"Whistleblower guardians" to monitor NHS bullying
Employees specifically tasked with creating openness are vital for long-term improvements in the health service, argues Sir Robert Francis QC
NHS trusts are set to appoint “guardians” who will promote the ability of staff to flag up poor working practices, following today’s long-awaited publication of the Freedom to Speak Up review. Sir Robert Francis QC’s wide-ranging assessment of reporting culture in the NHS follows a run of recent scandals within the organisation – such as a damaging decline of standards at the Staffordshire Trust.
Francis based his report on oral testimony from 600 people about their experiences with the workings of the NHS, plus a further 19,000 responses to an online survey. According to Francis, one dominant theme that emerged from the findings was that endemic bullying and intimidation have routinely prevented concerned employees from raising their voices against unethical behaviour.
“There were more references to bullying in the written contributions than to any other problem,” Francis wrote in his executive summary. “These included staff raising concerns about bullying, or being afraid to do so, bullying of people who had raised concerns, and frustration that no one ever appeared to be held to account for bullying. This is corroborated by [a recent] NHS staff survey, and by other reports including the General Medical Council (GMC) National Training Survey and the Royal College of Nursing (RCN) employee survey. Some individual trusts have also acknowledged the existence of a bullying culture and taken steps to address it.”
Francis warned: “Bullying in the NHS cannot be allowed to continue. Quite apart from the unacceptable impact on victims, bullying is a safety issue if it deters people from speaking up. It also has implications for staff morale and for attendance and retention. We heard many examples of unacceptable behaviour and lack of respect by individuals. This has a significant impact on whether people feel able to speak up – particularly in a hierarchical culture such as the NHS.”
With that in mind, Francis urged NHS bodies to install “Freedom to Speak Up Guardians” who will create a climate of mentorship and encouragement – defusing intimidation and paving the way for greater openness.
“I believe such a role can make a huge contribution to developing trust within an organisation,” he wrote, “and improving the culture and the way cases are handled. I believe there would be merit in having similar roles in all NHS organisations – with a common job title such as ‘Freedom to Speak Up Guardian’ – so that those who move between organisations know immediately where to go for help.”
He added: “They could also form a network to share good practice and to identify common issues and themes. I strongly encourage all NHS organisations to consider it … as a minimum, there needs to be someone to whom staff can go, who is recognised as independent and impartial, has the authority to speak to anyone within or outside the trust, is expert in all aspects of raising and handling concerns, has the tenacity to ensure safety issues are addressed, and has dedicated time to perform this role.”
On the role that NHS leaders must play in establishing new management styles, Francis wrote: “Culture change is essential – but experience from other sectors where safety is an issue suggests that it takes time and considerable effort by the leadership of an organisation. Boards must devote time and resource to achieving this change. There was support for the concept of a ‘just culture’, as opposed to a ‘no blame’ culture. The primary need is to move from a culture which focuses on ‘who is to blame?’ to one focused on ‘has the safety issue been addressed?’ and ‘what can we learn?’ Without this, senior levels of [NHS] organisations will remain ignorant of important concerns, some of which give rise to serious safety risks.’
He stressed: “Visible leadership is essential to the creation of the right culture. Leaders at all levels, but particularly at board level, need to be accessible and to demonstrate through actions as well as words the importance and value they attach to hearing from people at all levels. There is some excellent practice in some trusts, which should be shared and adopted across the NHS.”
Following the publication of the report, Francis’ recommendations were wholeheartedly accepted by the government.
In the recent Chartered Management Institute (CMI) report The MoralDNA of Performance, Elisabeth Buggins – chair of the Birmingham Women’s NHS Foundation Trust – noted that current pressures on the NHS cause “anxiety levels – and their harmful effects on people and the organisation – to go up. It makes objective ethical thinking more difficult, but all the more necessary”. To that end, she suggested, strong hierarchies in the organisation will have to be broken up to create the conditions for improvement. “We need a more adult-adult relationship with our staff and our patients, rather than an adult-child relationship,” she wrote.