Bullying management is counterproductive and harmful. NHS organisations that engage with their staff provide better patient care, says Roger Kline

Nursing, medical and other staff do not join the NHS intending to do harm. The problem is that staff wishing to raise concerns over patient care often face serious obstacles, not least bullying, which is endemic in the NHS.

‘Staff declare mistakes and the organisations learn from those mistakes’

Last year alone, 24 per cent of staff reported being bullied. Meanwhile, many senior managers fear the consequences of raising concerns as much as their staff do, if not more so.

Evidence of the negative effects of a bullying management in healthcare is clear. Organisations where a “just” culture prevails rather than a “blame” culture, and those that seek out data and experience, deliver safer care; in these instances, staff declare mistakes and the organisations learn from those mistakes.

Contrary to tabloid reports, most NHS managers care deeply about the services they run. The unethical behaviour at Mid Staffordshire, or more recently at the top of the Care Quality Commission, runs counter to the principles most NHS staff seek to follow.

As the health secretary Jeremy Hunt recently said: “We must ensure that the compassion that led nurses and care assistants into the profession does not get ground out of them.”

Duty of care

Public World’s handbook, The Duty of Care of Healthcare Professionals, brings together the experience of several years of advising and representing NHS staff who have raised concerns − some successfully and others at great personal sacrifice. The principles we set out for doctors, nurses and professionals allied to medicine are largely applicable to general managers too.

‘The principles of openness, transparency and candour espoused by Robert Francis will not primarily come about through increased regulation’

Indeed, the best organisations are already trying to adopt many of the principles we set out on how best to safely raise concerns (see box below), while creating an environment in which all staff are encouraged − and expected − to raise concerns in the public interest to ensure they can comply with their duty of care.

The principles of openness, transparency and candour espoused by Robert Francis will not primarily come about through increased regulation. They will emerge when leaders, managers and staff fundamentally change their organisation’s culture, placing patients at the heart of decisions, not the needs of the organisation or its leaders.

There are a small but growing number of trusts starting to do just that. We all need to learn from them.

Our handbook is designed for the organisations, departments or teams where the message has not got through; where the staff still need advice and courage to raise concerns.

12 steps to blowing the whistle safely

  • Gather your evidence: stick to the facts and be specific about the particular risks you are concerned about.
  • Get the tone right: express yourself in a low key, professional manner, however angry and distressed you might be.
  • Use the risk assessment framework: identify the particular policies, protocols and guidance you believe are being compromised.
  • Specify your duty of care: relate it to your particular professional code if you are covered by one.
  • Be positive: state what you think should be done, as well as pointing to what should not be happening.
  • Follow procedures: make sure you know how you are supposed to raise a concern.
  • Create a paper trail: keep notes of all relevant conversations and keep a file of all written communication sent and received.
  • Work with others: you might have no choice but to go alone, but you will be more effective and less vulnerable if you can raise concerns collectively.
  • Pose potential solutions: if possible, set out what you think should be done as well as highlighting the problem.
  • Keep it on the record: if you receive assurances of action in response place these on the record. If you are met with silence or receive threats in response, place that on the record too, always professionally and in a low key.
  • Be balanced: how quickly and in what ways you escalate concerns should depend on how urgent or serious they are.
  • Seek allies: look for friends and allies to share the burden with.

You do not have to use your employer’s formal whistleblowing procedure for your concern to be a protected disclosure, as long as you have a reasonable belief that it is a matter covered by the Public Interest Disclosure Act and you have drawn your concern in writing to an appropriate person.

The breaches under new statutory duty of candour are also included. If raising your concerns internally fails then there are ways of raising them externally, with regulators in the first instance.

Risks of raising concerns

The handbook spends some time explaining the contractual framework to apply when facing excessive workloads, inappropriate skill mix and poor practice by colleagues, or those who manage you or who you manage. Our advice assumes that where a bullying culture prevails, staff raising concerns risk serious detriment and that it is essential to take great care in how concerns are raised, to who and when.

‘The bullying culture so central to the examples of poor practice that informed the Francis report can and must be challenged’

Equally we stress the evidence that facilitative management, caring for staff, openness and transparency benefit everyone, especially patients.

NHS Employers’ 2012 guidance Speaking Up says: “Safety should be at the heart of all care, and must be underpinned by a just culture which is open and transparent. This leads to increased reporting, learning and sharing of incidents, and best practice. Individuals providing care services should always feel free to raise concerns through local processes and be supported to do so directly with their employer, professional regulatory body, professional association, regulator or union.

“The Public Interest Disclosure Act 1998 makes provision to protect those individuals who report concerns using any such processes appropriately.”

Our handbook sets a contractual framework and the website provides detailed advice such as sample letters, checklists, preparation for meetings and when and how to use trade unions and lawyers.

We believe the bullying culture so central to the examples of poor practice that informed the Francis report can and must be challenged, and some trusts are really working hard to do that. Our patients deserve nothing less.

Roger Kline is director of Patients First and an associate of Public World