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  • We all want a culture of speaking up, don’t we? So, why isn’t it happening?

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    Effective speaking up arrangements protect patients and improve the experience of NHS workers. The guidance set out by Sir Robert Francis in his Freedom to Speak Up review, was to develop a more open and supportive culture that encourages staff to speak up about any issues of patient care, quality or safety. 

    In this blog I want to explore why this hasn’t been happening in Trusts up and down the country, despite everyone wanting a safe culture to speak up, no more so than myself, a clinician who has a keen interest in patient and staff safety.

    Sir Robert Francis laid out six principles for Trusts to follow in his review of speaking up in NHS Trusts in 2015. I would like to reflect on the times when I have spoken up about patient safety issues and the responses I have had when I have raised them.  I will use Francis’ six principles to frame the blog. 


    Principle 1 – Culture of safety

    Every organisation involved in providing NHS healthcare should actively foster a culture of safety and learning in which all staff feel safe to raise concerns.

    How can you describe a culture?  What does it look like?  I am sure that there has been many an hour at board meetings discussing this very subject. Describing the ideal safety culture is easy, we are told to adopt a ‘just culture’, however fostering a culture of safety is not that simple, following a guide doesn’t work.

    ‘Fostering a culture’ means to nurture and support a way of working. This principle also asks for Trusts to ‘actively foster’, to me this means that it is a dynamic action. It is not just a ‘thing’ that is said, but a ‘thing’ that you do. Working in the NHS for years, I feel I have become institutionalised, along with middle management. Bad habits are hard to break, we may start out trying to change our behaviours, but the old-world bites back. Its easy to fit in. It feels safer for us to fit in.

    There are multiple layers of management. Each layer has its own processes and brings with it its own culture. Hierarchy is steep in the NHS, if you do not go through the correct chain of command, you may be labelled as a troublemaker or whistleblower. 

    This principle mentions that ALL staff should feel safe to raise concerns. As a clinician, I have the safety net of my professional body, they will support me. But what about porters, domestic and support staff or volunteers?  Do they feel empowered to speak up? They may feel at the very bottom of this hierarchy.  How are Trusts ensuring that they also have a voice? 

    This principle excludes the most important group. Patients. Why are Trusts not empowering patients to speak up? Why are there no robust mechanisms for them to speak up? It is not just staff that need to feel safe in speaking up, it's patients and their families.  

    Principle 2 – Culture of raising concerns

    Raising concerns should be part of the normal routine business of any well-led NHS organisation.

    I have raised concerns where I work, as I am sure we all have. We do it via Datix. There is a usual process. We spot the harm/concern and we log it on the computer. It gets graded by the safety team and we hear nothing back.  It then happens again and the cycle repeats. This within normal behaviour. This is normal routine.

    Many staff are not happy with this routine of raising concerns. They have taken the effort to take the time to log the concern but feel disengaged when they hear nothing back. So why bother? They bother because it is to cover themselves and they also bother in the hope that improvements will be made.

    However, what if these concerns are larger. What if these concerns you have are a system wide problem? Datix is not always the correct route, it doesn’t fit.

    You can alert your manager, who then will alert their manager and so it goes up the chain. If at any point you feel you are not being listened to you can then go and see your Freedom to Speak Up Guardian (FTSUG). Sounds ideal.   

    Some FTSUG work part time, some work clinically on top of this role. They are not always easily accessible.  I am unclear on what value they bring to an organisation. What changes can they make? Are they listened to? Have they been put there to ‘tick the box’? 

    Principle 3 – Culture free from bullying

    Freedom to speak up about concerns depends on staff being able to work in a culture which is free from bullying and other oppressive behaviours.

    I have raised concerns where I work.  If I follow the usual routine of raising concerns, all is good. Nothing happens.

    If I raise a concern outside of the normal routine, this is where the problems start.

    Reflecting back on a time when I raised a concern about three wards and their lack of equipment, I raised the concern with the Matron and the Patient Safety lead. More equipment needed to be purchased to prevent harm from happening to patients. This equipment was needed urgently, and I felt that the Datix system would take too long and harm would have happened before the problem was addressed.

    I received an email from the Head of Nursing for that area, defending why there was a lack of equipment and that I was wrong for emailing the Matron and the safety lead, that I went through the wrong channels and that she would like to see me to discuss the matter.

    Of course, I accepted the offer of meeting up. After all, what had I done wrong? Emailed the wrong person? Raised a concern? Had I spoken out of turn? 

    When I received this email I felt upset and scared, then angry. This was bullying behaviour from a senior member of the Trust.  

    I then thought, why?  

    The Head of Nursing was known to me. She has been a real inspiration to me, so what has happened? This must be a cultural way of coping with concerns that are directly involved in the way she had managed this area. Now she was being faced with a concern raised by someone low down in the ranks, which could possibly look like an attack on the way she manages this area.

    Was she annoyed that she wasn’t involved in the email trail? Whatever it was, the way that the concern was raised was out of the usual. It upset the way we do things round here.

    I don’t want to be labelled as a whistleblower. I am doing my job and doing what the board have asked. I am raising concerns.  

    As you see this blog is anonymous. The fear of vilification is strong and is very real.

    And all this with an issue where my intervention prevented a never event and for which I was thanked. 

    With this experience, will I raise concerns again in real time to prevent harm? Or will I choose to go through the official route, wait and see if anything happens and be ready to explain (if asked) when the Trust undertakes a serious incident investigation or defends a clinical negligence claim? 

    Principle 4 – Culture of visible leadership

    All employers of NHS staff should demonstrate, through visible leadership at all levels in the organisation, that they welcome and encourage the raising of concerns by staff.

    Initiating the FTSUG in every NHS Trust was a great idea, however, if we had visible leadership that welcomed and encouraged raising of concerns, we would not need this service.

    The FTSUP is a sticking plaster for a deeper routed problem.

    The Head of Nursing had a very human response to my concerns. She was defending actions that others had taken and defending why the problem happened. This is a natural reaction to feeling threatened, so perhaps I was in the wrong in the tone in which I raised the concern?

    This led me to question what training middle managers have on dealing with staff or patient concerns. When confronted with a concern do they know what to do? What do they do with this knowledge, how do they communicate with the staff or patient raising the concern? How do they raise up the line with their directors and the Board? Will they be thanked for highlighting opportunities to improve or will they be met with defensiveness and hostility? 

    And what about ‘raising concerns’ training for staff and patients? We also need to know what is expected of us and what we can expect back, that someone has our back when we raise concerns.

    Principle 5 – Culture of valuing staff

    Employers should show that they value staff who raise concerns, and celebrate the benefits for patients and the public from the improvements made in response to the issues identified.

    If adequate training in this area existed perhaps more staff and patients would speak up as they feel that they were being heard, being cared for and feel safe. In turn, middle management would feel more equipped to handle concerns with a more inquisitive approach rather than one of defence.

    Being involved in improvements in care is a wonderful experience. Seeing that you have made a difference to patients is a privilege.

    We need to react to people raising concerns in a different way, using a different lens and we all need the training and support to do so.

    What are Trusts doing to show that raising concerns is welcomed, makes a difference and helps us improve safety? Shouldn’t this be publicly reported to staff, to commissioners and the general public?

    Principle 6 – Culture of reflective practice 

    There should be opportunities for all staff to engage in regular reflection of concerns in their work.

    Reflections of our concerns for work could be taken as evidence, this has been seen in the Dr Garber incident. This has made us fearful of writing our reflections down.

    Shwartz rounds are great but take a lot of organising and are only for the few staff.  

    Time will always be an issue, so quick-fire reflections about what has gone wrong, and even better what has gone right, with your immediate team are a fantastic opportunity. 

    We try and have after action reviews, however the harsh reality of clinical practice does not lend itself to a half a dozen staff downing tools to talk about just what happened.  The capacity to do this is just not there.

    I am reflecting now on concerns that I have raised.  It’s a shame I don’t feel confident in putting my name to this blog for fear of what my Trust will say.

    As I said, I do not want to be a whistleblower, none of us do. We want to raise concerns, have them acted on and keep our patients safe.

    Call for action 

    At present the conditions are not right for us to speak up safely for these reasons:

    • Our current reporting process doesn’t fit large system wide concerns, this is set up for incidents that have already harmed patients or staff.
    • A Just Culture approach is spoken about but is not demonstrated or welcomed when concerns are raised.
    • Staff are not equipped to handle concerns once they are raised to them.
    • Patients or staff are not encouraged to speak up or have the mechanism to do so.
    • Taking time out to reflect on our concerns and our practice is not valued.

    There are some great initiatives out there, but unless the fundamentals are in place to allow safe speaking up repeated harm will continue to happen.

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    An excellent blog which tells it as it is, your clear understanding of why staff can’t or will not speak up reads like the first chapter of many whistleblower biographies.

    We all begin the same way; those of us who wish to do our duty and protect patients from harm, or to stop harm that we can see is already happening speak up in the hope that practices will improve. It is then that we find that what we thought was a management culture which has caring, safety and respect at its heart is, in fact, nothing of the sort.

    The flimsy structures which hold together many NHS senior management teams are often headed by narcissists and bullies who build a structure of sycophants and ‘yes men’ around them to preserve their position. There can be no dissenting, no admission of problems or bad practice and this usually results in the removal of both the person raising concerns and the manager who acknowledged it. Instead the concern is met with denial or if reported to the FTSUG, the person who reports will be told that it will be dealt with confidentially and that they no longer need to worry about it; management will now have this person in their sights, in true ‘Big Brother’ fashion their card is marked. The brave blogger above will be ‘known’ and he or she must take care as any further suggestions that they will follow up their concerns or raise new ones will set in motion a chain of events which will destroy their career and cause them serious psychological harm; they will be ostracised and vilified in their own department, denied opportunities for training and promotion and excluded from decision-making, meetings and making clinical contributions.

    This is not a figment of my imagination but a true scenario played out and endured by many healthcare professionals at all levels in the NHS, the experience of myself and many others.

    A final word of warning to our blogger who believes the BMA will support him or her, professional bodies have failed many in the past and have very close allegiances with senior NHS managers, it is more likely you will be sacrificed.

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    Thanks Sue for your comment and sorry to hear that you’ve had direct personal experience of these issues. 

    I think the saddest part of your response for me was ‘There can be no dissenting, no admission of problems or bad practice and this usually results in the removal of both the person raising concerns and the manager who acknowledged it.’ We are destined to repeat errors and harm patients unless we challenge the status quo. 

    Alarming also what you say about the role and approach of professional bodies. Would you like to share more? You’d be very welcome to contact me direct on this. Maybe that’s something we can explore and highlight on the hub? 

    Thanks again for your insight and comment helen@patientsafetylearning.org

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    i read this and see why issues will not be dealt with i can also see why people move to other areas of medicine and then eventually leaving if they can not simply speak up

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    Dr Rick Fraser asked us to post his response to this blog:

    Good to hear about the work you are doing.

    An open/transparent culture of speaking up is something I am really interested in for so many important reasons - I have found the IHI model of safe, reliable and effective care is enormously helpful in linking patient safety and culture.

    When an organisation has a culture where psychological safety is clearly evident then staff, patients, family & others all feel able to speak up and raise concerns as & when they occur. The organisational response is crucial and needs to be absolutely linked to patient safety as that cannot be disputed and is always the common ground we look for when trying to connect across systems and with others eg staff.

    An authentic, consistent approach that is humane, proportionate and transparent is crucial and must be led from the Board all the way through the organisation. Included in this humane approach are kindness, forgiveness, fallibility and equality. Some of these will come naturally and others have to be nurtured within individuals and the organisation. Some may criticise and call it 'woolly' or 'fluffy' however when the evidence can link all of these culture based approaches patient safety and outcomes then there can be no dispute.

    That’s what is so elegant about the IHI model (below) as it links all these aspects of the system together and allows for development of culture & learning system and then ongoing monitoring from Board to Ward. As a Dr this makes perfect sense as it combines the science/evidence with the learning system/culture to ensure patient care is optimal and safe every time.

    Dr Rick Fraser, Chief Medical Officer 


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