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Found 42 results
  1. Content Article
    Rachel Wright, founder and director of Born at the Right Time, is a qualified nurse, wife of a GP and parent of a young man with complex disabilities. In this BMJ opinion piece, she describes her experience of navigating the healthcare system on behalf of her son, and highlights the gap between narratives about empowering parents and the reality of her experience as a parent carer. She describes the mistrust and institutionalised bias that the healthcare system shows parents and the impact this has on parents' mental health. She calls on the healthcare system to examine the causes of this bias, rather than focusing on empowering parents to deal with the problems the system presents as they advocate for their children.
  2. Community Post
    Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views?
  3. Content Article
    Two years after his 13-year-old child died needlessly in hospital, Paul Laity reflects on life without her. Martha Mills died of septic shock due to a series of serious failures in her care after she injured her pancreas in a cycling accident. Her father Paul talks about the ongoing pain of grief, and the additional burden of knowing that Martha's death was preventable, caused by the complacency of her doctors and a culture in the hospital that meant consultants were reluctant to ask expert advice from paediatric ICU. "Martha’s avoidable death was unusual in that the prime causes weren’t overwork or a lack of resources, but complacency, overconfidence and the culture on the ward. What upsets me most was that the consultants – a different one most days – took a punt that she was going to be OK over the weekend. No one assumed responsibility; they hoped for the best rather than playing safe. Was everything done for Martha that could have been done? Emphatically not. It’s very hard to live with this knowledge. But just as hard is the recognition that I, too, didn’t do enough." Further reading ‘We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death (The Guardian, 3 September 2022) Prevention of Future Deaths Report: Martha Mills (28 February 2022)
  4. Content Article
    In this blog, Dr Faisal Saeed talks about the patient-provider power imbalance using an AI generated image of two chairs to illustrate his points.  When Vincent Van Gogh painted the empty chairs, it was his purpose to distinguish the two chairs; his and that of Gaugin’s. Van Gogh’s chair is painted to be less mystical; straight backed and with no armrests, made of plain unpolished wood. Gauguin's chair was a more ornate and luxurious piece of furniture, with a high back and a carved seat. The chairs were a reflection of the two artist’s personalities and their relationship with each other. While visiting the Van Gogh Alive festival in Adelaide, these paintings of Van Gogh’s chairs stood out at me because I have always found it uncomfortable when I had to point to a simple chair (a backless stool or a plastic chair without armrests) to sit down for my patient, while I was sitting in an imposing high back black leather executive chair with padded armrests, lumbar support, back and head rest adjustment and a swivel base. The image below is an AI generated image. I used the prompt: “painting of a doctor's chair and a patient's chair in a consultation room, painted in the style of Van Gogh”. Guess which chair is the patient’s chair? The concept is so ingrained in society that even generative AI and natural language processing models take it for granted that the patient should be seated in the smaller chair. Since early history, elaborate chairs have been used as a symbol of power by the higher strata of the society – kings, priests and the like – and the simpler backless version of the chair, the stool, is used primarily by the lower strata. Authority, domination and power is what come ultimately to mind when one thinks of chairs (Danto, 1987). The design and the use of the chair is deliberate and the the symbolism is still evident today. It is no accident that the high-ranking officials are given the best and expensive chairs positioned at the front, while others sit in less conspicuous or cheaper ones. It is designed to show power and status. Given the power imbalance between the doctor and the patient, with the seemingly powerful situation the doctor is given in the relationship due to the deference to expertise, the simple chair the patient sits on only acts to reinforce the power imbalance. As it is, several barriers exist that make patients hard to speak up, even where patients are well-informed and well educated. Many patients feel they can’t participate in shared decision-making, and the power imbalances are a key barrier even if patients have the knowledge (Joseph-Williams, 2014). Because patients must have equal power in the relationship as a partner in care, it is time we do not make this distinction in the design of the clinical environment. The patient is an equal partner in the therapeutic relationship and is very much an expert in the lived experience of their illness. We cannot imagine two leaders of a company being shown two very different types of chairs – one simple and one expensive – when seated to discuss and finalise on an agreement. Why must it be any different for the doctor and the patient?
  5. Content Article
    This is the protocol for a Campbell systematic review. The main aim of this systematic review was to identify whether hospital leadership styles predict patient safety as measured through several indicators over time. The second aim was to assess the extent to which the prediction of hospital leadership styles on patient safety indicators varies as a function of the leader's hierarchy level in the organisation.
  6. Content Article
    It was recently reported that NHS Finance Directors were ‘incensed’ that the Health Services Safety Investigations Body (HSSIB) should think that they could be working more closely with patient safety chiefs. Whereas medical staff and clinicians represent the sharp end of healthcare delivery, the administrative functions, including finance, are the blunt end. Removed in space and time from the action, it can be hard to see how their behaviour can directly influence workplace outcomes. To understand the issue, Norman MacLeod reflects on how systems behave and the decision-making hierarchy within healthcare organisations. Most discussion of ‘systems’ revolves around assemblages of artefacts: tools, processes, people and spaces. However, the late Jens Rasmussen described a system as a set of nested decision-making processes.[1] Leveson, at MIT, adds that systems are hierarchical, with control being exercised by higher tiers over the lower levels. She adds that control is exercised through communication and feedback.[2] From this perspective, a ‘system’ comprises actors engaged in different types of decision making. The hierarchy of decision making At the lowest level, we have the individual in the workplace. At any moment, our behaviour is directed at a specific goal and our probability of success is shaped by such factors as stress and fatigue, competence, expertise and motivation. Control is represented by direct action and feedback is in the form of observed outcomes. Because of the complexity of work, individuals form teams to get work done and this is the next level in the system. Teams make decisions about allocation of work, priorities, coordinating effort, problem solving. When an individual joins a team they surrender a degree of autonomy: you are no longer a free agent. Control is exercised through briefings, instructions and procedures, and feedback is manifested in behaviour meeting expectations, through raising queries, declaring problems, etc. Teams can be both real and virtual. Real teams are typically those assigned to a task, working in close proximity. Virtual teams comprise agents that collaborate for a specific purpose and are usually remotely located. Virtual teams often work asynchronously: a request is submitted and the response follows after a lag. Virtual teams require additional skills as they typically involve working across organisational boundaries. Individuals and teams are where direct action occurs. The next level in the system is the organisation. At this level, decisions are made in relation to the specific goals the organisation has been set up to achieve and cover configuring assets, allocating resources, command and control. The organisation exercises control over teams and individuals through contracts of employment, codes of conduct, policies, etc. Feedback is typically through audit and compliance, event reporting, tracking of resource utilisation. Of course, the ‘organisation’ is also made up of individuals and teams: the model is recursive. What differentiates each level is the nature of the decisions it makes. The next, and possibly, highest level in the hierarchy are those entities that facilitate the functioning of the system but do not, in themselves, get directly involved. Here we see government departments, regulatory bodies, accrediting bodies. Actors at this level set strategic goals, allocate resources at the macro level and grant permissions. The components outlined here all exist in a broader environment. By convention, the environment describes attributes that exert influence on the actors in the system but is not influenced, in turn, by those actors. For example, the public health profile in a geographic area will shape the strategic goals set for the organisation and will influence the healthcare capabilities that need to be provided in that area. However, the action of an individual healthcare organisation will not necessarily shape the public health profile of its hinterland. Emergence and cross-scale effect So, where do finance directors fit into all of this? Obviously, as actors at the level of the organisation their decisions relate to the allocation of financial resource. As such, they shape decision making by others in the system responsible for spending on specific functions. But we now need to look at some other properties of systems: emergence and cross-scale effect. Emergence describes behaviours that cannot be explained simply based on the functioning of the parts of the system. Cross-scale effects captures how actions at one level in the system can have unintended consequences at another level. If we start with emergence, ‘safety’ is an emergent property at the level of the individual. Only individuals can act in a manner that bolsters safety or, conversely, it is the actions of individuals that create unsafe states. ‘Culture’ is an emergent property at the level of the team, while at the level of the organisation we see morale as a key emergent. Patient safety activities compete for resources in a landscape where other demands can be seen to have a more direct influence on outcomes. In financial terms, patient safety can be seen as a discretionary spend. This attitude to a legitimate demand can shape morale. Cross-scale effects are akin to Reason’s Latent Factors.[3] Their presence is often only revealed when something goes wrong. We can see cross-scale effects at work in the case of staff recruitment. For example, to save money posts are often ‘gapped’: a post is not advertised until after the incumbent has left. While the post remains unfilled, the burden of work is borne by others or simply not done. Where workload is increased, outcomes can include increased fatigue, staff turnover, sickness/absence or risk of error. So, a simple, rational decision at one level can have multiple consequences elsewhere. The example given here – gapping posts – is typically a response to financial constraints. My intention here is not to portray finance directors as villains: they simply have their hands on some powerful levers of control. But their protestations do possibly support the need for a more sophisticated attempt to understand how systems work. References Rasmussen J, Svedung I. Proactive Risk Management in a Dynamic Society. Swedish Rescue Services Agency, Karlstad, Sweden; 2000. Leveson N. Engineering a Safer World. MIT Press; 2012. Reason J. Human Error. Cambridge University Press; 1991. Other blogs from Norman MacLeod: What is a ‘safety management system’? Error isn’t a problem – the problem is the word ‘error’
  7. News Article
    Patient safety is being put at risk by the “toxic” behaviour of doctors in the NHS, the health ombudsman has said. Rob Behrens, who investigates complaints about the NHS in England, warned that the hierarchical and high-handed attitude of clinicians was undermining the quality of care in some hospitals. He called for medical training to be redesigned to encourage a more empathetic and collaborative approach from doctors. Pointing to failings in the treatment of sepsis and the problems in maternity services, Behrens said he was “shocked on a daily basis” by what he saw as ombudsman. Too often, “organisational reputation has been put above patient safety”, he told The Times Health Commission. The ombudsman warned of a “Balkanisation” of health professionals, with rivalries between doctors and nurses or midwives and obstetricians harming patient care. “For all the brilliance of clinicians quite often they’re not very good at working together,” he said. “Time and again, the handover from one clinician to another, from one shift to another, or the inability to raise the issue at a senior level has been a key factor in what has gone wrong.” Read full story (paywalled) Source: The Times, 18 November 2023
  8. Content Article
    In this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored, side-lined or victimised. Why staff don't speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Steve concludes with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit. The scale of the problem The hidden costs of stigmatisation of healthcare whistleblowers are immense. System-wide problems in this area of healthcare are reinforced by a lack of transparency and the failure of accountability. The consequences of this failure have been investigated many times over the years. A seminal case was that of the Bristol heart surgery scandal in the 1990s. This was brought to light by the anaesthetist Steve Bolsin and led to the implementation of a system of clinical governance.[1] This advance in measures to deliver quality, consistent and safe care remains as relevant today as it ever was. More recently, the investigation into the failings at mid Staffordshire[2] highlighted how a ‘good news’ only culture, where reputation management was placed above patient safety, is failing patients. Critically for me the shocking fact is that where staff who blow the whistle can't, or don't, speak out, are ignored or silenced, the onus to expose wrongdoing falls on patients and their relatives. This involves great personal cost. The onus to expose wrongdoing falls on patients and their relatives. This involves great personal cost. This shameful thread of patient-led whistleblowing goes back a long way and has not stopped. Examples where patients, carers or relatives have had to take the lead and blow the whistle include the death of Robbie Powell,[3] Elizabeth Dixon,[4] Oliver McGowan,[5] Claire Roberts and those who died in the Belfast Hyponatraemia scandal,[6] the Gosport War Memorial Hospital scandal,[7] and the investigation into maternity services in East Kent.[8] These patient safety scandals show no sign of abating despite the report on the failings at mid Staffordshire[2] and Sir Robert Francis’ major review into whistleblowing in the NHS.[9] This is reinforced by the 2023 Bewick Review,[10] which is the first of three planned reviews into University Hospitals Birmingham NHS Foundation Trust. This review was commissioned following repeated serious concerns relating to patient safety, leadership, culture and governance, which were initially downplayed or ignored. The full story behind these failings and their significance has yet to fully come to light. Patients have to blow the whistle on unsafe care A stream of healthcare scandals (too many to mention all of them here) have been exposed by members of the public. Key examples include the case of Robbie Powell who died of untreated Addison's disease in 1990.[3] Thanks to the tenacity of Robbie’s father (Will Powell) this led to the clarification of the absence of an individual legal Duty of Candour for healthcare professionals.[11] Despite numerous reports and failed investigations, including one of which put forward 35 suggested criminal charges, the Robbie Powell case remains open with the Crown Prosecution Service (CPS). In addition, the former Welsh Ombudsman and the English Ombudsman are both calling for a public inquiry into the case.[12] Another case concerns those who died at Gosport War Memorial Hospital in the 1990s who were prescribed opioid medicines that were not indicated for their condition. This led to an Independent Review Panel,[7] which took four years and cost £14 million. The Panel found that 456 deaths in the 1990s had "followed inappropriate administration of opioid drugs". In 2019, Assistant Chief Constable Nick Downing, head of the Serious Crime Directorate for Kent and Essex Police, announced that a new criminal investigation into the deaths was to take place and the campaign for justice continues. Other serious issues include premature deaths of people with learning disabilities and autism,[13] which led to the implementation of the learning from deaths programme. On average, the life expectancy of women with a learning disability is 18 years shorter than for women in the general population. The life expectancy of men with a learning disability is 14 years shorter than for men in the general population.[14] There are numerous individual cases that support this finding, many of which were first highlighted by parents, informal carers or relatives. In 2014, the Department of Health and Social Care published a report that found that almost two-fifths of people with learning disabilities died from causes "amenable to good quality healthcare."[15] In 2022, a report by Dr Bill Kirkup into deaths in East Kent NHS maternity services[8] confirmed that the "onus was on patients to raise concerns" because the culture of fear prevented whistleblowers from speaking out. “In every case staff were aware of serious mistakes or wrongdoing but they were unaware of how to raise concerns because those who tried were subjected to peer pressure to be silent and everyone was afraid of the [personal] consequences.” These consequences were exemplified by the experience of the nursing director who was told that speaking up would harm her career. Another significant report is that into the life and death of Elizabeth Dixon,[4] which contains recommendations that apply across the board: "…6. Clinical error, openly disclosed, investigated and learned from, must not be subject to blame. Conversely, there should be zero tolerance of cover up, deception and fabrication in any health care setting, not least in the aftermath of error. (NHSE, GMC, NMC, MoJ) 7. There should be a clear mechanism to hold individuals to account for giving false information or concealing information relating to public services, and for failing to assist investigations. The Public Authority (Accountability) Bill drawn up in the aftermath of the Hillsborough Independent Panel and Inquests sets out a commendable framework to put this in legislation… It should be re-examined. (MoJ) 8. The existing haphazard system of generating clinical expert witnesses is not fit for purpose. It should be reviewed, taking onto account the clear need for transparent, formalised systems and clinical governance. (DHSC, MoJ)…" The amount of evidence and the number of reports that were initiated thanks to the tenacity and courage of patients, relatives, carers and parents, is truly shocking. How can we change this? How many more reports do we need? The only thing we can say with confidence is that lessons have not been learned. Why don’t staff speak out? I was recently asked ‘why don't staff speak out?’ There's very little rigorous research on whistleblowing in health and social care, so I can only offer my personal views on this apparent absence of ethical behaviour. I believe this quote from Margaret Heffernan (Professor of Practice at the University of Bath School of Management) goes some way to explaining this: “I have never encountered an organisation as vicious in its treatment of whistleblowers as the NHS".[16] If anyone has any doubts there are a string of high-profile cases to support it, including the cases of Steve Bolsin, Raj Mattu, Kim Holt, Peter Duffy and Chris Day. When I was asked why staff stay silent my first thought was to say that those who would speak out have all left. Of course, this can't be the full story. So, what are the other reasons? One possible reason is that people who are promoted to highly paid jobs attain these positions because they ‘toe the line’. Organisational psychologists talk about the role of enablers and ‘flying monkeys’ in maintaining this culture. A flying monkey is a psychology term that refers to an enabler of a narcissistic person, a henchman so to speak. Many staff keep their heads down and don't look too hard at what's going on around them. Some commentators see this as a behaviour that is supported by the promotion of toxic positivity. What I mean by this is a culture of talking-up successes, however small, completely ignoring failure, and therefore missing the learning that comes from failure. The widely used phrase ‘rock the boat but stay in it'[17] springs to mind here, especially the empty references to ‘radicals’ and ‘change agents’. This forms part of learning materials that are often accompanied by reams of management jargon and pseudo-science. This leads to a morally bankrupt approach where ‘all is well’ (‘nothing to see here’) and toxic positivity prevails. The belief that no matter how bad a situation is, people should maintain a positive mindset, move on and not mention it, is a way of working that is directly contradicted in these wise words by the late Professor Aidan Halligan: "Run toward problems, especially on a bad day." My views may sound very harsh, especially coming from someone like me who left direct employment with the NHS in 2008. It's important to point out that I believe the vast majority of NHS staff, at all levels from clerical staff and porters to senior managers and chief executives, do their best to work around the bullying and toxicity to deliver safe care for patients. Doing their best despite the prevailing culture rather than being supported by it. Sometimes biding their time and subtly subverting directives that are not in patients’ best interests. For clinicians, the threat of being referred inappropriately to a professional body is ever present,[18] and an environment where the pressure of work is extreme, exhausting and unstainable are also major factors. For many, the prevailing culture also means that the careers of highly skilled accountable, ethical and caring staff are held back through denial of learning opportunities and promotion, and informal blacklisting which is commonplace. There's an army of people ready for change, a huge informal network of highly motivated caring people, which is why I'm optimistic about the future. Why have ‘speaking up’ reforms failed? These are my personal views based on my experience and that of my colleagues. Since Sir Robert Francis’ whistleblowing report[9] there have been several changes designed to improve the situation. These include Freedom to Speak up Guardians (FTSU), the introduction of an institutional Duty of Candour, the ‘Fit and Proper Persons Test'[14] for Board members and the NHS Whistleblower Support Scheme. In addition, the Health and Safety Investigation Branch (HSIB) was set up in 2017 and a National Patient Safety Commissioner was appointed in 2022. Given all the above, why has there not been a reduction in high-profile healthcare failings? In my view there are several reasons. Many believe, as I do, that the approach of the Care Quality Commission (CQC) to whistleblowing is part of the problem. We often learn from investigation reports that the CQC (and other regulators) had been listing problems in their reports for years and yet no meaningful action has been taken. ‘Regulatory capture’ is a serious problem, which is when regulators are adversely influenced by the people they are inspecting. This is often linked to the revolving door of staff who move from health and care employment to the regulators, and informal links which amount to cronyism. This behaviour is something that commentators have noted and which I have experienced myself.[20]. Patients suffer as a result. The introduction of the National Guardian Office and Freedom to Speak Up Guardians in each NHS trust is also problematic. This initiative has an inbuilt conflict of interest, as the Guardians are employed by the trusts themselves. The All-Party Parliamentary Group on Whistleblowing (APPG) has heard from whistleblowers who have been failed by local Guardians, sharing their experiences that have included the disclosure of their identity to hospital management and boards, which resulted in retaliation. The APPG has also heard from local Guardians who were not supported and themselves the target of retaliation after supporting whistleblowers.[21] In addition, something which I find shocking is that the National Guardian Office appears to studiously avoid the word ‘whistleblowing’ in its material and outputs wherever possible. This adds to the stigma around healthcare whistleblowers and is inexcusable. Another lesser-known initiative is the NHS Speaking Up Support Scheme[22] (originally titled the Whistleblower Support Scheme). There is not much information available on this scheme in the public domain. I became aware of the scheme when I was asked if I wanted to apply. Later I signposted several people to the scheme. I learned that although the scheme has benefited some people, for others it appears to have made their situation worse. Through a freedom of information request, and thanks to the intervention of my MP, I have managed to obtain a redacted copy of the evaluation of the pilot scheme which supports the view of mixed results.[23] Having read this report, it is unclear to me why it hasn’t been published and why it was redacted. Particularly as I think (I can’t be sure of course) that one of the redactions is a comment I made. A comment I wanted to be shared. As for the other post-Francis review initiatives, the Kark Review in 2018 on the Fit and Proper Person Test (FPPT) is unequivocal in its findings: "Essentially it [FPPT] does not ensure directors are fit and proper for the post they hold, and it does not stop the unfit or misbehaved from moving around the system."[24] In addition, the statutory current Duty of Candour[25] seems, at times, to be little more than a tick box, with the responsibility for talking to patients often left to the most junior staff. A Duty of Candour is about simply telling the truth and is everyone’s responsibility, not a task to be delegated. The need for a legal duty of candour on individuals has been highlighted by Robbie Powell’s father Will Powell and links to proposals for a Hillsborough Law. The HSIB and the National Patient Safety Commissioner initiatives have some built in limitations to what can be achieved. The HSIB’s remit does not include investigation of systemic problems. This limits the areas that they can cover. As for the National Patient Safety Commissioner, this is a new role which is very promising. Unfortunately, the scope of this role is limited, with the remit covering only medicines and medical devices. This means that these two initiatives are not able to tackle the systemic organisational cultural issues that are at the root of major patient safety failings. One thing that stands out here is that none of the above measures specifically tackle the stigma around whistleblowing in healthcare. In fact, some reinforce the stigma. A way forward Much has been written about healthcare whistleblowing and measures that have been implemented to promote positive change. Despite these, the victimisation of healthcare whistleblowers and the stigmatisation around whistleblowing in health and in social care has not abated. The measures introduced have so far achieved very little. In some instances, I believe, they have made the problem worse. The Protection for Whistleblowing Bill,[26] which passed its second reading in December 2022, proposes the repeal of the current Public Interest Disclosure Act,[27] replacing it with an Office of the Whistleblower. This would prevent concerns of genuine healthcare whistleblowers becoming buried under an employment issue, and their original patient safety concerns being side-lined. The Public Interest Disclosure Act is expensive, limited in scope and beyond the reach of most whistleblowers. It is also overly complex, with cases currently waiting for over 2 years to be heard. Employers game the system to run whistleblowers out of funds. Fewer than 12% of cases that go to the Employment Tribunal win. It does not protect patients and is not accessible to members of the public who blow the whistle. Currently there is no statutory provision to investigate or address the wrongdoing highlighted by whistleblowers. Many whistleblowers have been denied any protection because they are not workers. An Office of the Whistleblower would change this and help us identify the root causes of systemic patient safety failings.[26] I urge everyone with an interest in this subject to read the bill and watch the video of Baroness Kramer introducing the second reading of the Bill.[28] For the first time in years, I am optimistic. References Department of Health. The report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995: learning from Bristol (Cm5207(II)); 2001. Department of Health. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry; 2013. Hartles S. Robbie Powell: Time for Truth, Justice and Accountability. Open University Harm & Evidence Research Collaborative; 2021. Kirkup B. Independent report. The life and death of Elizabeth Dixon: a catalyst for change; 2020. Ritchie F. Independent Review into Thomas Oliver McGowan’s LeDeR Process Phase two; 2020. Department of Health, Northern Ireland. Report of the inquiry into hyponatraemia related deaths; 2018. Gosport Independent Review Panel Report. The Panel Report - 20th June 2018. Dr Kirkup B. Reading the signals: maternity and neonatal services in East Kent – the report of the independent investigation; 2022. Francis R. Report on the Freedom to Speak Up review; 2015. Bewick M, et al. University Hospitals Birmingham NHS FT (UHB) Phase 1 Review by I4QU. Clinical Safety. iQ4U Consultants; 2023. Action against Medical Accidents. Robbie’s Law. The European Court Ruling in full: https://hudoc.echr.coe.int/fre#{%22itemid%22:[%22002-6998%22]}. Parliamentary and Health Service Ombudsman. Radio Ombudsman: Will Powell’s 32-year quest for justice for son Robbie; 2022. NHS England. About LeDeR; 2023. NHS Digital. Health and Care of People with Learning Disabilities, Experimental Statistics: 2018 to 2019 [PAS]; 2020. Department of Health and Social care. Premature Deaths of People with Learning Disabilities: Progress Update; 2014. Heffernan M. I have never encountered an organisation as vicious in its treatment of whistleblowers as the NHS. BMJ Talk Medicine Podcast; 2020. Bevan H. Rocking the boat and staying in it: how to be a great change agent. Slide set; 2016. Grossman D, Clare S. Birmingham hospital culture worrying - health secretary. BBC Newsnight; 2023. Care Quality Commission. Fit and proper persons: directors; 2022.   Clegg A. How cronyism corrodes workplace relations and trust. Financial Times; 2022. WhistleblowersUK, Meeting with Dr Bill Kirkup CBE and the APPG for Whistleblowing: blog; 2022. NHS England. Speaking up support scheme; 2022. Greenop D. NHSI Whistleblowers Support Scheme pilot. Final Evaluation (redacted); 2019. Obtained in 2022 following a Freedom of Information Request. Kark K, Russel J. A review of the Fit and Proper Person Test. Commissioned by the Minister of State for Health; 2018. Care Quality Commission. Regulation 20. Duty of Candour; 2023. UK Parliament. Protection for Whistleblowing Bill [HL]; 2023. UK Government. The Public Interest Disclosure Act 1998 [PIDA]. Baroness Kramer. Protection for Whistleblowing Bill, 2nd Reading, Baroness Kramer 2022. Video recording of the House of Lords introduction.
  9. Content Article
    This discussion paper, published in The Journal of Patient Safety and Risk Management, explores some of the opportunities which healthcare organisations could embrace to positively influence the effects of power and hierarchy on staff safety. The author concludes: "This exploration into how power and hierarchy influence both staff and patient safety has identified and briefly explored some of the tensions created by misplaced brand loyalty inherent within healthcare institutions, and the legacy of harms resulting." See also Helen Elliott-Mainwaring's poster on the research (also available to download from the attachment below):
  10. Content Article
    This article from Wood and Wiegmann, in the International Journal for Quality in Healthcare, discusses the action hierarchy, which is a tool for generating corrective actions to improve safety and focuses on those recommendations relying less on human factors and more on systems change. The authors propose a multifaceted definition of ‘systems change’ and a rubric for determining the extent to which a corrective action addresses ‘systems change’ (‘systems change hierarchy’).
  11. Content Article
    The quality and safety of patient care relies on good communication, teamwork and respect between staff. However, in many areas of the NHS hierarchical attitudes lead to a dictatorial approach in which senior nurses make decisions affecting their colleagues without any discussion or consideration of the impact and practicality of these decisions. This can lead to dysfunctional organisational cultures in which staff either tolerate and emulate disrespect or leave the profession. Ellen Wightman, a staff nurse at University Hospitals Bristol NHS Foundation Trust, reflects on the importance of nurses being supported in developing leadership skills – and having the motivation to create collaborative and positive cultures.
  12. Content Article
    This blog from the PatientSafe Network discusses cognitive dissonance. Cognitive dissonance — the pain of accepting ego-dystonic facts — mitigates against an open, rational aggressive cycle of process improvement. Unfortunately the hierarchical structures in healthcare mean we are likely to suffer from this. Those further up, best positioned to bring about positive change, are the most likely to suffer cognitive dissonance.
  13. Content Article
    The COVID-19 pandemic has had one of the biggest effects on work-as-done in healthcare in living memory. So what might we learn about work from the perspectives of frontline workers? Steven Shorrock asked a variety of practitioners to give a short answer – whatever came to mind. The themes that emerge centre around people, their activities, their contexts, and their tools. Many insights concerned the varieties of human work, goal conflicts, design, training, communication, teamwork, social capital, leadership, organisational hierarchy, problem solving and innovation, and – generally – change. Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives.
  14. Content Article
    When James Titcombe is hit by the biggest tragedy imaginable to any parent, he and his wife need to confront a tragedy on a bigger scale still: the structural learning disabilities of the organisation that robbed them of their child. The ‘complexity of failure’ video documents the struggle to get the largest employer of the land to account for what was lost. Behind the bureaucracy and posturing, the lies and denials, it discovers a humanity and a richly facetted suffering by many others. It drives a determined James Titcombe to change how we learn from failure forever.
  15. Content Article
    Paul Batalden has defined quality improvement as: “the combined and unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)”. Quality improvement (QI) goes beyond traditional management, target setting and policy making. QI methodology is best applied when tackling complex adaptive problems – where the problem isn’t completely understood and where the answer isn’t known – for example, how to reduce frequency of violence on inpatient mental health wards. QI utilises the subject matter expertise of people closest to the issue – staff and service users – to identify potential solutions and test them. East London NHS Foundation Trust (ELFT) is a provider of mental health and community services, to a population of approximately 1.5 million people, mainly across East London, Bedfordshire and Luton. ELFT's Quality Improvement website provides many resources, as well as their QI projects, events and training.
  16. Content Article
    The Care Quality Commission (CGC) is the independent regulator of health and adult social care in England. They make sure that health and social care services provide people with safe, effective, compassionate, high-quality care and encourage care services to improve.  Independent acute hospitals play an important role in delivering healthcare services in England, providing a range of services, including surgery, diagnostics and medical care. As the independent regulator, the CQC, hold all providers of healthcare to the same standards, regardless of how they are funded.  In this report the CQC have seen much good and outstanding care, in particular around: responsiveness staff interactions with patients effective treatment leadership and engagement with staff and patients. However, there were a number of areas where services needed to make substantial improvements: governance clinical audit safety culture.
  17. Content Article
    An insightful blog from a nurse on the frontline. The author of this blog has requested to stay anonymous. Courage is one of the nursing 6Cs "Courage enables us to do the right thing for the people we care for, to speak up when we have concerns. It means we have the personal strength and vision to innovate and to embrace new ways of working." (NHS England, 2015). But... Why should we need courage to come to work? Why do we need to find this strength to do our job? Why do patients have to rely on us to have courage to keep them safe? Being able to speak up, to innovate and implement new ideas should be a way of normality. We should not have to feel threatened, inadequate or ‘the pest’. I would like to share my experience the other shift. A story of ‘courage’ and advocating for patient safety within a clinical setting. Working in Black escalation is hard. Working on an acute surgical ward we have elective patients that are booked in weeks in advance, often we have to cancel cases to make sure the flow of patients keeps moving through the hospital. It’s a constant raft of bed meetings and handovers to various managers about who can go home, who is medically fit to move off, why can they go home today, why are they not ready... Much of the day is consumed by this. It feels like a conveyor belt, laden with sick patients – some will go home but some will slip off the edge. I feel like we are trying to keep everyone moving in the right direction and not to lose anyone down the cracks in the process. So, what happened that shift that made me apprehensive about raising concerns about a patient and their care? It was 4:30pm. A patient arrives from the emergency department (ED), his NEWS Score was 5. This is a high score and this score has increased since his admission to ED, so this patient was deteriorating. He was in his late 60s, ordinarily a fit man. A stoic man, who doesn’t like to cause a fuss. He is lying in bed, he has intravenous fluids running. He is pale, he has mottling over his tummy and has a pain score of 8/10. His family is by his bedside compliant and submissive with current plans of care. He had been admitted to our ward with a perforated duodenum (a hole in the bowel). It is written in the notes, which is barely legible, that this man is for conservative management. This means that there will be no surgical intervention and he will be treated with medicines only while the hole ‘self-repairs’. In my experience as a nurse in this area, these types of perforations do not heal themselves. What do I do? Firstly, I assess the patient. I perform an ABCDE assessment. I look at his observations and his fluid chart, his blood results. I take some further blood, along with a venous blood gas. Collecting numerical data on sick patients is a way of communicating to doctors. As nurses, we see subtle changes to our patient; they may become more confused, more clammy, pale, agitated or ‘just different’. This type of information is difficult to articulate and quantify. So, finding a common language within the multidisciplinary team is vital to ensure your concerns are taken seriously. After I take the blood, the patients family ask me if I am concerned. I ask them why they have asked this question, as this is not something that relatives usually ask… unless they have concerns too. The relatives are concerned about the decision not to operate at this point. They see that their loved one is unwell and can see he is getting worse since admission. They feel that they have not been listened to. I call the surgeon to come and reassess, he is about to go home – but kindly comes up before he goes. "…but, we are just the peasants…" This was the response from the family when I asked them what their concerns were. They felt that their opinion was not credible. This made me feel so sad. Even relatives and carers feel unempowered to speak up. This offers little hope for the patient lying in bed. The patient’s wife claims that she is worried sick, she knows that he is getting worse. She feels she is watching him deteriorate in front of her eyes. She wants someone to listen to her and act on her concerns. The next set of observations show that his NEWS is now 7. He has deteriorated further, despite the patient looking the same. At this point the surgeon is in the room. He is also assessing the patient. "...In my view, I think you are a little better Sir." The patient’s wife looks at me. I look at her. We both know that this is not the case. What are my options? I agree with the surgeon. Regurgitate what he has explained to the patient back to her and agree with ‘watching and waiting’. This is not advocating for the patient or the family and, on my part, negligent. Losing the trust of a family is a complete failure in care. I disagree with the surgeon, risking his response to be defensive. By being confrontational, I risk him not engaging with anything I say – especially in front of the patient and relatives. Once the surgeon is out of the room, I place a medical emergency call. This is within our escalation policy. However, this may damage the relationship we have with our surgeons by going ’above their head’. We have to work together on a daily basis. We need to trust them, and they need to trust us. I didn’t do any of the above, which is a breach of the Trust's escalation policy. This is a ‘work as imagined’ (policy) and ‘work as done’ is how it actually works. I am aware of what I should be doing but choose to escalate my concerns with the parent team. If I was to place a medical emergency call out now – the surgeon is left with feelings of disempowerment, failure and mistrust. Like I say, we have to work as a team. If the patient was deteriorating quickly, and we were unable to get any help and he was not receiving the treatment then of course a medical emergency call would be placed. I decided not to agree or disagree. I stated facts. Facts that could not be ignored. "Patient [X] NEWS score has increased from 5 to 7, his blood pressure has dropped by 30 mmHg, his heart rate is 130 bpm, he has been oliguric but now in the last hour, anuric despite having 4 litres of fluid. His venous lactate remains high. He is deteriorating." There was a pause. The surgeon looked at me and agreed. We both then made the plan that he would call his consultant and I would get intensive care involved. The patient went to theatre within the next hour or so. He is recovering well. There are many themes at play here. Cognitive bias from the surgeon, fear from the surgeon to call his consultant out of hours, fear from asking for help. 'Imposter syndrome' from the nurse – I can’t disagree with a surgeon – "I’m just a nurse". Hierarchy has a place in healthcare but, when looking after sick patients, hierarchy is a huge barrier to escalating that patient to receive the right care in a timely fashion. Courage was displayed by the nurse (myself) in speaking up to the surgeon. The surgeon showed courage in listening to the nurse and asking for help to his consultant. We should not need courage to keep our patient safe.
  18. Content Article
    See how incivility affects all of us in the NHS and how that can impact patient safety. Join the staff of Epsom and St Helier University Hospitals NHS Trust on their journey as they reflect on the real-life effects of both incivility and active kindness.  This video was devised, filmed and produced by the Elena Power Simulation Centre.
  19. Content Article
    Tejal K. Gandhi, Institute for Healthcare Improvement's (IHI) Chief Clinical and Safety Officer, reflects on the World Health Organization (WHO) challenge to “Speak Up for Patient Safety” and how broadly it applies to improvement work.
  20. Content Article
    Everyone should be treated with dignity and respect at work. Bullying and harassment is unacceptable and constitutes a violation of human and legal rights that can lead to criminal prosecution and civil law claims. Employers have a duty of care to provide a safe and healthy working environment for their staff, and this is an implied term of every contract of employment. Bullying and harassment undermines physical and mental health, frequently resulting in poor work performance. Possible consequences include: insomnia and inability to relax loss of confidence and self-doubt loss of appetite hypervigilance and excessive double-checking of all actions inability to switch off from work. This guide is designed to help people experiencing bullying and harassment at work. It covers: What is bullying? Examples of bullying What is harassment? What to do next The legal position Mediation and counselling Employer responsibilities Best practice for employers Students: being bullied whilst on placement Cyber bullying Sickness and work-related stress Been accused of bullying and/or harassment? Witnessed bullying? Further information
  21. Content Article
    This leaflet by NHS Employers (Wales) explains what bullying in the workplace is, how it can affect people and what to do about it.
  22. Content Article
    Empowering doctors to speak up when they have concerns is essential to making our NHS safer, say Peter Brennan and Mike Davidson in this BMJ article. They discuss how healthcare can learn a lot from aviation and other high risk organisations, particularly in how they’ve embraced and applied human factors, the importance of looking after ourselves at work, and reducing hierarchy.
  23. Content Article
    In this BMJ blog, Drs Blair Bigham and Amitha Kalaichandran discuss hospital culture of bullying and a culture of not speaking up. When hospitals fail to create a culture where doctors and nurses can speak up, patients pay the price. This blog highlights solutions to the problem of poor culture of speaking up and bullying within healthcare. Dr Blair Bigham and Dr Amitha Kalaichandran propose three solutions to enable a culture without fear. Measure culture within the organisation. Hire talented leaders. Embrace diversity and inclusion and reject hierarchy.
  24. Content Article
    This guide, by NHS Improvement, contains key questions for chairs, chief executives and senior leaders about common barriers to clinicians taking part in senior organisational management. It addresses the NHS Long Term Plan priority around nurturing the next generation of leaders and supporting all those with the capability and ambition to reach the most senior levels of the service. It was developed in response to the 2018 recommendations to the Secretary of State for Health and Social Care to ensure more clinicians from all professional backgrounds take on strategic leadership roles.
  25. Content Article
    Nikki Davey, Clinical Human Factors Group Trustee, talks about how we might measure if a human factors intervention has been implemented on an operational basis.
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