Following on from the powerful blog “After the speeches…” that outlined actions needed to reduce discrimination, we are delighted to publish part nine of a ten part blog series by Roger Kline with suggestions on how to tackle structural racism in the NHS.

Bullying in healthcare undermines patient care and safety making staff less willing to admit mistakes and report concerns. Its organisational impact includes greater turnover, lower job satisfaction and organisational commitment, higher absenteeism and presenteeism, lower productivity and undermines the effectiveness of teams, costing the NHS at least £2.28 billion annually.

Bullying 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’.  In NHS hospitals, managing staff with respect and compassion correlates with improved patient satisfaction, infection and mortality rates, Care Quality Commission ratings and financial performance as well as lower turnover and absenteeism.

Despite the evidence of its detrimental impact, the last NHS staff survey (500,000 responses) found 12.3% staff (almost one in eight) experiencing bullying and harassment from managers and 19.0% (almost one in five) from colleagues. Those numbers do not include staff who have witnessed bullying and harassment. Nor do they include some of the staff who suffered incivility (or rudeness). Yet both these have an impact almost as great as being the direct victim of bullying.

So what message does the Not Guilty decision of the Prime Minister in Priti Patel’s case mean?

Firstly, this case has consequences for the NHS. Matt Hancock joined Priti’s Praetorian Guard assembled by the Prime Minister assuring us that though he had yet not seen the inquiry’s report – a draft version of which was leaked to the media – she’d been “been courteous and kind” in “all the dealings” he’s had with her.

Second, the definition of bullying the independent report found she met is similar in the civil service and the NHS, unsurprisingly since both follow the the ACAS definition.

“Bullying is behaviour from a person or group that’s unwanted and makes you feel uncomfortable, including feeling:

• frightened (‘intimidated’)
• less respected or put down (‘degraded’)
• you’re made fun of and it makes you feel uncomfortable (‘humiliated’)
• upset (insulted or ‘offended’)”

The independent report into Priti Patel’s behaviours similarly states

“The definition of bullying adopted by the civil service defines bullying as intimidating or insulting behaviour that makes an individual feel uncomfortable, frightened, less respected or put down”.

The NHS staff Conditions of Service Handbook Section 32: Dignity at Work states

“32.2 For the purposes of this agreement, the following definitions apply:

Bullying – offensive, intimidating, malicious or insulting behaviour, an abuse or misuse of power which may undermine, humiliate, denigrate or injure the recipient. This can include “cyber-bullying” or other actions that may take place outside of the workplace but are linked to that employment.

In all cases of bullying and harassment it will be for the recipient to define what is inappropriate or demeaning behaviour”. (my emphasis) 

In other words, in the NHS as in the civil service, ”intention” or “motive” is not relevant as to whether what happened is defined as bullying. Johnson’s stated reason for exculpating Priti Patel is her claim that she never intended to bully anyone and was never told her behaviour was seen as bullying. That might be relevant (if true) as grounds for mitigation but should not affect the judgement as to whether bullying took place.

Third the interference in the investigation appears to be quite scandalous and sets a dubious precedent. This appeared to include preventing the key witness (the civil servant whose resignation sparked the investigation) being prevented from being interviewed and an attempt by Boris Johnson to interfere with the text of the final report

Fourth, the way in which the outcome of the investigation and decision was delayed feel familiar. It appears Boris Johnson had the report in April but only released his decision in November. Such delays are common in health service investigations and are a grave cause of stress for staff who have given evidence in particular.

Fifth, consider the consequences for those who speak truth to power about bullying. In the Home Office case the most senior civil servant felt obliged to resign having raised his concerns and now the investigator himself has. If it is not safe for either of them to speak out safely why on earth would anyone else feel safe? Again that feels familiar. How many times have we seen NHS organisations with astronomical levels of bullying but almost no formal complaints or grievances?

Sixth, where are the victims in all this, those the Minister may have bullied? The mental and physical health of those more junior staff whose concerns were highlighted – and presumably some of whom were interviewed – will have deteriorated. Some will leave. Other will keep their heads down. Only the bravest or most foolhardy Home Office employee is going to raise concerns about bullying anymore since the Minister appears to be clearly untouchable and “lack of motive” is an alibi for all bullies in the department. For NHS staff working in organisations where bullying is ignored, this will feel familiar.

Finally, consider where were HR in all this? The inquiry in Priti Patel’s case relied on individuals coming forward, and does not appear to be underpinned by an HR strategy that was proactive and actively seeking to prevent bullying.

If so, and it is still familiar to many NHS staff, that approach is contrary to the evidence on what is likely to work. As an ACAS research report put it:

• “In sum, while policies and training are doubtless essential components of effective strategies for addressing bullying in the workplace, there are significant obstacles to resolution at every stage of the process that such policies typically provide. It is perhaps not surprising, then, that research has generated no evidence that, in isolation, this approach can work to reduce the overall incidence of bullying in Britain’s workplaces.”

Effective approaches to bullying require leaders to act as role models and ensure early informal challenges to bullying are encouraged and expected but with serious consequences for serial perpetrators if they fail. Boris Johnson’s decision may have sent a message that as long as you can claim you didn’t “intend” to bully, there are no consequences, and there is nothing wrong with interfering in investigations.

In the NHS that is bad news for staff and bad news for patients. At a time when the NHS is starting to understand the damage that bullying causes, maybe Matt Hancock should have thought twice before looking the other way?

Roger Kline

Roger Kline is Research Fellow at Middlesex University Business School. He authored “The Snowy White Peaks of the NHS” (2014), designed the Workforce Race Equality Standard (WRES) and was then appointed as the joint national director of the WRES team 2015-17. Recent publications include) the recent report Fair to Refer (2019) to the General Medical Council on the disproportionate referrals of some groups of doctors (co-authored with Dr Doyin Atewologun) and The Price of Fear (2018), the first detailed estimate of the cost of bullying in the NHS, co-authored with Prof Duncan Lewis.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.