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This edited collection can be seen to facilitate global learning. This book will, hopefully, form a bridge for those countries seeking to enhance their patient safety policies. Contributors to this book challenge many supposed generalisations about human societies, including consideration of how medical care is mediated within those societies and how patient safety is assured or compromised. By introducing major theories from the developing world in the book, readers are encouraged to reflect on their impact on the patient safety and the health quality debate. The development of practical patient safety policies for wider use is also encouraged. The volume presents a ground-breaking perspective by exploring fundamental issues relating to patient safety through different academic disciplines. It develops the possibility of a new patient safety and health quality synthesis and discourse relevant to all concerned with patient safety and health quality in a global context.

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.

Findings: Almost two-thirds of respondents continued to report they – or someone in their organisation's Freedom to Speak Up network – had been asked to take on other duties to support efforts to respond to the pandemic. Workers continued to be encouraged to speak up. 93%)of respondents to this survey believe workers were being encouraged to speak up – up from 72% in April. When asked about the types of issues workers were speaking up, the biggest percentage of respondents (79%) selected worker safety and wellbeing. This included matters such as PPE, social distancing and risk assessments. There was a large increase in the percentage of respondents reporting that workers were speaking up about the impact of COVID-19 on BAME workers. There has also been a sharp increase in respondents indicating workers were speaking up about behavioural issues, such as bullying and harassment.

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.

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.