On avoidance and denial

Roger Kline Middlesex UniversityRoger Kline is a Research Fellow at Middlesex University Business School, the author of ‘Discrimination by Appointment’ (2013) and ‘The Snowy White Peaks of the NHS’ (2014), and has been closely involved in the development of the NHS Workforce Race Equality Standard. In his latest blog for Middlesex Minds, he argues that the NHS must acknowledge its problems.

Last week an independent review found 68 per cent of London Ambulance Service staff reported they had experiencing bullying or harassment in the last year. The report described a “blame culture” and stated “evidence suggests that bullying and harassment is prevalent across the whole organisation, including the … senior management team.” The trust’s interim chief executive, Fionna Moore, who commissioned the report, described the figure as “shocking”.

Even by NHS standards this figure is stunning. But the report and Fionna Moore’s response might actually be good news if they represent a move away from the denial and avoidance that so often characterises the NHS response to such difficult news.

Robert Francis said of patient care and safety when launching his 2013 Public Inquiry Report on Mid Staffordshire NHS Foundation Trust that “there lurks within the system an institutional instinct which, under pressure, will prefer concealment, formulaic responses and avoidance of public criticism” (Para 2.164 Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry 2013).

Photo by Benjamin Ellis - Creative Commons 2.0

A London ambulance responds to a 999 call (Photo by benjaminellis.org/photography (Creative Commons 2.0))

‘Cultures of blame and bullying’

In too many NHS Trusts it has regrettably taken a CQC report, not the internal governance of the organisation, to bring into the open cultures of blame and bullying.  The Mid Staffordshire NHS Foundation Trust Board was rightly criticised for “wilful blindness” about shortcomings, but the patterns of avoidance are common.

The 2014 Kings Fund survey of culture and leadership suggested a parallel discourse exists between many Boards and their staff. When asked whether their organisation was characterised by openness, honesty and challenge, 84 per cent of Board members felt there was but only 37 per cent of doctors and 31 per cent of nurses agreed. Similarly 90 per cent of Board members felt concerns staff raised would be dealt with appropriately but only 55 per cent of senior managers, 36 per cent of doctors and 26 per cent of nurses agreed.

There is no doubt that some Trusts have sought to be open and honest about difficult issues. But evidence of any step change, system-wide improvement is thin. Staff engagement levels have increased a little but as significant appears to be the widening gap between the better NHS Trusts and the rest.

Few NHS leaders will admit to no improvement in culture since 2010. Yet, for example, the proportion of NHS staff saying they would feel safe when raising concerns has not improved. Between one quarter and one third of staff remain unable to say they felt safe raising concerns. While some Trusts are making real improvements, overall the national staff survey data shows no improvement at all.

Table 1. Would you feel safe raising your concern?

NHS Staff Survey

Source: NHS staff surveys. *Question changed to “Would you feel safe raising concerns about unsafe clinical practice?”

Similarly, the proportion of NHS staff “witnessing potentially harmful errors, near misses or incidents in the last month” has been stable since 2009, but over the same period there has been a significant fall in the proportion of staff reporting such incidents.

Table 2. Witnessing and reporting of accidents

NHS Staff Survey

Source: NHS staff surveys N.B. Slight change in question asked from 2012.

The NHS staff survey reports that the percentage of staff reporting “experiencing harassment, bullying or abuse in the last 12 months” from colleagues and managers has increased since 2010, while the likelihood that an incident of bullying will be reported has actually fallen significantly from 54 per cent to 42 per cent in the last decade.

Table 3. Bullying

NHS Staff Survey

Source: NHS staff surveys. N.B. Slight change in question asked from 2012.

In launching his 2013 Public Inquiry Report on Mid Staffordshire NHS Foundation Trust, Robert Francis identified an institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern” (Letter to Secretary of State, 5 January 2013).

Despite the immense funding challenges the NHS faces there are signs of culture change. In Hull and East Yorkshire NHS Trust, faced with similarly dramatic bullying data to that of the London Ambulance Service, the new trust leadership appointed a Bullying Ombudswoman, Dr Makani Purva, who is leading a comprehensive training programme backed from the top of the organisation. The CQC itself, faced with shocking evidence of bullying towards its own staff, placed its own bullying data on its web page and began a sustained effort, showing significant success, to move away from a blame culture. 

What is true for bullying applies equally to another litmus test of NHS culture, race discrimination. A decade of false assurance in the NHS after the Race Equality Action Plan of 2004 was dispelled by the publication of The Snowy White Peaks of the NHS, which led to the NHS Workforce Race Equality Standard which obliges all NHS organisations (many for the first time) to scrutinise and act on their own data on race discrimination and publish the results. Since then both the NHS nationally, and some key individual Trusts, have acknowledged what their own staff have known for years. At Barts NHS Trust, CQC inspection reports highlighting bullying prompted the Board to commission a report from Plymouth University which described widespread discrimination based on religion, disability, and race – with the latter named as “the most prevalent”. In a sign of welcome progress, the Trust Board chair finally acknowledged what BME staff in the Trust had known for some years.

The Chairman said that he felt there was an undercurrent of racism in the NHS and the Trust and he wanted to ensure that this was being tackled as part of the work (Item 12.15 Barts Board minutes 4th February 2015)

Robert Francis himself, having been persuaded by DH spin doctors in 2009 that there was no systemic culture of bullying at the DH and across the NHS, subsequently devoted an entire section of his 2015 Francis Speak Up Review to the overwhelming evidence of the bullying of whistleblowers and stated: Bullying in the NHS cannot be allowed to continue. Quite apart from the unacceptable impact on victims, bullying is a safety issue if it deters people from speaking up.”

Margaret Hefferman’s 2011 classic Willful Blindness: Why We Ignore the Obvious at our Peril still rings true in large parts of the NHS. Fionna Moore’s acknowledgement of the scale of the challenge in the London Ambulance Service is, hopefully, a first step in turning round its wider culture. A problem acknowledged is one that can be tackled. A problem avoided or denied will just get worse.

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