Much of the debate around the Francis report has centred on staff’s freedom to blow the whistle about risks to patient safety. HSJ gathered 15 experts, from foundation trust chief executives to those who have spoken out themselves, to discuss the challenges and propose solutions
Financial restraints and the huge changes facing the NHS are having a catastrophic effect on workforce motivation and staff’s confidence that they can raise concerns about patient safety.
This was the message from a panel of experts at HSJ’s rapid reaction roundtable. Claire Murdoch, chief executive of Central and North West London Foundation Trust, spoke for many around the table when she highlighted the difficulty in meeting the quality, innovation, productivity and prevention challenge when the goalposts are continiously moving. “We are all on a heroic quest to find the £20bn but I’m no longer sure which £20bn that is,” she said.
How do you decide which concerns to focus on? See what the panel said (desktop site only)
‘We must make it alright to talk freely and openly about the impact of resource on care’
“I think as leaders of healthcare systems we must – in addition to recruiting great staff and creating a culture where people can come forward and discuss problems – make it alright to talk freely and openly about the impact of resource on care,” she added.
The discussion took place in response to the Francis report into failures at Mid Staffordshire Foundation Trust. Much of the debate since the report’s publication has centred on the ability of staff to raise concerns on patient safety – and the level of poor care that this may be disguising.
HSJ editor Alastair McLellan asked the panel what the nature of poor care in the NHS was, and whether it was getting better or worse. The panel was divided between those who felt it was likely to get worse and those who felt the level of care was the same as previous years.
BMA chair Mark Porter felt the tensions that led to problems such as Mid Staffordshire are inevitably going to get worse.
“We are going through a period where organisational change will continue, in fact over the next few months and years it’s going to intensify. Then of course it might all slip again with the next government – who knows?” said Dr Porter.
“I think at the moment there is no relief from the amount of organisational change expected of people.”
NHS Confederation associate director Simon Pleydell also stressed the impact of resources on care quality. “I think taking 4 per cent out of the tariff year on year will be extremely tough for hospital, community and mental health providers, if they get to the tariff”, he said.
King’s College London chair in nursing research Professor Jill Maben quoted a study published last year which found that nursing burnout in the UK was “second only to recession hit Greece”. The study examined 12 European countries as well as the US.
“My guess would be it’s likely to get worse with the resource constraints we are currently facing in the NHS”, said Professor Maben. “I think we’ve incentivised sometimes the wrong things and we’ve encouraged people to move away from the bedside, particularly in nursing,” she added.
- Claire Murdoch, chief executive, Central and North West London Foundation Trust
- Dr Mark Porter, chair, BMA council
- Dr Jonathan Fielden, medical director, University College London Hospitals Foundation Trust
- Jon Restell, chief executive, Managers in Partnership
- Niall Dickson, chief executive, General Medical Council
- Elaine Maxwell, assistant director, Health Foundation
- Professor Jill Maben, chair in nursing research, King’s College London
- Dr Phil Hammond, GP, journalist and broadcaster
- Dr Amit Bhargava, clinical accountable officer, Crawley clinical commissioning group, and executive board member, NHS Alliance
- Steve Shrubb, chief executive, West London Mental Health Trust
- Francesca West, policy director, Public Concern at Work
- Dr Kim Holt, chair, Patients First
- Steve Appleton, director, Contact Consulting
- Dr Mark Newbold, chief executive, Heart of England Foundation Trust
- Mr Simon Pleydell, associate director, NHS Confederation
- Alastair McLellan, editor, HSJ
Better care, higher expectations
University College London Hospitals Foundation Trust medical director Dr Jonathan Fielden was more optimistic. He said things were improving but also the healthcare system as a whole had become more transparent and the public had moved to a position where they were no longer tolerant of things that they used to tolerate before.
‘The combination of massive political reform pushed on a reluctant workforce, coupled with no money, is a perfect storm for more disasters’
Dr Phil Hammond
“They are used to getting information about many things very quickly,” he said. “We are going through that transparency and we have a great opportunity to improve care even more by being more transparent.”
However, journalist and GP Phil Hammond summarised the mood when he said, “I think the combination of massive political reform pushed on a reluctant workforce who aren’t engaged with it by top-down fixing and enforcement, coupled with no money, is a perfect storm for more disasters”. He added, “I think we’re in trouble.”
The Francis report placed a great emphasis on the training and recruitment of top quality managers and clinicians. But the panel’s rigorous discussion highlighted that one key issue was perhaps missing: not how to recruit better staff, but what happens to those staff once they become part of the healthcare system.
“We know that when we recruit student nurses and doctors we appoint staff that are by and large a motivated and idealistic bunch,” said Heart of England Foundation Trust chief executive Mark Newbold. “But we know that they become progressively less engaged over time so there’s something the system does to our staff that must increase the risk of poor care,” he suggested.
Elaine Maxwell, associate director at the Health Foundation, explained: “The way staff go about raising concerns about resources would be very different if you know you are a challenged trust where everybody you are reporting to won’t be able to do anything about it and they just want you to go away.
“We know there’s a lot of research linking nurse staffing to patient outcomes, but what we don’t know is what is the critical point in which it becomes unsafe, and I think we need to know what that is.
“If you are working with colleagues who are not following what’s deemed to be best practice, I think the way you deal with that is different to the way you deal with problems about resources,” she added.
‘I think it’s about how you encourage staff at whatever level to be able to challenge one another’
Steve Appleton, director at Contact Consulting, built on this point. “I think it’s about how you encourage staff at whatever level they might be, from very junior staff to very senior colleagues, to be able to challenge one another in their day to day practices as an accepted way of working,” he said.
When risk becomes real
But how can staff raise an issue on the potential for harm or blow the whistle on a lack of resources? Jon Restell, chief executive of the managers’ union Managers in Partnership, asked how we define concern for managers operating at a senior level where there isn’t yet an exact example of harm but there is a risk of or potential for harm.
“We need to do a lot of work to help managers, whether they are clinical or general, to work out what potentially should be the things they are raising concerns about.”
Ms Maxwell pointed out that a lot of concerns are being raised with middle and junior managers who are also under pressure.
“They are being performance-managed to deliver activity within budget so they are stressed. They do have a problem with whistleblowers because the whistleblowers are going to cause them grief, and get them in trouble with their boss.”
Ms Maxwell said that there is a problem with the culture in which middle managers know that it is likely to be them in the firing line if something were to happen. “I look at the Francis [report] and I see people at the top of the trees being protected and people at the front line being held to account and I think that some of the managers can see that.”
‘I see people at the top of the trees being protected and people at the front line being held to account’
General Medical Council chief executive Niall Dickson argued there has been a narrowing of responsibilities, exacerbating the culture problem. “At the moment staff feel ‘my responsibility is with the patient that I’m dealing with at this moment’ and less ‘actually my responsibility is a professional whether I am a nurse or a doctor’”.
Responsibility, Mr Dickson explained, should be “not just for the patient it’s not even for the patient in the next door bed, it’s all the patients and it’s what I come across and I am the eyes and ears of this service”.
“We have to get that message across and empower people to believe that their responsibility is not just for the immediate clinical interaction.”
Checks and balances
John Restell added that relying on whistleblowers to catch failures was “a bad safety net”, relying on “exceptional qualities on a routine basis to identify problems”. I don’t think you can build a system based on that assumption that everyone is going to find the courage [and take] the potential risk to their careers, their livelihoods”.
Dr Porter concurred, suggesting the system as a whole, rather than being driven by financial checks, should place as much emphasis on clinical quality checks.
“We have a huge industry devoted to collecting information about what we do in order to write it down on a piece of paper send it to a commissioner and get the bill, we’ve got a lot of people working in financial probity, we don’t have the same number of people working in clinical probity”.
Mr Pleydell referenced international examples from the US. “I went to some of the top safety hospitals in the country and they had departments with clinicians of 20 or 30 years’ experience looking at their outcomes data – they’d look at those numbers every week as a senior team,” he said.
Mr Restell advocated a more open culture on dealing with falling standards of care. He mentioned one trust that had been open and honest about the problems they were experiencing within its services. “It wasn’t just ‘we’re going to deal with this internally’ but ‘we will tell the public that we have a problem and what we’re doing about it,’” he added.
The downside of openness
But there are consequences to this approach. Steve Shrubb, chief executive of West London Mental Health Trust drew attention to similar organisations whose bold openness drew negative press.
Mr Shrubb said Devon Partnership Trust quite rightly raised concerns about mortality in its older people’s services and they were rounded on by the CQC. Despite being a brave thing to do, Mr Shrubb said that there are organisations that “have attempted to blow the whistle and paid a really heavy price”.
‘Organisations have attempted to blow the whistle and paid a really heavy price’
Dr Fielden added to this by pointing to a long tradition in the NHS of telling people what they want to hear. He stressed the consequences of this approach was that “a toxic pace-setting leadership culture has been created [which] fundamentally has to change”.
“A change is needed in how we train our leaders,” he continued.
Dr Hammond called this “the glitterisation of the NHS”. “The imperative for the Department of Health only to deliver good news to Downing Street means that we celebrate the brilliant stuff that we do but we are still in denial at every level of the service I would say about the bad stuff,” he alleged.
As a solution Dr Hammond suggested an HSJ Award for “whistleblower of the year”, celebrating people who raise concerns about patient safety and poor care. “In the US they have their own whistleblowing senate because they know its effective, far more effective than any regulators,” he added.
Alastair McLellan asked the chief executives on the panel whether they would be comfortable with Dr Hammond’s suggestion and whether they would be comfortable hailing whistleblowers as exemplars within their own organisations.
There was scepticism over how this could be carried out and encouraged. Mr Pleydell expressed concerns on the danger of making it too personal and the worry of preserving the reputation of the individual while looking into claims made. “We have improvement awards every year and I would like to see an improvement award that has come out of raising a concern not about the individual”, he said.
Mr Shrubb added there was a difference “between awarding someone a golden whistle and being seen to act if a whistleblower is discriminated against”.
“You do need to be seen to act if someone has been courageous enough and the system has directly or indirectly taken against them,” he added.
Francesca West, policy director at whistleblowing charity Public Concern at Work, said: “What might be of help to us in thinking a way around this is to say how many patients are safer because of people raising concerns? How many wards have improved as a result of people raising concerns?” Ms West said it was important to highlight the benefits of whistleblowing.
Leading from the top
Dr Newbold thought the solution lay in chief executives positioning themselves appropriately. “My line to the new staff is you are part of my process for managing safety, and I can put in place every policy and every process but actually you are 11,000 eyes and ears and I need you to keep a look out and to tell me if you see anything wrong, and do not be fobbed off by anybody telling you that this is deliberate, the chief exec wanted this to save money. It will not be true.”
The Heart of England Foundation Trust chief executive said he could see the benefits of staff being able to go over their immediate managers’ heads to raise a concern if they felt it was important.
“Since I’ve been positioning myself like that I have had a steady stream of concerns – mostly trivial but they are genuinely held concerns – and they feel it’s safer to raise it with the CEO than with a line manager. That is a really important position to be in as a CEO.”
Dr Amit Bhargava, clinical accountable officer at Crawley CCG and an NHS Alliance board member, welcomed Dr Newbold’s suggestion. He said: “Bad care is never a secret because somebody knows about it, usually clinical colleagues, and there are a number of reasons why they don’t address it.”
Dr Bhargava and colleagues have set up an email address, “where people can put in any soft concerns from anywhere in the system”.
“Whether it’s from primary care from nursing homes, hospitals or community, they are going to one place and are looked at by our quality team and they are rated and that goes out to the providers,” he explains
Changes to the law are also needed in whistleblowing cases, suggested Kim Holt, chair of Patient’s First, a campaign group focused on lobbying the government to create policies and laws that ensure the NHS becomes open and accountable.
“It is incredibly difficult to win a whistleblowing case and that is not sending out the right message to frontline staff,” she argued.
Dr Holt, who sounded the alarm in the Baby Peter case, pointed out that “within an employment tribunal you do not get your costs back… It actually leaves people, at the end of it, in a great deal of financial difficulty”.
Professor Jill Maben had the final word; she stressed the concerns of reputational damage. “I think it stops people speaking out.” She concluded, “everyone needs to be open to challenge.”