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  • Still not safe to speak up: NHS Staff Survey Results 2022 (Patient Safety Learning blog)


    Patient Safety Learning

    Summary

    In this blog, Patient Safety Learning looks in detail at the results of the NHS Staff Survey 2022, focusing on responses relating to reporting, speaking up and acting on safety concerns. It includes the following key points:

    • It is difficult to imagine other safety critical industries would deem these results acceptable. Nearly half of all respondents did not feel confident their organisation would address their concerns about unsafe clinical practice.
    • It is hugely concerning that over 40% of respondents could not say that they would be treated fairly if involved in a patient safety incident. This could significantly undermine the willingness of staff to raise concerns, with significant consequences for patient safety.
    • There needs to be greater urgency to improve the safety culture in the health service. NHS England needs to recognise the scale of this challenge and provide clarity on how it will work with organisations to tackle this.
    • NHS England, working in partnership with the National Guardian and the Care Quality Commission, should bring forward as a matter of urgency robust and specific commitments to drive forward the work of improving the safety culture in the NHS.

    Content

    On 9 March 2023, the NHS published the results of its 2022 staff survey. 636,348 staff from 246 organisations took part in this, with the results providing a snapshot of their experiences of working in the health service.[1] This survey presents an opportunity to assess staff views on a range of important safety issues, from safe staffing levels to witnessing incidents and near misses.

    In this blog we focus on the survey results relating to reporting and acting on patient safety concerns. Staff feeling able to speak up, and being assured that action will be taken to address concerns, is crucial if patient safety incidents are to be reported consistently and acted on to prevent future harm. At Patient Safety Learning we’ve previously highlighted the survey’s results in relation to these issues in 2020, 2021 and 2022.[2-4] Here we consider what the most recent results reveal about the safety culture in the NHS.

    What does this tell us about speaking up and raising concerns?

    Raising concerns about unsafe clinical practice

    • 71.9% of staff said they would feel secure raising concerns about unsafe clinical practice (down from 75% in 2021).
    • 56.7% of staff said they were confident that their organisation would address their concern (down from 59.5% in 2021).

    Over 170,000 staff (28.1% of respondents) could not say that they would feel secure raising concerns about unsafe clinical practice, with more than 270,000 staff (43.3% of respondents) not confident their organisation would address clinical practice concerns that they did raise. The results to these questions also vary significantly depending on the type of trust, with 80.9% of respondents from community trusts feeling secure to raise concerns about unsafe clinical practice, but only 65.2% from ambulance trusts.

    It is difficult to imagine that such figures in other safety critical industries, where the consequences of such incidents may be serious injury or loss of life, would be deemed acceptable. We should not accept a situation where nearly half of NHS staff do not feel confident their organisation would address their concerns about unsafe clinical practice.

    Looking at previous years scores it is also deeply concerning that there has not been any significant improvements in this area, with the latest 2022 figures very similar to those in 2018 (70.9% and 58.6%, respectively).

    Speaking up about any concerns

    • 61.5% of staff said they feel safe to speak up about anything that concerns them in their organisation (down from 62.1% in 2021).
    • 48.7% of staff were confident that their organisation would address their concern (down from 49.8% in 2021).

    More than 240,000 staff (38.5% of respondents) could not say that they felt safe to speak up about anything that concerns them in their organisation. When asked about confidence in their organisation acting on any concerns, this figure drops even further, with over 320,000 staff (51.3% of respondents) not believing their concerns would be addressed.

    It is a shocking figure that over a third of NHS staff surveyed do not feeling safe to speak up about concerns. It is a clear indication that we remain far away from the NHS vision of creating a patient safety culture throughout the health service. When compared with previous years, again this is not an area where we are seeing progress, with the rate of staff stating that they feel safe speaking up now falling for three consecutive years (2020: 65.7%; 2021: 62.1%).

    Reporting of errors, near misses and incidents

    • 86.1% of staff said their organisation encourages staff to report errors, near misses or incidents.
    • 67.3% of staff said that when errors, near misses or incidents are reported, their organisation takes action to ensure they do not happen again.
    • 58.1% of staff said their organisation treats staff who are involved in an error, near miss or incident fairly.

    Due to changes to the questions in this part of the survey, it is not possible to make a like-for-like comparison with the 2021 results. While the percentage of staff saying that their organisation encourages them to report patient safety issues is noticeably higher than some of the other responses we have highlighted in this blog, this sits somewhat uncomfortably with scores concerning how people actually feel about speaking up.

    It is hugely concerning that over 260,000 staff (41.9% of respondents) could not say they would be treated fairly if involved in a patient safety incident. This lack of confidence could undermine the willingness of staff to raise concerns, with significant consequences for patient safety. A significant number of respondents (32.7%) also felt unable to say that their organisation took action after errors, near misses or incidents to ensure these did not happen again.

    Are we moving towards a safety culture in the NHS?

    An organisational culture that seeks to assign blame when things go wrong makes patient harm more likely to happen again. In our report, A Blueprint for Action, we identify a Just Culture as one of the six foundations of safer care to improve patient safety.[5] A just culture considers wider systemic issues where things go wrong, enabling professionals and those operating the system to learn without fear of retribution. In A Blueprint for Action we make the case that organisations should publish goals and deliver programmes to eliminate blame and fear, introduce or deepen a Just Culture, and measure and report progress. 

    This year’s staff survey results indicate that in too many parts of the NHS staff do not feel that such a culture exists. Significant numbers of staff still do not feel safe to speak up or confident that their concerns will be acted on.

    Although the Staff Survey only provides a snapshot of staff views at one point in time, these results are reinforced by the experiences and testimonies of many whistleblowers, as well as the findings of numerous inquiries into major patient safety scandals. A recurring theme often emerges of problematic cultures where staff cover up the actions that lead to avoidable harm rather than reporting them for fear of retribution. Most recently this was raised again by the East Kent Maternity review, with evidence of ‘a “blame culture” when things went wrong’.[6]

    NHS safety culture objectives

    Creating a safety culture is identified as a core part of the NHS Patient Safety Strategy.[7] In its last update on this, published in 2021, NHS England set out several activities aimed at monitoring the development of this in the NHS and following actions aimed at supporting this:[8]

    • Establish the safety culture work programme to bring together data, research and practical support for safety culture improvement by Q1 2021/22.
    • Produce a safety culture guide to help organisations implement specific improvement activities by Q1 2021/22 (see key enablers objective under Safety system).
    • Extend the exploration of safety culture processes and infrastructure to mental health, community and primary care settings by Q4 2021/22.
    • Continue to establish and test safety culture interventions to support local systems, as part of the key enablers objective.

    A new Safety Culture Programme Group met in July 2021 to discuss recommendations to develop a safety culture in the NHS.[9] This led to the decision to create a new Safety Culture Implementation Group to meet every 2-3 months to oversee this work. We would hope as part of the latest update on the NHS Patient Safety Strategy, due to be released this year, further details of this work will be shared. In addition to this, in November 2022 a new guide aiming to help Trusts learn from safety culture best practice was published by NHS England.[10]

    What more action is needed?

    It is difficult to make an assessment of the activities underway by the NHS England Safety Culture Implementation Group to drive forward these changes as, to the best of our knowledge, details of the membership of this group and its work it undertakes have not to date been shared in the public domain.

    However, we would make the case, based on the current work we are aware of and the significant lack of progress as measured by Staff Survey results, that there needs to be greater urgency to tackle these issues in the NHS. Below we have identified three gaps in the existing approach which we believe need to be tackled:

    1.    Acknowledging the scale of the problem

    The formal NHS response to the Staff Survey results was brief.[11] There has been no real recognition of the serious speaking up problems that this year’s results have again highlighted. Despite declines in all the scores relating to raising concerns, there has been no significant public comment on this by NHS England. If creating a safety culture is truly a priority for NHS England, it can’t simply brush these scores aside. It needs to acknowledge the scale of the challenge and be clear how it will work with organisations to tackle this.

    2.    Implementing good practice

    Having published its new good practice guidance, we believe it would be beneficial for NHS England to set out how this is being rolled out, monitored and evaluated. Currently it isn’t easy see which organisations are implementing this, what progress they have made and, crucially, what impact it is having. We believe there needs to be greater transparency in this area and clear reporting from individual Trusts.

    3.    Intervening for improvement

    There are significant variations between different organisations in the scores to the Staff Survey questions highlighted here. In cases where responses around speaking up and concerns around unsafe practice are particularly low, or on a significant downward trend, we believe there needs to be mechanisms in place to identify where this is the case, and if necessary intervene. We don’t believe the onus of this can simply be left to individual Trusts, there needs to be a central approach to monitoring and managing this. Likewise, we believe there should be greater efforts to highlight cases where organisations are making significant improvements and demonstrating their commitment to becoming learning organisations with a strong commitment to achieving a safety culture.

    If there is to be any positive movement on scores on safety issues in coming years, now is the time to act. NHS England, working in partnership with the National Guardian and the Care Quality Commission, should bring forward as a matter of urgency robust and specific commitments to drive forward the work of improving the safety culture in the NHS.

    References

    1. NHS Staff Survey, NHS Staff Survey National Results, 9 March 2022.
    2. Patient Safety Learning, Results of the NHS Staff Survey 2019, 18 February 2020.
    3. Patient Safety Learning, Tackling the blame culture? NHS Staff Survey Results 2020, 22 March 2021.
    4. Patient Safety Learning, Safe to speak up? NHS Staff Survey Results 2021, 31 March 2022.
    5. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action. Report, 2019.
    6. Independent Investigation into East Kent Maternity Services, Maternity and neonatal services in East Kent – the Report of the Independent Investigation, 19 October 2022.
    7. NHS England and NHS Improvement, The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019.
    8. NHS England and NHS Improvement, NHS Patient Safety Strategy: 2021 update, February 2021.
    9. NHS England, Safety culture programme group (SCPG) report: Overview of safety culture discovery and discussions 2021, Last Accessed 16 March 2023.
    10. NHS England, Safety culture: learning from best practice, 15 November 2022.
    11. NHS England, Response to latest NHS Staff Survey results, 9 March 2023.
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