and clinicians having to treat conditions they have no experience of. Unless these workforce challenges are addressed it is difficult to see how the transformation of mental health care, envisioned in the Five Year Forward View for Mental Health, can be realised.” (p.7) NHS Staff Survey 2017 [England] – 6 March 2018 “NHS Staff Survey: National briefing” “KF17–38.4% felt unwell due to work related stress in the last 12 months • This has worsened from 36.7% in 2016 • Staff from mental health/learning disability trusts (41%) and ambulance trusts (49%) report higher than average levels of illness due to work related stress” (p.13) “KF6 –33.5% of staff reported good communication between senior management and staff • This has improved from 2016 (33.0%) • 32.1% said that senior managers act on staff feedback (q8d –up from 31.7% in 2016 and 28.6% in 2013)” (p.17) “KF26–24.3% of staff experienced harassment, bullying or abuse from staff in the last 12 months • This has risen slightly since 2016 (24.2%), but is lower than 2015 (24.9%) • Community trusts report the lowest incidence of harassment, bullying or abuse from staff (19%) and ambulance trusts report the highest (29%) (p.22) Jeremy Dawson – 21 February 2018 “Links between NHS staff experience and patient satisfaction: Analysis of surveys from 2014 and 2015” “There are some clear and strong associations between staff experience and how satisfied patients are (p.6). “The effects for BME staff specifically indicate that the extent to which an organisation values its minority staff is a good barometer of how well patients are likely to feel cared for” (p.7) “What is clear is that in organisations where any lack of respect between humans is more prevalent, patients bear the brunt of this” (p.19). Scottish Government – February 2018 “Health and Social Care Staff Experience Report 2017: ‘Positive Staff Experience Supports Improved Care’” 9% of the respondents experienced bullying/harassment from their manager. 25% of these reported it. Of those who had reported it 27% felt satisfied with the response they received. 15% of the respondents experienced bullying/harassment from other colleagues. 43% stated they had reported it. Of those that reported it, 38% were satisfied with the response they received (p.38). These figures are slightly worse than the figures for 2015. Steve Sizmur and Veena Raleigh – Picker institute and The King’s Fund - 31 January 2018 “The risks to care quality and staff wellbeing of an NHS system under pressure” “There is a large body of research showing that the wellbeing, experience and outcomes of staff impact on the quality of care and experience and outcomes for patients” (p.4). Parliamentary and Health Service Ombudsman – December 2017 “Ignoring the alarms: How NHS eating disorder services are failing patients” ‘Averil Hart was a young woman with anorexia nervosa. She died on 15 December 2012, aged 19, following a series of failures that involved every NHS organisation that should have cared for her. Her death was avoidable’ (p.7). “The responses to Mr Hart’s requests for information were delayed and appeared evasive, and information he requested was often not provided. The responses to his complaints were equally unsatisfactory, and often appeared defensive or protective of the organisation concerned. Some information stored in electronic format turned out to have been deleted; the decision to delete material related to a significant safety incident was illconsidered and inappropriate” (p.10). “Individually, these failures are seriously unsatisfactory. Taken collectively, they paint a consistent picture of unhelpfulness, lack of transparency, individual defensiveness and organisational self-protection that is of great concern. It is hardly surprising that this leads to a lack of trust from complainants, in this case Mr Hart. Equally unacceptable are the missed opportunities to learn and to improve services inherent in the incomplete and defensive investigations of safety incidents such as this” (p.10). “NHS England’s approach was not customer focused. It was so poor that it was maladministration. The death of Averil Hart was an avoidable tragedy. Every NHS organisation involved in her care missed significant opportunities to prevent the tragedy unfolding at every stage of her illness from August 2012 to her death on 15 December 2012. The subsequent responses to Averil’s family were inadequate and served only to compound their distress. The NHS must learn from these events, for the sake of future patients” (p.12). National Guardian’s Office – Jan/Feb 2018 “Northern Lincolnshire and Goole NHS Foundation Trust: A case review of speaking up processes, policies and culture” “Evidence of a poor speaking up culture in the trust where issues raised by workers were not always responded to according to good practice, including where staff had raised serious safety issues. Evidence of bullying in the trust, including the existence of a bullying culture within specific teams, that made workers fear the consequences of speaking up” (p.4) Bill Kirkup – January 2018 “Report of the Liverpool Community Health Independent Review” “1.1. Liverpool Community Health NHS Trust (LCH) was a dysfunctional organisation from the outset. The Trust acted inappropriately in pursuit of Foundation Trust (FT) status, setting infeasible financial targets that damaged patient services. The Trust managed services that it was ill-equipped to deal with, particularly prison healthcare in HMP Liverpool. Senior leadership and the Board failed to realise that the Trust was out of its depth, and did not take heed of the effects. Staff were overstretched, demoralised and, in some instances, bullied. Significant unnecessary harm occurred to patients. External NHS bodies failed to pick up the problems for four years” (p.4). “4.44. Staff approached Trust patient safety and incident reviews with trepidation. They were often blamed for incidents where the lack of qualified workers, proper supervision or expertise was the root cause. Error was not approached in an open and proportionate way. Mechanisms for managing patient safety and poor quality were based on blaming individuals, while organisational shortcomings were ignored or glossed over. Reporting of errors was seen as a slight on the external image of the Trust. This led to under-reporting of problems. Where problems were identified, they were either not escalated or risk-rated lower that they should have been and often ignored. The problems at the prison came to light when the new management team placed prison healthcare at the highest level within its risk rating – despite internal opposition” (p.48). 3.28. We also heard repeatedly that the HR Department in the Trust was chaotic. HR managers failed to follow the Trust’s own procedures and were inadequate in communicating with those staff subject to apparently arbitrary disciplinary processes. As a result of this, we heard and saw documentary evidence of some appalling instances of staff treatment, including individuals who were suspended for prolonged periods with no apparent rationale or process for resolution. 3.29. The evidence we saw and heard confirmed that management of the organisation was excessively top-down, with a punitive and blame culture that spread throughout the organisation. Management and senior leaders in the organisation were aware of the poor training figures and appraisal rates and, in the Advisory, Conciliation and Arbitration Service (ACAS) Report of June 2014, staff reported “They were just told to fix it” (p.19). Arne Bjornberg - Health Consumer Powerhouse – 29 January 2018 “Euro Health Consumer Index 2017” "United Kingdom 15th place, 735 points. A 2014 survey to the public of the UK, asking about “What is the essence of being British?” got the most common response “Having access to the NHS”. Nevertheless, the UK healthcare system has never made it into the top 10 of the EHCI, mainly due to poor Accessibility (in 2017 only beating Ireland on this sub-discipline) and an autocratic top-down management culture. The country, which once created the Bletchley Park code-breaking institution would do well to study the style of management of professional specialists created there[6]! Mediocre Outcomes of the British healthcare system have been improving, but in the absence of real excellence, the tightened 2017 criteria puts the U.K. on par with Spain and the Czech Republic in the middle of the field. During the autumn of 2017 there were also worrying media reports about increasing Waiting Time problems, and reduced quality of cancer care.” (p.14). “3.1.1 Country scores With the possible exception of the Netherlands and Switzerland, there are no countries, which excel across the entire range of EHCI indicators. The national scores seem to reflect more of “national and organisational cultures and attitudes”, rather than mirroring how large resources a country is spending on healthcare. The cultural streaks have in all likelihood deep historical roots. Turning a large corporation around takes a couple of years – turning a country around can take decades!” (p.29). "5.5.5 In many European countries, the hospital CEO is nothing but a Head Paper Shuffler... 4. After these things are in place, the most important task for the hospital CEO is to stand in the main entrance of the hospital, equipped with a stool and a whip, keeping amateurs (including bureaucrats and politicians) out, to let the professionals get on with it!” (p.45) John O’Hara – January 2018 “Report of the Inquiry into Hyponatraemia related Deaths” The Northern Ireland inquiry found that it was difficult to “…persuade some witnesses to be open and frank with the work of the Inquiry. All too often, concessions and admissions were extracted only with disproportionate time and effort. The reticence of some clinicians and healthcare professionals to concede error or identify the underperformance of colleagues was frustrating and depressing, most especially for the families of the dead children" (p.25). There was a ‘…culture which concealed error’ (p.18), a failure to learn from the initial deaths and a great reluctance to admit fault. An “…underlying institutionalised reluctance to admit major shortcomings” (p.111) “I am compelled to the view that clinicians did not admit to error for the obvious reasons of self-protection and that this defensiveness amounted to concealment and deceit” (p.222). Nuffield Trust - 30 October 2017 “The NHS workforce in numbers: Facts on staffing and staff shortages in England.” “The NHS employs 1.7 million people across the UK. It is the country’s biggest employer and ranks at number five globally. Of that 1.7 million people, some 1.2 million are employed by England’s NHS.[1] Despite the huge scale of its labour force, it is increasingly apparent that the NHS in England doesn’t have enough staff.” Chidiebere Ogbonnaya and Kevin Daniels - What Works Centre for Wellbeing - December 2017 “Good work, wellbeing and changes in performance outcomes: Illustrating the effects of good people management practices with an analysis of the National Health Service” “We illustrate the benefits of good people management for performance and wellbeing with an analysis of National Health Service Trusts in England. Key findings We found that NHS Trusts that made the most extensive use of good people‐management practices were: ● Over twice as likely to have staff with the highest levels of job satisfaction compared to NHS Trusts that made least use of these practices. ● Over three times more likely to have staff with the highest levels of engagement. ● Over four times more likely to have the most satisfied patients. ● Over three times more likely to have the lowest levels of sickness absence. There is a clear role for managers, professional bodies and policy makers in implementing and maintaining good people management practice; improving awareness of the benefits for performance and wellbeing; and incentivising good people management.” (p.3-4) Dr Minh Alexander - 13 December 2017 "Two years of national CQC whistleblowing data on health and social care services" “It may assist those who seek further information about particular providers to know that CQC has in the past disclosed more detailed data about the nature of whistleblowing disclosures and its responses. For example, this previous CQC disclosure on whistleblowing about North Cumbria: North Cumbria FOI 20161019 FINAL Information for Disclosure CQC IAT 1617 0427 I have carried out a preliminary analysis of the national data on whistleblowing contacts relating to NHS trusts: ANALYSIS OF CQC WHISTLEBLOWING DATA – NHS TRUSTS BY NUMBER OF WHISTLEBLOWING CONTACTS 2015-16 AND 2016-17 13.12.2017” The Public Accounts Select Committee – 29 November 2017 “Managing the costs of clinical negligence in hospital trusts” “Conclusions and recommendations... 4.The NHS’s culture when things go wrong appears to be predominantly defensive, rather than candid and transparent, which limits its ability to learn lessons. This Committee has reported before that the NHS appears to be defensive when things go wrong. Although there have been initiatives such as duty of candour, the NHS has started from a low base and the progress towards an open and transparent culture is slow. There is a growing body of evidence that when things go wrong many people simply want an apology, or want to know that the issue is being dealt with and that it won’t happen again. However, they may make a claim if they are dissatisfied with the response they receive from trusts following a harmful incident. We are concerned that there is no system in place to understand which hospitals are doing well in managing harmful incidents and complaints, to identify good practice and to promote wider learning between trusts. Recent research suggests that greater transparency does not lead to a greater number of claims. Recommendation: The Department and NHS Resolution should work with trusts to identify and spread best practice in handling harmful incidents and complaints. This should include how trusts say sorry and support patients when things go wrong.” Dennis Stevenson and Paul Farmer – 26 October 2017 “Thriving at work: The Stevenson / Farmer review of mental health and employers” “Good work consists of autonomy, fair pay, work life balance and opportunities for progression, and the absence of bullying and harassment. Good work can help prevent new mental health problems and support those with existing conditions to get on in work and thrive. We want all employers and employees to understand the benefits of good work, including those with mental health problems who may be off sick or out of work” (p.16). “Introducing the mental health core standards We believe all employers can and should: 1. Produce, implement and communicate a mental health at work plan that promotes good mental health of all employees and outlines the support available for those who may need it. 2. Develop mental health awareness among employees by making information, tools and support accessible. 3. Encourage open conversations about mental health and the support available when employees are struggling, during the recruitment process and at regular intervals throughout employment, offer appropriate workplace adjustments to employees who require them. 4. Provide employees with good working conditions and ensure they have a healthy work life balance and opportunities for development. 5. Promote effective people management to ensure all employees have a regular conversation about their health and well-being with their line manager, supervisor or organisational leader and train and support line managers and supervisors in effective management practices. 6. Routinely monitor employee mental health and wellbeing by understanding available data, talking to employees, and understanding risk factors” (p.32). Holly Holder and Helen Buckingham – Nuffield Trust research report – November 2017 “A two-way street: What can CCGs teach us about accountability in STPs?” “Some CCG leaders described a culture of blame towards leaders, some of which was described as evident across the NHS, not just within commissioning, and also as something that was not a new phenomenon. One leader summarised it in the following way: “It seems that the natural behaviour at senior echelons of the NHS is to think it’s motivating to threaten you with your job. It doesn’t motivate me.” (p.18). National Guardian Freedom to Speak Up – November 2017 “Southport and Ormskirk Hospital NHS Trust: A case review of speaking up processes, policies and culture” “There were several important areas where the trust’s support for its workers to speak did not meet with good practice. These areas included:
James Buchan, Anita Charlesworth, Ben Gershlick, Ian Seccombe - Health Foundation - October 2017 “Rising pressure: the NHS workforce challenge Workforce profile and trends of the NHS in England” “It identified significant challenges to the NHS in England including substantial staff shortages in nursing and primary care. Yet these are not isolated problems – rather, they are symptoms of a more fundamental fault line. The approach to planning for the million-plus NHS workforce in England is not fit for purpose and there is no overall discernible strategy to ensure that the NHS has the workforce it needs” (p.2). “It is clear that while providing more training places for nurses, reducing attrition from training and increasing retention are all identified in national rhetoric, there is a substantial disconnect between headline statements and actual policy implementation and local delivery – the gap between national rhetoric and the reality for the NHS workforce is growing” (p.6). “In the 30 months for which comparable data are currently available, the number of full-time equivalent (FTE) managers and senior managers has grown by just under 11%. The number of hospital and community health service (HCHS) doctors has risen more slowly – by just under 3% to 106,540. Among registered nurses, health visitors and midwives, the workforce is up by around 1.1% to 306,160. Allied health professionals (AHPs) exhibited a similar pattern of growth followed by negligible change during late 2016 and into 2017, while the number of health care scientists has fallen slightly” (p.12). The Right Reverend James Jones KBE – 1 November 2017 “‘The patronising disposition of unaccountable power’ A report to ensure the pain and suffering of the Hillsborough families is not repeated” “Over the last two decades as I have listened to what the families have endured, a phrase has formed in my mind to describe what they have come up against whenever they have sought to challenge those in authority – ‘the patronising disposition of unaccountable power’. Those authorities have been in both the public and the private sectors. The Hillsborough families are not the only ones who have suffered from ‘the patronising disposition of unaccountable power’. The families know that there are others who have found that when in all innocence and with a good conscience they have asked questions of those in authority on behalf of those they love the institution has closed ranks, refused to disclose information, used public money to defend its interests and acted in a way that was both intimidating and oppressive. And so the Hillsborough families’ struggle to gain justice for the 96 has a vicarious quality to it so that whatever they can achieve in calling to account those in authority is of value to the whole nation” (p.2). “What this report describes as a ‘patronising disposition’ is a cultural condition, a mindset which defines how organisations and people within them behave and which can act as an unwritten, even unspoken, connection between individuals in organisations. One of its core features is an instinctive prioritisation of the reputation of an organisation over the citizen’s right to expect people to be held to account for their actions. This represents a barrier to real accountability. As a cultural condition, this mindset is not automatically changed, still less dislodged, by changes in policies and processes. What is needed is a change in attitude, culture, heart and mind. To bring this about, I first ask that those in positions of leadership listen seriously to the experiences of the Hillsborough families described in this report. I ask that they note too the perspectives of other families bereaved by public tragedy who I have listened to in the writing of this report, and whose experiences echo those of the Hillsborough families” (p.6). “First, I propose the creation of a Charter for Families Bereaved through Public Tragedy – a charter inspired by the experience of the Hillsborough families. The experience of the Hillsborough families demonstrates the need for a substantial change in the culture of public bodies. To help bring about that cultural change, I propose a charter drawn from the bereaved families’ experiences and made up of a series of commitments to change – each related to transparency and acting in the public interest. I encourage leaders of all public bodies to make a commitment to cultural change by publicly signing up to the charter. The text of the charter is as follows: Charter for Families Bereaved through Public Tragedy In adopting this charter I commit to ensuring that [this public body] learns the lessons of the Hillsborough disaster and its aftermath, so that the perspective of the bereaved families is not lost. I commit to [this public body] becoming an organisation which strives to: 1. In the event of a public tragedy, activate its emergency plan and deploy its resources to rescue victims, to support the bereaved and to protect the vulnerable. 2. Place the public interest above our own reputation. 3. Approach forms of public scrutiny – including public inquiries and inquests – with candour, in an open, honest and transparent way, making full disclosure of relevant documents, material and facts. Our objective is to assist the search for the truth. We accept that we should learn from the findings of external scrutiny and from past mistakes. 4. Avoid seeking to defend the indefensible or to dismiss or disparage those who may have suffered where we have fallen short. 5. Ensure all members of staff treat members of the public and each other with mutual respect and with courtesy. Where we fall short, we should apologise straightforwardly and genuinely. 6. Recognise that we are accountable and open to challenge. We will ensure that processes are in place to allow the public to hold us to account for the work we do and for the way in which we do it. We do not knowingly mislead the public or the media.” (p.7) [The book ‘Justice for Laughing Boy’ is recommended reading for anyone who wants to understands how the NHS behaves when 'its back is against the wall', and who wants to see our health services improve. My mind was immediately taken to the various Francis reports (2010, 2013) and Julie Baileys book ‘From Ward to Whitehall’ (2012). Has anything been learnt in the NHS? It seems not. People die and families/friends are ignored, deflected and undermined. The themes of lack of accountability, dishonesty and intimidation continue to run through the NHS. The protection of reputation is more important than the welfare of patients and families. The NHS ‘house’ needs to be put in order. There needs to be a major ‘clean up’ in the way the NHS conducts its business. The most recent Hillsborough report ‘The patronising disposition of unaccountable power’ (1 November 2017) makes recommendations that need to be applied to many of our large institutions in the UK. RP] Dr Sara Ryan “Justice for Laughing Boy” “We came to learn much later how Southern Health used their experience of dealing with unexpected deaths and the coronial system to ensure measures were in place to reduce the whiff of accountability. We had no idea how uneven the ‘playing field’ was in a game we didn’t yet understand we were playing” (p.84). “Unknown to us, in the midst of this early grief and horror ‘reputation repair work’ had kicked into action big time at both Oxfordshire County Council (who paid for the service at the Unit) and Southern Health NHS Foundation Trust (who provided it). They were speedily careering along on separate and discordant tracks trying to wriggle out of any responsibility for what had happened” (p.97). “…a persistent theme: the fobbing off of responsibility or blaming others for failures when responsibility should lay with the Trusts executive board” (p.106). “There is particular pain associated with the preventable death of a loved one in the care of the NHS. First, the shock associated with finding out that the organisation which you have grown up thinking of only in terms of benevolent goodness can act with malevolence. This realisation involves the peeling back of layers of awfulness over time as more details are uncovered or further brutality is meted out to the family by the Trust” (p.138). “…naively assumed that the Coroner was going to carefully examine all the evidence and determine how Connor died and why. In reality this assumption is founded on a belief that a Trust, or other public body, is willing to act with candour and integrity and will actually want to find out exactly what happened. ‘Dream on sunshine’ is my response to this assumption” (p.153). “The level of power-wielding and obliterating of humanity in a context of apparent public service is simply extraordinary” (p.155). Baroness Helena Kennedy QC – Foreword in ‘Justice for Laughing Boy’ “Institutions close ranks to protect reputations and persons in authority all too often defend the indefensible. Connor Sparrowhawk was without doubt an extraordinary human being. His learning difficulties and epilepsy may have meant he needed special care but he was a life-loving, talented and amazing boy with a hugely supportive family and a great network of friends. He died by drowning in a shabby, under-resourced NHS unit for those with special needs… Connor’s mother Sara Ryan is a remarkable woman. She could not let the death of her son go unquestioned. She could not rest until she had answers and placed responsibility at the doors of those who were really guilty of failing Connor. Those people further up the chain of command who are richly rewarded yet rarely held to account” (p.17-18). The Royal College of Surgeons of Edinburgh – June 2017 “Bullying and Undermining Campaign” “The Royal College of Surgeons of Edinburgh (RCSEd) has a zero tolerance approach to bullying, undermining and harassment and categorically condemns this in all circumstances. The link between bullying and undermining behaviour and patient safety is now clear. Evidence that this kind of behaviour has a negative impact on the workings of a team is getting bigger year on year. The extent of bullying and undermining throughout healthcare is well documented, and surgery in particular is often reported as being a specialty where it is particularly prevalent. In the College’s own membership survey, nearly 40% of respondents reported they had been victims of such behaviour, with the same amount reporting that they had witnessed it. It has been estimated that this issue costs organisations in the UK £13.75billion annually, and healthcare professionals have attributed disruptive behaviour in the perioperative area alone to 67% of adverse events, 71% of medical errors, and 27% of perioperative deaths. Bullying harms your profession and your patients. Let’s remove it. We all have a role to play if we want to change the culture of the surgical and dental workplace. Disruptive behaviour in the surgical and dental environment does not allow staff to work in a supportive environment, is bad for patient safety and is not in keeping with the GMC's Good Medical Practice.
Rachael Pope - Journal of Business Ethics - October 2017 Pope, R. J Bus Ethics (2017) 145: 577. https://doi.org/10.1007/s10551-015-2861-4 Full-text read only version http://rdcu.be/wDcq Roger Kline – 19 September 2017 "Rethinking disciplinary action in the NHS" "The biggest cost of all is the impact on patient care. Unnecessary disciplinary investigations and hearings risk creating an environment where the response to a mistake or sub-standard behaviour is not “how do we prevent it happening again” but “who is to blame.” The steep authority gradients in much of the NHS as a whole, and within individual occupations, exacerbate the problem. As Mary Rowe explained nearly two decades ago, when “the organisational culture is too hierarchical and oriented towards punishment (it) may inhibit willingness to act or come forward.” An environment of blame is toxic for patient care and safety." Minh Alexander – 24 August 2017 "Four years of published coroners Section 28 reports to prevent future deaths in England and Wales" “CORONERS’ WARNINGS ABOUT AMBULANCE SERVICES AND RELATED MATTERS The effectiveness of ambulance services matters to all. Ambulance performance is a matter of political sensitivity as are the controversial schemes for diverting patients to less acute forms of care, which some have criticised as a means of saving money and downgrading services. There are 10 English NHS ambulance trusts and one Welsh ambulance trust. They operate under great pressure. English national NHS staff survey returns for ambulance trusts show the highest levels of bullying out of all types of NHS trusts (average of 28% in 2016). Ambulance trusts also return very low scores on communication between staff and senior management, with an English national average of just 19% ambulance trust staff reporting good communication with senior managers in 2016. Key 2016 staff survey results on English ambulance trusts: [See table through link provided p.33] Staff survey data for the Welsh Ambulance service in 2016 revealed that 21% of staff reported bullying by other staff and 21% of staff reporting that communication with senior managers was effective. http://www.ambulance.wales.nhs.uk/assets/documents/5da36e00-1e47-4285-854c-0fa55e788f50636175031416660627.pdf Whistleblowing by ambulance staff to the media has now become a regular occurrence. Curiously though, there are no published CQC ‘intelligent monitoring’ reports at all on ambulance trusts. It was therefore not possible to check the extent to which CQC has received whistleblowing alerts about ambulance services.” (p.32-34) Nuffield Trust - Alice Hartley – 14 June 2017 “Bullying behaviour should have no place in surgical teams" "Alice Hartley explains why and how the Royal College of Surgeons of Edinburgh is spearheading a campaign to tackle bullying behaviour within surgery teams.” “But it takes very strong leadership not to abuse a position of power, and in an environment where dominant behaviour often goes unchallenged, this can become the norm. It is this acceptance of bullying behaviour that needs to be challenged.” Guardian - Richard Vize – 2 June 2017 “The NHS needs a culture shift if it truly wants to put patient safety first” “The Healthcare Safety Investigation Branch may be good for patients and staff, but will it tackle a piecemeal approach and design safety into the NHS?” “The launch of the Healthcare Safety Investigation Branch (HSIB) marks an opportunity for substantial improvement in patient safety. But there may be fears that it will provide a veneer of progress, while the wider system still fails to tackle the root causes of safety problems”. “Despite much talk from health secretary Jeremy Hunt on creating a safety culture and making the NHS a learning organisation, there is no clarity on how this will be achieved. In particular, it is difficult to see how the HSIB will influence the rest of the system. If the secretary of state’s words are to mean anything, the HSIB’s work will need to trigger a fundamental rethinking of everything, from clinical training and pathway design, to the culture and skills of trust boards, the inspection regime and the regulation of organisations and professions”. “The simple truth that the best safety culture comes from the bottom up, rather than the top down, has still not been learned. Instead, there are concerns among clinicians about the “criminalisation of healthcare”, with a growing number of prosecutions for gross negligence manslaughter. These were rare until the 1990s and most doctors were acquitted, according to the BMJ. But between 2012 and 2015, four doctors were convicted and three went to prison”. BMJ Editorial - Kieran Walshe and Naomi Chambers – 2 May 2017 “Clinical governance and the role of NHS boards: Learning lessons from the case of Ian Paterson - Medicine’s enduring professional “club” culture must be eradicated” “To anyone who is familiar with the litany of medical failures and scandals of the past two decades—Rodney Ledward, Richard Neale, Dick van Velzen, James Wisheart, Harold Shipman, and several others—the Paterson case will seem depressingly familiar. Once again, we see a charismatic, powerful doctor whose incompetence, misconduct, and criminal behaviour went unchecked for years, in healthcare organisations where senior leaders knew what was going on but did not act. The Kennedy report describes an organisational culture at HEFT of secrecy, bullying, and professional control, in which whistleblowers (even senior clinicians) were wary of putting their heads above the parapet. It outlines how senior leaders knew about serious concerns but repeatedly failed to act. It finds that governance systems and processes were ad hoc and informal. It describes a board that was out of touch and kept in the dark about what was going on. And, most painfully, it shows that many women experienced serious avoidable harm as a consequence of Ian Paterson’s actions and the failures of the NHS and private sector hospitals where he worked”. Solihull Hospital Kennedy Breast Care Review - Professor Sir Ian Kennedy - 2013 “Review of the Response of Heart of England NHS Foundation Trust to Concerns about Mr Ian Paterson’s Surgical Practice; Lessons to be Learned; and Recommendations” “It is a story of women faced with a life threatening disease who have been harmed. It is a story of clinicians at their wits’ ends trying for years to get the Trust to address what was going on. It is a story of clinicians going along with what they knew to be poor performance. It is a story of weak and indecisive leadership from senior managers. It is a story of secrecy and containment. It is a story of a Board which did not carry out its responsibilities. It is a story of a surgeon who chose on occasions to operate on women in a way unrecognised by his peers and thereby exposed them to harm” (p.3). “For the future, and reflecting on the past history of the NHS, Dr Stockdale’s dilemma could not be more challenging. He had taken what he, and contemporaries in the NHS, would see as a risk: he had drawn attention to the practice of a senior colleague, outside his specific area of expertise, and criticised it. He had blown a whistle. Whistleblowers do not fare well in the NHS. This is one of the major indictments of management in the NHS: that it is inwards-looking, over-defensive, and prone to destroy, by a variety of means, those who suggest that the Emperor has no clothes. This is not unique to this Review. It is a blight on the NHS and is one of the principal areas where lessons must be learned. This was the context in which Dr Stockdale and his colleagues had to wrestle with what to do” (p.37). “The culture was variously described as oppressive and one in which people felt bullied. Well-regarded members of staff left the Trust as a consequence. The sense was of a culture in which most staff were unaware of what was going on in the Trust in which they worked. There was a lack of engagement and openness between senior member of staff and the rest, a sense of a party line which had to be toed. By contrast, the culture changed with the appointment of the new Chief Executive and Medical Director. It was not only more open, but it was keen to be seen as such” (p.45). “Of course, this cultural challenge of hierarchy and “tribalism” has long been recognised…It is clear that the culture of the Trust was dogged by inter-personal tensions and clashes which were not effectively managed. Too often, clinicians in different parts of the Trust behaved inappropriately. Too often, their behaviour went, and to some extent, continues to go unchecked and unchallenged. The failure to confront poor performance and inappropriate behaviour was clearly an abiding feature of the Trust. It may not be easy to confront but failure to do so means that other members of staff, and, crucially, patients suffer. Such a culture develops over time. It is the direct result of a lack of effective leadership. The abnormal is normalised. Once entrenched, it is enormously hard to address without clear, strong and visionary leadership” (p.46). NHS Equality and Diversity Council - 2017 “NHS workforce race equality standard: 2016 Data analysis report for NHS Trusts” “Bullying and discrimination There is universal recognition that the levels of bullying of NHS staff, by colleagues and managers, is far too high since there are adverse consequences for staff, for organisational effectiveness, and upon patient care and safety. For staff, bullying impacts adversely on both physical and mental health, is a cause of turnover and absenteeism and lowers morale. For organisations there is a cost in absenteeism, turnover and a heightened risk due to the impact on patient care and safety. Researchers have found: • A strong negative correlation between whether, in the NHS staff survey, staff reported harassment, bullying or abuse from other staff and whether patients reported being treated with dignity and respect. • Higher levels of bullying of staff lead to poorer patient care, more clinical errors, adverse events and compromised safety. Levels of reported bullying by staff and managers in the NHS staff survey have consistently been, on average, higher for BME staff. Interestingly the levels of reported bullying for BME staff by patients, relatives and the public have consistently been similar. The Freedom to Speak up Review noted the impact of the disproportionate bullying of BME staff that had raised concerns. The literature on what strategies work in tackling workplace bullying emphasises “organisational climate”. Evesson et al found that bullying is most common in organisations with poor workplace climates. It is best prevented by strategies that focus proactively and preventatively on ensuring worker wellbeing and fostering good relations, giving employees and managers the confidence to engage in early and informal resolution. Evesson and colleagues were critical of an over-reliance, in isolation, on policies, procedures and training and concluded that: Trusts that have sought to address bullying with some success are those that have agreed at board level that: • The levels of bullying are such that they constitute a significant risk and must be tackled. • Bullying of staff is linked to the wider narrative regarding the impact on organisational effectiveness. • There are links between the bullying of staff, and the care and safety of all patients. • Sustained and meaningful staff engagement is important. • Board members should model the behaviours they expect of others and hold themselves to account. • There should not be reliance upon individual members of staff raising concerns, but instead, there should be an endeavour to improve the organisational climate. That approach is reflected in the most recent NHS Social Partnership “call to action” on bullying. In addition, the better trusts have then linked staff and manager training (starting at board level) to an approach that seeks to be proactive analysing staff survey data alongside other data (such as turnover, exit interviews and informal intelligence) to identify areas of good and bad practice. They have found that “early intervention” is crucial to act quickly. It should be noted that such interventions have found BME staff may be particularly cautious about raising concerns openly because of the fear of consequences” (p.121-123). Social Partnership Forum – December 2016 “Tackling Bullying in the NHS: A collective call to action” “To deliver the best possible care to patients, we need to create healthy, supportive, positive cultures in our organisations. Innovation and change thrive where there are conditions for healthy challenge, stretch and accountability. Creating cultures of compassionate care is a key task for leaders at all levels of the NHS. There is no place for bullying in compassionate cultures. Good staff engagement can improve patient outcomes and boost productivity. Indicators of good staff engagement, including prevalence of bullying, are amongst the key indicators looked at by commissioners and regulators. The NHS staff survey has repeatedly shown that about a quarter of staff feel bullied by their managers, subordinates or colleagues. This is unacceptable. Bullying can lead to low self-esteem, anxiety, depression and disengagement in affected individuals. This in turn impacts on their organisations, leading to low morale, reduced productivity, increased absenteeism and poorer patient care including clinical errors, adverse events and compromised safety. A much higher proportion of BME staff report harassment, bullying or abuse by staff in the last 12 months compared to white staff (NHS England, 2016). The NHS has an opportunity to improve the experience of staff working in the NHS by tackling bullying and creating positive cultures” (p.2). House of Lords Select Committee report – 5 April 2017 “The Long-term Sustainability of the NHS and Adult Social Care” "A culture of short-termism seems to prevail in the NHS and adult social care. The short-sightedness of successive governments is reflected in a Department of Health that is unable or unwilling to think beyond the next few years. The Department of Health, over a number of years, has failed in this regard. Almost everyone involved in the health service and social care system seems to be absorbed by the day-to-day struggles, leaving the future to ‘take care of itself’. A new political consensus on the future of the health and care system is desperately needed and this should emerge as a result of Government-initiated cross-party talks and a robust national conversation” (p.3). “We also heard repeatedly of the linkage between over-burdensome regulation, unnecessary bureaucracy, a prolonged period of pay restraint, low levels of morale and retention problems” (p.5). “There appeared to be a prevailing culture of complacency within the Department of Health, including amongst its ministers and officials who did not see the benefit of planning for the long term“ (p.84). Professor John Appleby and Mark Dayan - Briefing April 2017 Nuffield Winter Insight Briefing 3: The ambulance service “…ambulance services, like other parts of the NHS, have faced growing pressures over the last few years as the increase in funding has slowed while at the same time patient demand has grown. The ambulance service has worked harder than ever – Category A calls (those involving life-critical and very urgent incidents) resulting in an ambulance at an incident have increased by a third in the last five years. But headline response times have suffered and the morale of staff remains among the lowest of all the NHS workforce” (p.1). “Ambulance staff morale: taking a hit? Even allowing for the inherently stressful nature of the job, the poor responses in the annual NHS Staff Survey from ambulance personnel are striking. Compared to all acute and community staff, ambulance staff tend to report feeling less satisfied or respond more negatively to most questions asked by the survey…A further clear reflection of the difficult nature of the job and the issues of concern emerging from the Staff Survey is the fact that ambulance trust staff consistently have the highest sickness absence rates compared to all other types of NHS organisation.” (pp.7-8). “Key issues Given the evidence from recent performance against targets and the views of ambulance services staff themselves, there are three key issues the service needs to address: staffing, morale and management. Staffing: A key issue for the ambulance service has been the lack of growth in staff numbers at a time of increased demand for emergency services. However, there are signs that this is changing. Between 2009 and 2014, the numbers of non-managerial and non-clerical staff remained virtually unchanged. But in the last two years numbers have risen by over 2,500. Despite this increase, as the results of the 2016 NHS Staff Survey indicate, staffing remains a top concern among ambulance staff. Morale: As is clear from the results of the NHS Staff Survey (on pay, feelings that they are valued by their organisation and recognition for good work), morale among ambulance staff could not be said to be particularly buoyant. The effect on morale of the recent increases in ‘frontline’ staff numbers remains to be seen. But staff morale is hugely important, not just for staff themselves, but for the positive impact it has on patients’ experience and outcomes of care. Positive efforts to improve morale are therefore crucial. Management: A striking result from the NHS Staff Survey is the relatively poor responses relating to management issues. From communications and feedback to feelings of worth and general involvement in changes at work, ambulance staff are consistently much less satisfied than their non-emergency colleagues in the NHS. Clearly there is more to be done to engage ambulance staff – particularly at a time of funding pressures and service changes – and to improve those aspects of management staff currently feel adversely affect their attitudes to work” (p.8). Carl Macrae and Charles Vincent – March 2017 “Investigating for Improvement: Building a national safety investigator for healthcare” “How our healthcare system can best learn from serious failures is an issue of urgent concern. In the UK, the past five years have seen a string of major inquiries and reviews into serious patient safety failings. The Francis inquiries into the disaster at Mid Staffordshire, the Kirkup investigation into the tragedies at Morecambe Bay, the Keogh review of hospital mortality outliers, the Berwick review of patient safety in the NHS and the Public Administration Select Committee inquiry into the investigation of clinical incidents all insist on the critical importance of openly acknowledging, rigorously investigating and honestly learning from past events” (p.6). “Healthcare faces particular challenges in developing a successful national safety investigator. Two of the most difficult issues concern the scale of harm and the culture of blame. First, enormous numbers of serious safety events harm thousands of people each year…Second, healthcare faces a challenge of immediate and unthinking blame” (p.8). “A national patient safety investigator must above all encourage a culture of openness and learning: staff should trust in the investigative process enough to willingly, actively and openly engage with it” (p.18). “In simple terms, it is not possible to learn and improve after an event if frontline professionals, leaders and policymakers do not understand the causes of tragedy in the first place. I have a personal desire to see that the system improves from every tragedy so that patients and staff in the future do not have to endure the pain, loss and heartbreak of disaster. But that simple desire is vastly complicated to deliver in healthcare because of the sheer numbers of systemic issues and the tragedies that play out daily, combined with the further harm of so many well-intentioned—but often broken—promises that ‘it will never happen again’” (Martin Bromiley, p.4) NHS Staff Survey 2016 – 7 March 2017 “Briefing Note: Issues highlighted by the 2016 NHS Staff Survey in England” "Across all trust types, one in eight staff (13%) reported that they have experienced harassment or bullying from their manager one or more times. A slightly higher proportion of staff (18%) reported experiencing harassment or bullying from other colleagues on one or more occasions" (p.9). The national key finding score for NHS staff "...experiencing harassment, bullying or abuse from staff in last 12 months" (p.11) is 24.1%, compared to 24.8% in 2015. The percentage of staff reporting good communication between senior management and staff was 33% (up from 31.3% in 2015). CQC report – 2 March 2017 “The state of care in NHS acute hospitals: 2014-2016” “The importance of staffing and leadership The overarching message from our inspections is that effective leadership, which is values-driven and has a strong culture of learning, delivers high-quality care. In hospitals rated good or outstanding, the trust boards actively engaged with staff, asking them how they needed to improve. They had worked hard to create a culture where staff felt valued and empowered to suggest improvements and question poor practice. Where the culture was based around the needs and safety of patients, staff at all levels understood their role in making sure that patients were always put first. Many hospitals have told us that staff recruitment is one of their most difficult challenges; this often leads to too much reliance on temporary and agency staff. While many factors influence recruitment, for many of these same trusts staff report high levels of work-related stress, bullying and discrimination, which are either not recognised or not sufficiently addressed by the trust. This can vary between hospitals and departments within a trust, but we have found that the NHS staff survey is one of the most reliable predictors of the effectiveness of NHS trusts’ leadership and of the quality of care they provide for patients. Frontline staff are the heroes of our reports. We have found high levels of compassionate care in virtually every hospital. The exceptional daily commitment of staff has allowed hospitals to cope with the ever increasing demand, and the values and dedication of individual frontline teams are the fundamental factors in every good and outstanding service. High-quality care cannot be delivered without a focus on continuous improvement in quality, which only these teams can achieve. However, we have found that many hospitals do not listen effectively to the views of their staff. This is having a major impact on their ability to provide safe, efficient, high-quality care. Our reports are a start to putting this right. The strongest voices in these reports are those of the many patients who have told us about the compassionate care they have received, and of staff who have told us about their concerns about the safety and quality of care and the daily frustrations of their working lives” (p.9). HSJ, James Titcombe – 9 February 2017 “Will the NHS never learn from tragic lessons of the past? “For a learning culture to flourish, reporting incidents and being candid about mistakes need to be encouraged and healthcare staff need to be confident that the response to genuine human error will not focus on individual blame, but on system learning. Of course, there must always be accountability in the rare cases where individuals have acted recklessly or have covered up…the need to improve culture in the NHS has been highlighted repeatedly over the last 20 years with limited evidence of progress, so what do we need to do differently?” “There is now clarity that in order to make progress, the NHS as a whole needs to invest in building capacity and expertise in local investigations and improvement, that a system wide approach to understanding and cultivating a “just culture” is needed, that we need to recognise that some safety issues exist at a collective level and require coordinated responses across the system and that healthcare organisations needs to find new ways of sharing the learning and evaluation from local patient safety issues and improvement initiatives” (p.9) File on 4 – 7 February 2017 “Speaking Up - Whistleblowing in the NHS” CMF Blog, Steve Fouch – 9 January 2017 “Bullying and NHS culture” “It seems hard to credit that an organisation whose primary focus is the care of the sick, disabled and the vulnerable should have an appalling reputation for bullying and intimidation of staff. However in survey after survey of NHS staff at least one quarter and up to one third of all those who respond say that they have experienced bullying from colleagues and managers at some point. One in ten say that they have experienced discrimination in the workplace, and that figure is double for black and minority ethnic staff members, and nearly as high for disabled employees” Public Administration and Constitutional Affairs Committee – 31 January 2017 “Will the NHS never learn? Follow-up to PHSO report ‘Learning from Mistakes’ on the NHS in England” “The second PHSO report highlights systemic problems with clinical incident investigations in the NHS in England, where it found that a fear of blame inhibits open investigations, learning, and improvement. Our further report corroborates these findings. The Department of Health, NHS Improvement, and Care Quality Commission all acknowledged the need for the investigative culture to be transformed into one in which open-minded, learning focused investigations can routinely take place. However, despite repeated reports, both from PHSO and from PACAC, highlighting this as the critical issue facing complaint handling and clinical incident investigations in the NHS in England, there is precious little evidence that the NHS in England is learning” (p.3). “A system-wide ‘just culture’ The Committee commends the Department of Health for articulating the need for the NHS in England to develop a learning culture. However, the NHS must embed the attitudes and behaviours that are necessary for a learning culture to develop. Achieving a ‘just culture’ within organisations requires the leadership to establish the appropriate balance between learning and accountability” (p.28). “A culture of learning, as opposed to immediate and unthinking blame for error, can only be built slowly over time by trusted leaders at all levels of an organisation. This culture needs to permeate all aspects of clinical and management practice and not be confined simply to investigations. The dangers to staff, and the negative experiences of whistleblowers, come not so much from their experiences in investigations but from the more deep-rooted failure of some organisations to acknowledge safety problems in the first place and the failure of some leaders to provide staff with the assurances they need” (p.34). “Organisations need to accept their full responsibilities in creating a climate in which emerging safety issues can be discussed and acted on. After tragic events, organisations need to be proactive in their support for both the families and staff involved. Creating the conditions in which staff can speak without fear of reprisal during safety investigations is just one aspect of these wider responsibilities of senior leaders. To create a statutory ‘safe space (error in original corrected)’ within an organisation dominated by a blame culture could compound the problems by allowing such an organisation to conceal safety information and misuse safe space to evade its responsibilities to patients, families, and staff. The point that safe space is only one aspect of a wider learning culture emerged repeatedly in the Committee’s recent inquiry ‘Learning from mistakes’” (p.34). Statement by Bernard Jenkin MP CQC Report - December 2016 “Learning, candour and accountability: A review of the way NHS trusts review and investigate the deaths of patients in England” “This report describes what CQC found when it reviewed how NHS trusts identify, investigate and learn from the deaths of people under their care. It concludes that many carers and families do not experience the NHS as being open and transparent and that opportunities are missed to learn across the system from deaths that may have been prevented (p.2). “Reports into failings at Ely Hospital, Mid Staffordshire, Morecambe Bay and Southern Health have all called for a change in culture, a focus on patient safety and the need to do better” (p.4). “…learning from deaths is not being given enough consideration in the NHS and opportunities to improve care for future patients are being missed” (p.6). “Robust mechanisms to disseminate learning from investigations or benchmarking beyond a single trust do not exist. This means that mistakes may be repeated (p.8). “Throughout our review, families and carers have told us they often have a poor experience of investigations and are not consistently treated as equals with kindness, respect and honesty, even though many trusts state that they value family involvement. This was particularly the case for families and carers of people with a mental health problem or learning disability (p.57). “Trust boards have a major role in ensuring that there is a just learning culture within their organisations, and that opportunities to learn are maximised with improvements in care clearly evidenced. In addition, they need to make sure they keep all deaths in care under review, share learning and act on recommendations both within and beyond their trust” (p.57). “We must learn from these families. Their trust, honesty and candour are an example to us all. We owe it to them, their loved ones, and to ourselves to stop talking about learning lessons, to move beyond writing action plans, and to actually make change happen” (p.4). The Guardian - 26 October 2016 “NHS staff lay bare a bullying culture” “A shocking four-fifths of respondents to a Guardian survey reveal they have been bullied, and a third have lost jobs as result. One in 10 bullying victims was subject to violent behaviour and aggression”. “Bullying is a pernicious problem in the NHS. That’s the stark finding from exclusive research by the Guardian. The online survey of more than 1,500 doctors, nurses and other health workers in hospitals, primary care and community settings, found that 81% had experienced bullying and for almost half of them (44%), it is still ongoing. Close to nine out of 10 bullying victims who responded have been left with their cases unresolved. Although the survey on bullying was self-selecting, the findings underline the results of the official annual NHS staff survey. The 2015 survey of nearly 300,000 healthcare professionals across England found that a quarter of staff in NHS trusts had experienced bullying, harassment or abuse in the previous 12 months”. The Guardian - 26 October 2016 “'It's ruined my career': Accounts of bullying in the NHS” “Midwives, nurses, doctors, managers and other healthcare professionals speak out about the bullying they suffered and the effect on their health and wellbeing” Academy of Medical Royal Colleges Trainee Doctors Group - September 2016 “Creating supportive environments: Tackling behaviours that undermine a culture of safety” “There is increasing evidence that bullying and undermining is bad for patient safety” (p.2) “Bullying and undermining also damages the wellbeing of those involved. It is not conducive to high quality training and does not help recruitment and retention of staff. In addition, it can affect the patient’s experience of care and increase costs. It damages the reputation of medical specialities and the wider NHS” (p.2). “Factors identified as predisposing to bullying and undermining were dysfunctional leadership, division within teams and steep hierarchies” (p.2) House of Commons Hansard - 13 July 2016 "Capsticks report and NHS whistleblowing" Capsticks report - 22 March 2016 “Quality, safety and management assurance review at Liverpool Community Health NHS Trust” “The culture of the Trust at the time was hierarchical and seen as oppressive by many we spoke to. Inappropriate behaviour by some Executive Directors and senior and middle managers went unchecked. Speaking out about concerns was not easy” (p.11). The then executive team was seen as “…remote and autocratic” (p.96). The following findings related to a Staff Side survey conducted in 2013. In this situation negative behaviour appears not only to have been tolerated, but actually rewarded. “The main Staff Side survey findings were that respondents felt that Trust had an embedded culture of bullying and harassment which originated from the behaviours of the very senior managers in the Trust. In terms of the specific findings, they were:
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