The third Francis report on how to build a safe NHS has been published, this time focusing on the problem of how staff can raise their concerns about patient care without fear of victimisation or whistleblowing – a last resort that happens only when there are no other adequate avenues to report failures.
The report, which took evidence from more than 600 people about their experiences in the NHS and another 19,000 from an online survey, says nothing new to those working in the NHS, where bullying is endemic and most people survive working in the NHS’s “pervasive culture of fear” by keeping their mouths shut.
The new report tries to get to the bottom of this bullying crisis by going to the real experts, the people working in the NHS. Hardly a radical idea, but chronically missing in an institution dominated by top down targets and feverish policy-level action, all of which has totally and utterly ignored the working realities of the people that are supposed to deliver them.
As a result, there’s important stuff in the report about the reality of health and social care in the UK. Not wishing to blind you with all the research that confirms it, there are some really bad jobs in the NHS. Take the billion-pound business of agency nursing. In an attempt to save costs, the way people work in the NHS has changed with a radical increase in temporary and agency work, outsourcing, zero hours contracts, work intensification and a decline in real wages.
These changes in the employment relationship have triggered changes in the duty of care towards patients, including projecting risks and duties away from the principal employer onto service providers and labour agencies. And the negative impact on patient safety of these trends is a growing theme in both clinical and employment relations research.
A foundation of bullying
It is a stomach-churning reality that the NHS rests on bullying the people who are supposed to protect patients and service users. This systemic and leadership failure has become very personal for NHS workers, leading to high levels of burnout, stress and a growing number of cases of suicide – all detailed in the report.
Francis rightly says that any staff involved in raising concerns and whistleblowing will need therapeutic support to survive the brutal process ahead. But the reality is that mental health services continue to experience higher cuts than any other part of the NHS. With mental health workers some of the most vulnerable workers in the UK, you don’t have to be mad to work in the NHS but it’s extremely likely.
One of the reasons this report might be different from its predecessors is that it actually asks health workers about their experience of work and as a result looks at some of the problems from a pragmatic rather than a political perspective. It means that the report is for the first time pretty specific about what needs to happen next to address bullying. From training to reprimanding managers who don’t address bullying, the report also includes all NHS workplaces nominating a Freedom to Speak Up Guardian, people who will be tasked with encouraging people to talk and to support staff, which has been given the go-ahead by ministers.
For those of us who have worked on diversity, this is neither a good nor a bad thing. It remains to be seen whether these guardians will be able to negotiate the structural and management changes that need to happen to create environments where this can work.
Probably the key job of work is going to be influencing managers – particularly line managers – whose attitudes are crucial in setting workplace cultures, and management responses when cases of victimisation are raised. Without leadership buy-in to this system, individual guardians will go the way of decades of diversity and equality reps: burnt out and bullied into silence themselves.
In workplaces where these conflicts exist there is likely to be a stigma attached to trying to change things, as a defence against anxiety. Easier to bully a guardian into silence through a ruthless wall of non-cooperation than address the systemic problem of why they are needed in the first place.
In management speak this is about building teams where people feel safe to come forward rather than locking themselves in the staff toilets every time there is a staff meeting. It also means creating inclusive teams – involving everyone delivering care from the contract and agency workers, the part timers, the people that raise concerns every single week and the people that you just don’t really like. Everyone, across disciplines and employers needs to be involved.
What’s new about this report is that frontline staff started talking. The trick now is to keep them talking about what’s really going on, rather than continuing to focus on politically-set targets that won’t survive past May 2015. The capacity of NHS leadership to deliver these conversations should be the primary measurement of whether they are delivering quality care.