London Eye: Freedom to speak up

If repeated scandals in the NHS have shown us anything, it’s that you can’t entirely rely on any external body or mechanism to keep care safe – you just have to hope individual teams and departments hold themselves to high standards, and that when things go wrong, they get fixed quickly.

The threat of a Care Quality Commission inspection or being struck off by your regulatory organisation has an effect, but both are pretty flimsy safeguards compared to strong local management.

Freedom to Speak Up guardians were introduced after the Francis Inquiry into the avoidable deaths at Mid Staffs, and the latest figures for London raise questions about whether this extra level of safeguarding is working.

Data published this month shows that over a year, 30 per cent of the 712 reports to a FTSUG with an “element of patient safety/quality” in London came from one small trust.

Homerton Healthcare Foundation Trust – workforce 4,000 – saw 217 cases, while neighbouring Barts Health Trust – workforce 19,000, received… 26.

The next highest total in this category, across the whole of London, was Epsom and St Helier University Hospitals Trust (6,400 employees) with roughly a third of what the Homerton reported.

So, the east London acute and community trust is clearly an outlier. But are its staff reporting too much, or everyone else’s too little?

Comparing the data with the most recent staff survey, specifically the all-important question: “If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation?” Homerton comes out well.

With 72.1 per cent of staff answering yes, Homerton is sixth out of 18 trusts in the capital. And of the five that ranked above it in the table, three were Shelford Group trusts that do a lot of specialist work, which staff are more likely to recommend.

But Kingston and Chelsea and Westminster Hospital FTs scored slightly higher than Homerton on this staff survey score and saw only a fraction of FTSU concerns about safety/quality (two and eight respectively).

At the other end of the scale, Hillingdon Hospitals FT had less than half its staff say the standard of care was sufficient for a friend or relative but only five FTSU quality concerns raised over a year.

So is Homerton a high performer on quality of care (as assessed by staff) because it reports a lot to FTSU? The Kingston and ChelWest examples suggest the two things needn’t necessarily go together.

The east London FT told London Eye  its high FTSU numbers were down to it adding a box to its Datix [incident reporting] forms where the incident is confidentially shared with the FTSU guardian. A spokesman said this had driven the increase and “is something we are proud of as we view this increase as welcome and as an essential part of an effective, reporting and speaking up culture. Many of these are resolved through the safety team/Datix responses but the FTSU guardian follows up on all of the concerns.

“We included this option on Datix to improve accessibility and increase avenues for speaking up for all staff – this was linked to the Lucy Letby recommendations from NHS England later that year.”

Homerton is thought to be one of only a handful of trusts doing this.

An NHSE London spokesperson said: “High levels of reporting do not necessarily indicate a poor working culture and NHSE do not investigate employers based on this information. We use tools to observe regional patterns and trends in culture such as the NHS Staff Survey and the National Education and Training Survey.”

Is Hillingdon such an outlier on the staff survey quality measure because employees raise so few concerns with FTSU? University College London Hospitals raised even fewer (two in 2023-24) and were London’s top performer on the staff survey question.

For trusts that are not dissimilar in their hospital work, Hillingdon and Homerton have long been at opposite ends of the spectrum on more traditional performance measures (waiting times) although terrible things can happen at any unit.

Hillingdon also received a section 29a notice from the CQC last July, despite the wider NHS system and Penny Dash’s former ICB approving it to leave the NHSE performance management tier for the most challenged trusts.

The CQC said its visit revealed risks to patient safety in accident and emergency and the surgical assessment unit. Nine months later the care regulator has not published its reports on what they were. So, the public will just have to hope the situation has been made safe locally in the meantime. Although the staff survey is not encouraging.

More Moorfields

Dr Dash, who is now NHSE chair, might want to look at how freedom to speak up works between trusts and other parts of the NHS, as well as within individual trusts.

When the consultants at Moorfields sent their letter of no confidence in the leadership of the trust they said it was because they had lost faith in the FTSU process at the organisation. London Eye understands there was dissatisfaction about the handling of the escalation of complaints made to NHSE London also.

The process of abolishing NHSE and returning its powers to the Department of Health and Social Care is also going to see this sort of issue (among others) become part of “what the minister knew and when they knew it” governance response that the DHSC has grown unused to fielding.