February 07 2019

The NHS Long Term Plan & toxic workplace culture

Roger Kline is Research Fellow at Middlesex University Business school. Here he examines the new NHS Long Term Plan and asks if it’s enough to combat the toxic workplace culture revealed in the organisation by recent research. 

The Government’s new NHS Long Term Plan states an intention:

to build a modern working culture where all staff feel supported, valued and respected for what they do. And where the values we seek to achieve for our patients – kindness, compassion, professionalism – are the same values we demonstrate towards one another. (Para 4.40)

The statement suffers from being made ahead of publication of a long term NHS workforce strategy and from seriously inadequate funding, but the aspiration is important because if achieved (even partly) it will make a significant difference to staff health and well-being, organisational effectiveness and the quality and safety of patient care.

We have some way to go.

Patient and doctor

The toxic workplace

The NHS Staff Survey shows that in each of the last 3 years 24% of employed NHS staff reported they were subject to bullying, harassment or abuse from fellow workers and managers– and it was much higher in some Trusts and in some occupations. Stress is widespread. 53% of staff say they attended work in the last 3 months despite feeling unwell because they felt pressure from their manager, colleagues or themselves.

Staff who raise concerns or admit mistakes too often still meet denial not thanks – as the 2015 Francis Freedom to Speak Up report showed.

Discrimination is rife. We have a very diverse NHS workforce but one which faces systematic discrimination. We are very good at bringing staff into the NHS from across the globe but not so good at respecting the talent and humanity they bring. A large majority of the NHS workforce are female but only a minority of Very Senior Managers are. Staff with disabilities, and staff who are LGBT experience extraordinary levels of bullying.

Staff from BME backgrounds who are now almost one fifth of the NHS workforce experience discrimination in many aspects of their lives. For example:

  • One in four entry grade nurses and midwives are from BME backgrounds but that drops to about one in twenty for very senior nurses and midwives;
  • It is more likely that white shortlisted applicants will be appointed than BME ones;
  • It is more likely that BME staff will be disciplined than white staff and more likely that BME staff will be referred to regulators by their employers;
  • It is more likely BME staff will be bullied by colleagues and managers but, interestingly, it is not more likely that they will be bullied by members of the public. Again we know some groups of staff are especially vulnerable, such as paramedics and midwives;
  • BME staff are more likely to be victimised for raising concerns and less likely to be thanked for doing so even though this will benefit patients. Robert Francis found that just 3% of BME staff said they had been thanked for raising a concern.

Why does this matter?

We know that how NHS workers are treated impacts not only on their health and well-being but on organisational effectiveness and the quality and safety of patient care.

We know that bullying, for example, impacts on increased intentions to leave, job satisfaction and organizational commitment, absenteeism, presenteeism, productivity and the effectiveness of teams. When Duncan Lewis and myself estimated the annual cost of bullying to the NHS last year we came to a very conservative estimate of £2.28 billion a year.

We know that incivility leads staff to intentionally decrease their work effort, the time spent at work, the quality of their work and that 80% of affected staff lose work time worrying about the incident. It is no wonder that there is a consensus that “disrespect in medicine is a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices.”

I have summarised elsewhere some of the evidence that how staff are treated (especially through effective approaches to diversity and inclusion) benefits patient care and safety.

What’s preventing change?

If we know all this, why have we failed to tackle workplace toxicity? The first reason is denial. Robert Francis concluded in his Public Inquiry report into the Mid Staffordshire scandal that:

“There lurks within the system an institutional instinct which, under pressure, will prefer concealment, formulaic responses and avoidance of public criticism” and “an institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern.”

The second reason is a difficulty with having honest conversations about bullying or racism. We are anxious about raising concerns or admitting mistakes. In too many organisations difficult conversations about bullying or discrimination fail as “protective hesitancy” is triggered or a blame culture inhibits openness for fear of the consequences.

The third reason is the flawed paradigm which dominated much NHS HR approach to tackling workplace culture strategy until recently, in which the existence of policies, procedures, and training were seen as the key to make it safe and effective for individual members of staff to raise concerns about bullying, discrimination, unfair disciplinary action and unsafe practice. There is now a move towards a much more proactive and preventative approach, but there is still, too often, an excessive reliance on policies, procedures and training as HR departments drown in transactional work.

Yet research suggests this approach is fundamentally flawed. For example, a recent ACAS review concluded that “In sum, while policies and training are doubtless essential components of effective strategies for addressing bullying in the workplace, ……. research has generated no evidence that, in isolation, this approach can work to reduce the overall incidence of bullying in Britain’s workplaces.”

Similarly, Kalev and Dobbin found in a major study of diversity initiatives in 708 US companies that attempts to reduce managerial bias through diversity training and diversity evaluations were the least effective methods of increasing the proportion of women in management.” They criticised, what they called the “methodological individualism” which relies on individuals to challenge institutional shortcomings.

A different approach is needed (and is gaining some traction) in which NHS employers make it their responsibility to be proactive and take a “public health” approach, to workplace culture, using data to identify hot spots of poor practice (and good practice) and thus help change the organisational climate which permits discrimination, bullying or a blame culture.

Moving forward

So what should be done, since we do now know what some of the shared characteristics of effective interventions are?

Firstly, as in any other NHS challenge we should avoid “comfort seeking” information and seek out challenging data. Data does not explain why there is a problem but it will highlight where problems (and good practice) exist. In the NHS we have a wealth of workforce and staff survey data to draw on.

Secondly, improving the opportunities for, and treatment of, staff are not just about statutory compliance but about service improvement.  Treating staff better is good for staff, organisations and patient care. There is a raft of evidence now that inclusion, psychological safety, and the ability to have difficult conversations, can radically improve how staff are treated and improve creativity, productivity, innovation, risk awareness, turnover and team working.

Thirdly, we should refuse to collude in unevidenced interventions. Too many Action Plans on bullying, recruitment, and discipline still resemble tick boxes rather than evidenced plans. Changing biased outcomes in recruitment or development require a multifaceted approach rather than reliance on individual “silver bullets” such as unconscious bias training or placing a BME person on a panel. Those proposing workforce interventions should always be asked to explain “why what is being proposed is likely to mitigate or remove the problem that’s been identified?”

Fourthly, data driven accountability at every level is the cornerstone of good management and leadership. That does not mean the Board quietly meeting and deciding what everyone else should do. Nor does it mean thumping the table when things go wrong. It means patiently engaging and discussing with staff and managers what the challenges are, what the research and data says, and then what should be done, how, why and when. Wherever possible, support should drive change but senior managers responsible for recruitment, promotion, staff development, discipline and turnover will need to explain why patterns of behaviour and outcomes fall short of what is required and agreed – and then be expected and helped to change outcomes.

Fifthly, leaders who do not model the behaviours they expect of others have no chance of changing workplace culture. Leaders who talk the talk but don’t walk the walk cannot change the cultures of an organisation. We should beware the fad that somehow “changing culture” can change behaviours when the evidence suggests that, to the contrary, changing behaviours is what will change culture.

Sixth, we need to recognise that whilst the principles underlying effective change are simple, undertaking and sustaining change can be complex. Take recruitment. We know there are numerous ways in which bias can creep into recruitment and promotion processes. We know that successfully challenging individual decisions is usually almost impossible for individual members of staff. Data driven accountability, however, can help challenge patterns of bias and then adopt specific interventions which draw on the research about bias so we can mitigate or remove it.

Seventh, we have to focus attention on learning not blame. Mistakes happen. Anticipating them, admitting them, and acting on them is what counts. Vast amounts of money and time have been wasted on unnecessary disciplinary action and referrals to regulators. We know how to reduce discipline and simultaneously improve safety. Some trusts are doing it.

One critical driver of disciplinary investigations is when managers feel unable to have informal honest conversations with staff when mistakes are made or behaviour is inappropriate. The shared characteristic of effective interventions is a speedy response, a focus on learning not blame, and the insertion of accountability so managers cannot commence a formal investigation without explaining to a very senior manager why that was the appropriate response to an incident.

Eighth, in bullying even more than any other workplace culture challenge, individual grievances are not the way forward. Even if they win, the member of staff often has to leave their employer. In bullying, the first challenge is an acceptance there is an organisational problem. It is not enough to just hold individuals to account because it is the organisational climate from the top that permits or encourages bullying that has to stop.

Ninth, it is essential that those groups of staff most impacted by specific toxic aspects of culture have their voice heard and their lived experience understood and influence change. That means, for example, that staff who have been victimised for raising concerns should influence safe cultures for raising concerns, that BME staff impacted by discrimination are heard loud and clear within the board room, and so on.

Tenth, a mix of accountability and scrutiny will involve consequences. These may be incentives or they may be sanctions but they must be linked to transparency. They may involve measurable targets (what gets counted is what gets done). Initiatives such as the Workforce Race Equality Standard (WRES), which is both contractual for healthcare providers (public and private) and inspected against by the CQC, were created around this evidence base. The long term success of the WRES, for example, if it is to build on its initial progress, will require a relentless focus on using evidenced interventions.

There are some signs that national NHS leaders are starting to understand the importance of workplace culture as being more than declarations. There is no quick fix to change the treatment of staff in a sustainable way. It requires more than declarations, speeches and policies. It requires an understanding of how such change can take place and be sustained. Serious progress on workplace culture is essential and possible even at a time of immense funding pressures, but only if we learn from what has gone before.

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