The toxic mix of fear, denial and bullying that Robert Francis described in his 2010 report on the Mid-Staffs hospital trust continues in too many parts of the NHS. Twenty-four percent of staff told the 2012 NHS Staff survey they had been bullied in the previous 12 months by managers or colleagues.
Bullying is deep-rooted in the NHS, and starts at the top. Research commissioned in 2007 by the Department of Health reported a very senior NHS stakeholder as saying that a “pervasive culture of fear in the NHS and certain elements of the Department for Health” existed throughout the NHS and in parts of the DH, with fear among chief executives of public humiliation or losing their jobs as a prime driver for quality improvement” and that “the NHS has developed a widespread culture more of fear and compliance, than of learning, innovation and enthusiastic participation in improvement”.
But since 2007 matters have, if anything, become worse. The current NHS Confederation chief executive Mike Farrar accepted last year that “the fear of speaking out is worse than I’ve known it in over 32 years in the NHS”
Though Francis repeatedly referred to bullying as a key driver of the toxic culture at Mid-Staffordshire, not a single one of his 290 recommendations in 2013 referred to bullying. Not surprisingly, bullying was not mentioned in the Government’s response to the Francis Report either. Yet the the bullying culture which grew out of the need to meet the performance targets set by the DH is being replaced by a bullying culture driven by the instability and insecurity of hospitals and other healthcare providers. These hospitals are trying to meet the rising demand for healthcare at a time of reduced real funding and with a requirement to compete with each other being forced upon them..
But when staff raise concerns it is good for healthcare. The files of Patients First are full of concerns raised by whistleblowers about staffing shortfalls, the inappropriate delegation of work, and a climate in which staff are fearful of admitting mistakes or reporting concerns. This all has consequences for patients safety and care,most notably where the desire to provide compassionate care is ground out of some staff. .But a safe and caring culture is one where staff and patients feel able to raise concerns without fear of detriment. Bullying prevents this happening. It is also one where mistakes (unless malicious or repeated) are seen as learning opportunities, not occasions for punishment. How tragic, then, and shocking, that the recent history of the NHS is littered with the broken careers of those who did raise concerns or who suffered in other ways for doing so. Kim Holt, David Johnstone, Jennie Fecitt, Elsie Gayle, David Drew, Ed Jedaduson, Amanda Pollard, Stephen Bolsin, Gary Walker. The list is a long one and is still growing.
However, the recent crises at Mid-Staffordshire, Morecambe Bay, the CQC and elsewhere. in which whistleblowers played a crucial role, have started to tip the balance a little. Whistleblowing is increasingly seen, at least officially, as a “good” thing. A wealth of evidence and the work of the Department of Health Clinical Human Factors Group has helped to begin edging the NHS away from a ”blame” culture to one which recognises that human error is inevitable in a highly complex field like medicine. The head of NHS Employers has accepted that
‘ Robust staff engagement and encouraging a culture of openness and trust are key in addressing under-reporting. Confidence to report bullying is directly related to confidence to report workplace concerns’.
But we still have a long way to go. For example,the Nursing Times recently found that a mere 6.6% of student nurses who said ‘there are no barriers to raising concerns on my placement’. Recent research for Public Concern at Work found that 60% of whistleblowers receive no response from management, either negative or positive. If they do get a response then the most likely response is formal action (disciplinary or demotion). My own experience, and that of Patients First, suggests the NHS picture is not greatly different.
The recent Keogh Review reported that “during several of the reviews, staff came forward to tell the review teams about their concerns in confidence. These staff felt unable to share their anxieties about staffing levels and other issues with their senior managers”. Keogh reports that “a small number of trusts spent disproportionate time challenging the findings of the review team.” It is not hard to magine how these Trusts respond to ordinary staff who raise concerns.
The files of Patients First. which supports NHS whistleblowing and seeks to prevent the victimisation of NHS whistleblowers, continue to grow. We need an NHS culture where no one needs to be a “whistleblower” because everyone feels free to raise concerns without fear of detriment. Good healthcare relies on staff having the courage to speak out for those who cannot easily speak out for themselves, and on their employers supporting staff who do so. We’re not there yet, not least because it too often remains dangerous to do so.