April 05 2016

Has NHS patient safety culture improved since Mid Staffordshire?

Roger Kline Middlesex UniversityRoger Kline is a Research Fellow in the Business School at Middlesex University, the author of ‘Discrimination by Appointment’ (2013) and ‘The Snowy White Peaks of the NHS’ (2014), and was closely involved in the development of the NHS Workforce Race Equality Standard.

In the week when the first-ever national NHS Whistleblowing Policy was launched, he looks at what NHS staff surveys say about progress towards a culture conducive to patient safety three years on from the publication of the final Mid Staffordshire public inquiry report.

The NHS Constitution (Clause 3b) states:

“There is an expectation that NHS staff will raise concerns about safety, malpractice or wrongdoing at work which may affect patients, the public, other staff, or the organisation itself as early as possible.”

Ministers have launched a number of initiatives, partly in response to the Public Inquiry report into Mid Staffordshire NHS Foundation Trust intended to improve patient safety. However, several reports, including from Parliamentary Select Committees, the Sir Robert Francis ‘Freedom to Speak Up‘ review and NHS Staff Survey data, suggest that if improvement is under way it may be glacial.

Hospital corridor and doctor as a blurred defocused background


NHS Staff Survey data 2010-2015

The NHS Staff Survey analyses responses from about 300,000 NHS staff. It is the most authoritative analysis of staff opinion. It asks a number of questions directly linked to patient safety:

  • “My trust treats staff who are involved in an error, near miss, or incident fairly.”

There has been an increase in the proportion of staff agreeing (42 per cent to 43 per cent) and an increase in proportion of staff disagreeing with this statement (from five per cent to nine per cent).

  • “My trust encourages us to report errors, near misses, or incidents.”

An improvement in the proportion of staff agreeing with this statement (from 81 per cent to 85 per cent).

  • “My trust blames or punishes people who are involved in errors, near misses, or incidents.”

The proportion agreeing with this statement rose from nine per cent to 11 per cent, as did the proportion disagreeing with the statement (from 39 per cent to 45 per cent). This question was not asked in 2015.

  • “When errors, near misses, or incidents are reported, my trust takes action to ensure that they do not happen again.”

The proportion agreeing with this statement rose from 55 per cent to 62 per cent, as did the proportion disagreeing with the statement (from five per cent to seven per cent)

  • “We are given feedback about changes made in response to reported errors, near misses and incidents.”

The proportion agreeing with this statement rose from 35 per cent to 50 per cent while the proportion disagreeing with the statement fell (from 25 per cent to 17 per cent). A very clear improvement.

  • “Would you feel safe raising your concern?”

The proportion saying they felt safe raising their concerns fell from 72 per cent to 68 per cent between 2012 and 2015 while the proportion saying they did not feel safe rose slightly from ten per cent to 11 per cent. This question was not asked in 2010-11. Comparisons based on these responses should be treated with great caution as the question was changed in 2014 to “I would feel secure raising concerns about unsafe clinical practice”.

  • “Would you feel confident that your organisation would address your concern?”

The proportion agreeing with this statement rose from 55 per cent to 56 per cent, while the proportion disagreeing fell from 13 per cent to 12 per cent. This is statistically not significant.

Photo by Benjamin Ellis - Creative Commons 2.0

A London ambulance responds to a 999 call – Photo by Benjamin Ellis (Creative Commons 2.0)


On two of the Staff Survey questions there is clear improvement, most clearly on whether staff are given feedback about changes made in response to reported errors, near misses and incidents. On four of the questions there is both a slight improvement and a deterioration in staff views.

The adverse impact of bullying on the willingness of staff to raise concerns or admit mistakes (and work in effective teams) is an established factor in patient safety culture. Bullying of NHS staff by colleagues and managers has increased in recent years from 14 per cent (2010) to 23 per cent (2015), while the NHS Staff Survey records that the actual reporting by staff of incidents of bullying has fallen significantly from 54 per cent to 42 per cent in the last decade i.e. staff are less willing to report bullying as bullying levels have risen. The evidence of the ‘Freedom to Speak Up’ review suggests a major challenge remains to enable those staff who do raise concerns that it is safe to do so (see Fig. 1).

Figure 1: A comparison of responses given by white NHS staff members to those given by black and minority ethnic (BME) members of NHS staff regarding whistleblowing 

Question White staff % BME staff %
I was satisfied with the response to my concern about suspected wrongdoing 41 27
I was victimised by management after raising a concern 13 21
I was praised by management after raising a concern 7 3
I am less likely to report a concern again if I suspect wrongdoing 59 73

Slow progress

No step change in patient safety culture of the scale demanded by Sir Robert Francis and ministers appears to have yet taken place. There is evidence of significant improvement in whether staff are given feedback when they raise concerns, but otherwise the data suggests slow progress at best, with some evidence of deterioration.

West and Dawson (2012) link the raising of concerns and whistleblowing to staff engagement, demonstrating that “engaged staff are more likely to intervene to raise concerns about safety or address poor behaviours”. Whether the pattern of simultaneous improvement and regression that the NHS Staff survey data demonstrates parallels the findings on staff engagement reported by the Kings Fund of a growing gap between the better Trusts and the majority of Trusts, may be worthy of further exploration.

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