It is a decade since Sir Robert Francis told Ministers
“There lurks within the system an institutional instinct which, under pressure, will prefer concealment, formulaic responses and avoidance of public criticism…..an institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern.” Robert Francis. 2013 report
In 2022, after the arrest of Lucy Letby, the Chair of Countess of Chester NHS Trust Board wrote to colleagues to say
“They (the finance and performance committee) have also commented that all of the reporting and evidence indicates that we are chasing far too many challenges/objectives (CQC, elective activity, ED [emergency department] pressures, staffing recruitment and costs, data and Cerner [an IT system] etc) all of which compete and conflict in the final measure of our delivery, that of finance.” https://www.theguardian.com/uk-news/2023/aug/20/lucy-letby-nhs-trust-chair-says-hospital-bosses-misled-the-board#:~:text=The%20former%20chair%20of%20the,commissioned%20reviews%20in%20late%202016.
Research into the NHS response to the Francis report five years later suggested nothing had changed:
“Boards …[are]… focussed on reputation and image rather than substance … outwardly projecting an image of success whilst not having grip on operational performance”. https://research.manchester.ac.uk/en/publications/responses-to-francis-changes-in-board-leadership-and-governance-i
The Countess of Chester Finance and Performance Committee presumably thought finance was the crucial measure because they believed that was what NHS England require. You can see why. Last year, “NHS England’s chief finance officer has reprimanded local health service leaders for their inability to produce balanced plans almost a month into the finance year.” https://www.hsj.co.uk/finance-and-efficiency/nhse-turns-the-screws-on-dozens-of-trusts-without-acceptable-financial-plan/7034681.article?utm_medium=cpc&utm_source=bing&utm_campaign=Bing%20|%20Search%20|%20UK%20|%20Brand
After Lucy Letby’s jailing, the former Trust chair (and former Chief Executive of the National Health Service Management Executive), Sir Duncan Nichol, claimed the Board was “misled” by hospital executives, and said it was told there was “no criminal activity pointing to any one individual” after two hospital-commissioned reviews in late 2016. https://www.theguardian.com/uk-news/2023/aug/20/lucy-letby-nhs-trust-chair-says-hospital-bosses-misled-the-board#:~:text=The%20former%20chair%20of%20the,commissioned%20reviews%20in%20late%202016. It apparently did not occur to him to be curious and pop down and talk to the doctors who had repeatedly raised serious concerns?
These shortcomings are not unique to Countess of Chester.
- Reputation management that avoids timely decisive action is familiar to staff in many NHS organisations
- Primacy of finance at a time of gross NHS under-resourcing has roots in Government policy and a national failure to challenge it
- The failure of the Countess of Chester Board to be curious and create a culture where staff who raised concerns were seen as “gold dust” not troublemakers, is commonplace not unique.
No simple solutions
Scandals such as these flow directly from Government policy with national NHS leaders currently looking like onlookers. There is much talk of yet more procedural changes to prevent their recurrence. NHS England quickly highlighted two such changes – the revised Fit and Proper Person Framework and the revised . But as the authors of this new Framework themselves point out in their aptly named 2023 report “Fear and Futility”:
“there is a growing feeling that speaking up in the NHS is futile – that nothing changes as a result…… they fear experiencing negative consequences if they do…….When they speak up about matters including the impact of understaffing, their leaders themselves may struggle to be heard when trying to address these concerns”
“Of concern are the responses to the questions about whether workers have witnessed an incident which could harm patients or colleagues and whether they feel they will be treated fairly or that preventative action would be taken if they do report it. There is a disconnect between the encouragement which workers feel in reporting (very high) and the perception of how fairly those involved are treated.” https://nationalguardian.org.uk/2023/06/08/fear-and-futility/
NHS England’s exhortation to NHS Boards and staff to ensure concerns are raised is evidence-free. Research suggests
“the addition of further layers of formal policy may provide a veneer of order without enhancing understanding” https://pubmed.ncbi.nlm.nih.gov/34051553/
Other research concludes that
“instigating whistleblowing lines and training employees to be braver or insisting that they speak up out of duty, will achieve little therefore, without leaders owning their status and hierarchy, stepping out of their internal monologue and engaging with the reality of others’” https://bmjleader.bmj.com/content/leader/early/2020/11/06/leader-2020-000394.full.pdf
NHS staff and patients will struggle to see how further procedural initiatives such as regulating managers, especially when policed by NHS England or a DHSC quango, will, in isolation, drive culture change. https://www.england.nhs.uk/long-read/verdict-in-the-trial-of-lucy-letby/#verdict-in-the-trial-of-lucy-letby As I’ve argued elsewhere
“a primary reliance on policies, procedures and training will not, in isolation, reduce bullying, improve the effectiveness or safety of whistleblowing, (or) create a disciplinary environment focused on learning” https://bmjleader.bmj.com/content/leader/early/2023/05/17/leader-2022-000729.full.pdf
Senior staff and NHS Board members are already supposed to follow the Nolan Principles of selflessness, integrity, objectivity, accountability, openness, honesty and leadership. Regulation for managers is a performative gesture unless accompanied by other measures. Here are some suggestions (applying to NHS England too):
- Make patient safety the prime litmus test for all initiatives and “stop the line” (from Board to ward) when it is not. Do not allow organisational reputation to ever influence decision making in response to concerns. Be relentlessly “problem sensing” not “comforting seeking”.
- Adopt Bewick’s Recommendation that “transparency should be complete, timely and unequivocal” such that “all non-personal data on quality and safety, whether assembled by government, organisations, or professional societies, should be shared in a timely fashion with all parties who want it”. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf
- Require (in contracts, appraisals and performance management) every Board member and every manager to demonstrate they proactively intervene to encourage workers and patients to raise concerns, and support them when they do. underpinned by data on patient safety and staff wellbeing. Assume all concerns raised are genuinely held and should be investigated, quickly.
- Embed that requirement through acting on relevant granular local survey and patient data (including exit data) to identify divisions, sites, teams, services or occupations where workers or patients do not (or do) believe that raising concerns is normal, welcomed, safe and effective. Use both good practice and failure to learn (not blame), driving proactive intervention and prevention. All serious incident reviews should be conducted externally (ideally by qualified staff from elsewhere in the NHS) and always published.
- Regard as gross misconduct any attempt to prevent workers (including agency and contractor staff), or patients/relatives, raising reasonably held beliefs about patient safety or worker well-being, or any attempt to cause detriment to any such individual, Apologise speedily for any harm or detriment. Review all cases of staff who have left or been dismissed after raising concerns with a view to helping them gain NHS employment. Employer legal proceedings involving staff who have raised concerns should be regarded as a “never event” and all costs disclosed.
- Pay particular attention to those staff and patients who may be especially cautious about the personal consequences of raising concerns – notably agency staff, bank staff, contractor staff, probationary staff, junior staff, Black and Minority Ethnic staff and disabled staff. If Lucy Letby had been a Black and Minority Ethnic nurse, for example, would managers have been as protective as they were with Lucy Letby?
- Emphasise the importance of inclusive and compassionate behaviours alongside humility, curiosity and a willingness to speak truth to power. Expect evidence of understanding of, and acting upon, these principles to be central in all recruitment and promotion of all staff at every level.
Culture is created by the behaviours we tolerate. Research is absolutely clear: patient care and staff wellbeing is better and safer when, provided in teams where inclusive, compassionate behaviours are the norm and where psychological safety exists. A precondition of such a culture is leadership that is humble, incessantly curious, willing and able to speak truth to power.
Roger Kline is Research Fellow at Middlesex University Business School. He authored No more tick boxes: a review of the evidence on how to make recruitment and career progression fairer and “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 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.