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The first presentation draws on a recent National Institute for Health Research (NIHR) funded mixed-methods evaluation of the translation into practice of several ‘post-Francis’ policies that have aimed to improve openness in the NHS, and identifies key conditions necessary for policies to make sustainable impact on culture and behaviour. The second presentation reflects on material from a forthcoming book which will offer unfiltered accounts from patients, carers and healthcare professionals about their good and bad experiences of how care is organised, from birth up to the end of life. Their testimonies indicate the salience of kindness and attentiveness combined with efficiency and competence. Finally, the context for a culture of openness and for patient-centred services will be presented, alongside the development of a culture change programme which is being used in 70 Trusts in England. Significant and unacceptable variations in the availability of high quality care and in staff wellbeing persist across the NHS and social care, exemplified by very different COVID-19 experiences across the sector. How far does this kind of research on culture and these kinds of programme interventions help us to gain whole system traction in this important area of laying the conditions for reliably compassionate patient care? How can positive cultures and new working practices that have developed during the COVID-19 pandemic be sustained?

This resource covers: leadership culture resources improvement approaches safety, clinical audit and clinical governance during major change digitalisation innovation trust improvement stories.

It has been a month since the publication of the Cumberlege Report, which detailed the harm that has happened to tens of thousands of patients over many years. Following a 2-year period of gathering evidence, listening to views and deliberation, the report made several important recommendations. Since then, it has generated only modest headlines and within healthcare circles little debate. Has there ever been such an important report that has generated such little discussion and debate following publication? It would be easy and obvious to cite Covid as the reason for this, but surely the current pandemic is all the more reason for the importance of patient safety to be integral to our planning and priorities as we restart and reset services and look to the future. The report made several key recommendations across a number of devices, procedures and drugs. The main themes were to: involve patients more in their care and to listen and take their views seriously move away from a culture of blame so that staff could speak up and voice concerns improve data collection and incident reporting to aid learning provide more support to patients after things have gone wrong better address health inequalities improve leadership and regulation. It is one of several reports in the last 20 years that has considered patient safety scandals and sought to address this persistent and fundamental problem within healthcare. It is not just a UK problem, the OECD estimates 15% of healthcare budgets are spent on harm, much of it entirely preventable, and the remainder on rectifying or compensating for the problems created. Within the Cumberlege report was this quote: "I have to say 20 years later it is very frustrating how little progress we have made. It’s clear to me that we still have not got the leadership and culture around patient safety right. As long as you have that culture of people trying to hide things - then we are not going to win this." Professor Ted Baker, Chief Inspector of Hospitals, CQC At this time of unprecedented change, with an acceleration of acceptance and adoption of innovation and technologies like never before, surely now is the time to bring patient safety to the fore of the debate about how our healthcare services should be run and managed. If it is not deemed important now will it ever truly be important? Or will it remain forever in the camp of “too difficult” to solve? To ensure the safety of patients we should also recognise the need for people and organisations to share learning when they respond to incidents of harm, and when they develop good practice for making care safer. Patient Safety Learning’s the hub plays an important part in this, providing a platform to share resources, stories and good practice for anyone who wants to make care safer for patients. At PEP Health (Patient Experience Platform), we have one of the largest databases of patient comments tracking back to Jan 2018. It covers every hospital in the UK and includes every comment made by patients across social media platforms and online review sites. Our analysis of these comments demonstrates that what patients say matters and that patients provide remarkable insight and perspective. It also highlights that patient experience and patient safety are not two discrete components of “quality” but are closely interwoven and linked. For example, we hear patients commenting on issues such as repeated medicine errors, an inability to access essential services and being provided with either poor or confusing information So, in the spirit of starting some discussion following the Cumberlege report, here are my recommendations and thoughts: Without better, faster data to support change nothing will happen. This data needs to be a balance of quantitative and qualitative data that brings together patient safety, patient experience and the patient voice. A patient safety commissioner can provide leadership but they cannot change the culture alone. After so long trying internally without success, we should now publicise results and be more transparent than ever before. Organisations should be benchmarked and compared against their peers. Greater celebration and promotion should be made of successes. Best practice and learning is too slow to take hold. Teams should not only be encouraged to adopt change but be empowered to make change locally. The patient voice must be taken much more seriously by organisations and clinicians so that in 20 years’ time we are still not publishing reports following scandals with little change to celebrate and few lessons learnt.

The index has risen nationally from 75.5% in 2015 to 78.7% cent in 2019.Fostering a positive speaking up culture sits firmly with the leadership and organisations with higher FTSU Index scores tend to be rated as Outstanding or Good by the Care Quality Commission (CQC).All organisations should use the FTSU Index to help identify areas where workers feel less supported to speak up and to focus on ways to improve. This is especially important for those organisations which feature lower down the FTSU Index. It is good practice for all organisations to look at the results of their staff surveys to understand the reality of how workers feel about speaking up.For organisations which appear lower down on the FTSU Index, it encourages them to identify higher scoring or most improved Trusts in your region, and find out what you can learn from how they are embedding Freedom to Speak Up in their organisations.

Key messages: Organisational culture represents the shared ways of thinking, feeling, and behaving in healthcare organisations. Healthcare organisations are best viewed as comprising multiple subcultures, which may be driving forces for change or may undermine quality improvement initiatives. A growing body of evidence links cultures and quality, but we need a more nuanced and sophisticated understandings of cultural dynamics. Although culture is often identified as the primary culprit in healthcare scandals, with cultural reform required to remedy failings, such simplistic diagnoses and prescriptions lack depth and specificity.

Prerana Issar is the Chief People Officer of NHS England and NHS Improvement. She was appointed in February 2019 to this post, which was created after senior leaders in the NHS and Department of Health and Social Care realised that a new approach was needed to a number of serious workforce issues which had become apparent. Among these is the complex, and hugely important, issue of speaking up (sometimes referred to as whistleblowing or raising concerns). Prerana recently retweeted a message from NHS England and NHS Improvement that "It's so important (for NHS staff) to feel able to speak up about anything which gets in the way of patient care and their own wellbeing".[1],[2] She is absolutely right... in principle. She is right to point out that NHS staff have both the right and the duty to speak up about problems like this, as is spelt out in the NHS Constitution[3] and professional codes of conduct for healthcare professionals.[4],[5],[6] The problem is that in practice, as an unknown but substantial number of NHS staff have discovered to their cost, their careers may be at risk if they do speak up as is evident from almost all the replies to both tweets.[1],[2] There is a sad pattern of disciplinary action being taken against staff who have, in good faith, raised concerns in the public interest. Even though their motivation in speaking up in the first place is to improve patient care, they discover to their astonishment that they are considered to be troublemakers for having done so. A depressing cycle of suspension, isolation, unfair dismissal, denigration and blacklisting of the person who has spoken up is often played out, whilst the original concerns and their validity are covered up. What a waste of valuable resources. The existence of such hostility to staff who have spoken up is evidenced in the 2015 report of the Freedom To Speak Up (FTSU) Review: "an independent review into creating an honest and open reporting culture in the NHS".[7] The press release which accompanied its publication announced that the review "identifies an ongoing problem in the NHS, where staff are deterred from speaking up when they have concerns and can face shocking consequences when they do. The review heard stories of staff that have faced isolation, bullying and counter-allegations when they’ve raised concerns. In some extreme cases when staff have been brave enough to speak up, their lives have been ruined".[8] The FTSU report calls for "an overhaul of NHS policies so that they don’t stand in the way of people raising concerns with those who can take action about them" and sets out "20 Principles and Actions which aim to create the right conditions for NHS staff to speak up". The principles are divided into five categories: the need for culture change; improved handling of cases; measures to support good practice; particular measures for vulnerable groups; and extending the legal protection.[7] In theory the law protects whistleblowers, but in practice, as a procession of disillusioned NHS staff who have experienced reprisals from their employers after speaking up have discovered the hard way, it does not. Employment tribunals are an alien environment for most healthcare staff. Case after case has shown that they are woefully ill-equipped to deal with precipitating patient care issues, in which tribunals appear to have little interest. Even when NHS staff are, against massive odds, found to have been unfairly dismissed after raising concerns in the public interest, the so-called remedy they receive almost invariably amounts merely to paltry financial 'compensation'. These are monetary awards that generally come nowhere near compensating for the full financial consequences. The adverse impact of this lack of protection for whistleblowers is not only on the individual but also includes the chilling effect of deterring other staff from raising concerns and the consequences of cover ups. True overall costs to the NHS, patients, whistleblowers and taxpayers of retaliation against staff who speak up are very much greater than financial costs alone. Staff surveys show that nearly 30% of NHS staff would not feel secure raising concerns about unsafe clinical practice.[9] Over 40% would not be confident that their organisation would address their concern if they do speak up.[10] There is still a lot to do in this area, as has been brought to the fore by recent reports of hostile responses by some NHS organisations to staff who have raised serious personal protective equipment (PPE) concerns affecting patient safety and health of themselves and their families. To be fair, serial staff surveys show a marginal improvement in the percentage of NHS staff who agreed they would feel secure raising concerns about unsafe clinical practice, up from a disturbingly low 68.3% in 2015 to 71.6% in 2019.[9] And a further tiny improvement in the percentage confident that their organisation would address their concern, up from an even lower 56.2% in 2015 to 59.8% in 2019. Viewed from the perspective of NHS whistleblowers whose careers have been wrecked after speaking up these are painfully slow rates of improvement. Bearing in mind widespread reports of PPE shortages, and warnings to NHS staff not to make a fuss about this, it will be interesting to see whether this glacial pace of change in speaking up culture is maintained when the results of the 2020 survey are available. Based on experience in the last two years, we can expect another prolonged FTSU publicity campaign in the month preceding the annual autumn NHS staff survey. The NHS Interim People Plan, published in June 2019, refers to development of a focus on whistleblowing and speaking up. It highlights the need for inclusive and compassionate leadership so that all staff are listened to, understood and supported, and the need to do more to nurture leadership and management skills of middle managers.[11] The original aim was to publish a full, costed NHS People Plan by Christmas 2019,[12] building on the interim plan, but this was delayed by unforeseen events, including a change of government, general election, Brexit ramifications and now the coronavirus pandemic. The interim plan makes clear the need to embed culture changes and leadership capability in order to achieve the aim of making the NHS "the best place to work". There is much to do, and I wish well to those who want to make it safe for staff to speak up, but they must be under no illusion – there is a long way to go – and this will take more than an overhaul of NHS policies. I hope to develop these themes in future postings to the hub. Comments welcome. References NHS England and NHS Improvement tweet, @NHSEngland, 15 May 2020, 6:35pm. Prerana Issar tweet, @Prerana_Issar, 15 May 2020, 6:47pm. The NHS Constitution for England. Updated 14 October 2015. Nursing and Midwifery Council (NMC). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates, 2015, updated 2018. General Medical Council (GMC). Good medical practice: The duties of a doctor registered with the GMC. 2013, last update 2019. Health and Care Professions (HCPC). Standards of conduct, performance and ethics: The ethical framework within which our registrants must work, 2016. Freedom to speak up: An independent review into creating an open and honest reporting culture in the NHS. Report by Sir Robert Francis QC, 11 February 2015. Press release: Sir Robert Francis publishes his report on whistleblowing in the NHS, 11 February 2015. NHS Staff Survey 2019. q18b: % of staff agreeing or strongly agreeing with the statement that: 'I would feel secure raising concerns about unsafe clinical practice'. NHS Staff Survey 2019 q18c: % of staff agreeing or strongly agreeing with the statement that: 'I am confident that my organisation would address my concern'. Interim NHS People Plan, June 2019. https://www.longtermplan.nhs.uk/publication/interim-nhs-people-plan/ NHS People Plan overview, 2019.