Ockendon: thoughts on workforce issues

The Ockenden Report into the NHS’s biggest ever maternity care scandal raises concerns beyond Nottingham and beyond maternity. It examined 2,500 cases involving mothers and babies dying or being seriously injured, or babies being stillborn, while under the care of Nottingham University Hospitals NHS Trust between 2012 and 2015 but its recommendation are national in scope.

What workforce concerns did it find?

Ockenden lays bare the shocking treatment of patients. But she spoke with more than 800 individual members of NUH staff (past and present) and what they told her is not unique to Nottingham or maternity. She found (emphasis is mine):

• Some staff described pride in their service and the care they provide, as well as positive working relationships with colleagues with around half confirming both that colleagues support each other and are committed to improving safety. However, this was outweighed by negative experiences of working life at NUH. Amongst staff still working in the Trust there is a strong theme of commitment to improvement and some optimism that this time things can change

  
  

• Staffing levels were the most serious and pressing issue raised, with only 11% reporting sufficient staff for the workload and 59% that staff regularly work longer hours than is best for service quality.

  
  

• Moreover, staff all agree that senior and executive managers have either ignored or have been unable to respond to the concerns being raised over many years. When 50 staff signed a letter to the Board waying their ward was unsafe, the Board couldn’t even be bothered to discuss it.

  
  

• A bullying and toxic culture has been a long-running theme in NUH’s maternity services. More than 40% had either witnessed or personally experienced bullying by managers or other colleagues as a regular part of their working environment. Some staff members were specifically and consistently mentioned as forming intimidating cliques that were/are well known, but not confronted or challenged.

  
  

• NUH data indicates that only 8% of the midwifery workforce is from a global majority background (compared to 26% of the entire NUH workforce and 34% of the obstetric workforce). Ockenden says “It is therefore not surprising that very few of the staff who engaged with the Review raised issues relating to personal experiences or witnessing racism within the working environment.” That seems to raise a number of issues to me beyond what Ockenden says.

  
  

• The top five issues raised about maternity/obstetric management were that historically they were: invisible, unapproachable and unresponsive; ignored concerns raised; bullying, rudeness and aggression; rapid turnover.

  
  

• There is a running theme of poor governance within maternity going back to 2012, including Serious Incidents (SIs) not being investigated and reported in a timely manner and failure to learn and change after incidents. Nott9nghamshire police intervened after they found that data was being intentionally deleted.

  
  

• Maternity service managers and the trust’s senior leaders were repeatedly warned about a host of serious problems in the maternity units at both hospitals but did not take effective action. Only 35 of the 60 senior managers Ockenden asked to give evidence agreed to do so.

Health professionals are trained to exercise specific skills and provide care, support, advice and treatment to a safe and effective standard. This report demonstrates how immense pressures can undermine their duty of care, notably inadequate staffing, inappropriate skill mix, and a bullying environment where those who raise concerns are seen as “troublemakers”.

This is not a new NHS problem. In numerous maternity reviews, in the landmark Bristol Royal Infirmary Report two decades ago, and the Francis report on Mid Staffordshire Hospitals over a decade ago, similar themes emerged,

Each Review is followed by a “learning of lessons”, numerous recommendations, profuse apologies, supposed improvements to “clinical governance” whistleblowing procedures. In each case, breaches of the duty of care owed by the employer, managers and frontline staff occurred alongside retaliation for those who sought to raise concerns.

Acting on the duty of care

NHS employers (specifically the Board) have a duty of care to patients, and to staff which is supposed to be currently regulated by NHS England and the CQC.

NHS managers have a duty of care to patients, to s6taff and to themselves which is embedded in their contract of employment and if they are registered professionals, in their professional code of conduct

Front line staff have a duty of care to patients, their coll4eagues and themselves which is embedded in their contract of employment and if they are registered professionals, in their professional code of conduct

Healthcare providers must ensure, when resources are scarce, that

• what is done is done safely and competently,

  
  

• what cannot be done is made clear

  
  

• treatment and advice are provided with appropriate priority and urgency.

Employers must be able to demonstrate they have taken reasonable practicable step to ensure that the work environment in which staff practise is safe, such as by complying with minimum requirements of professional regulatory bodies and conducting regular risk assessments. It is clear this did not happen in Nottingham.

Professional accountability cannot be delegated to employers, managers or systems. However, the reality of NHS maternity services is that staffing, workload, acuity, communication and culture all affect whether safe care can be delivered consistently. Individual staff are accountable for their acts and omissions but safe care also depends on the Board ensuring effective staffing, clear escalation, supportive leadership and a culture that enables concerns to be raised and acted on.

Leaders

Unsafe care rarely results from individual failure alone. In Nottingham’s maternity service, sustained risks arose from chronic understaffing, poor escalation processes, ineffective multidisciplinary communication, repeated incidents without learning, and cultures in which challenge was actively discouraged. Where this happens, staff experience moral distress because they are unable to provide the standard of care required by their duty of care.

Staff should raise concerns promptly, escalate when risks remain, and document clearly what was seen, what action was taken and who was informed. The duty to preserve safety includes challenging unacceptable practice - which may involve failure to escalate deterioration, unsafe delegation, discriminatory behaviour, poor documentation, unsafe decision-making or attempts to discourage reporting.

Staff cannot be (or at least should not be) required by managers or employers to breach their professional Code or their duty of care, not least since these are embedded within their contract of employment.

Managers are equally and personally accountable both for the care to patients provided by those they manage and to those staff themselves. Those who lead organisations have a contractual and governance duty to ensure that how services are provided meets the duty of care of the organisation.

Workforce questions arising from Nottingham

Within the recommendations on “Immediate and Essential Actions to Improve Care and Safety in Maternity Services Across England”, Ockenden makes a raft of workforce recommendations notably:

Workforce planning and staff staffing. Professional bodies and trade unions representing midwives have been demanding (indeed pleading) additional staff and effective workforce planning for years. So have some Trust leaders.

But this costs money and requires leaders prepared to stand up for their staff and Ministers prepared to produce more than sound bites. Retaining trained midwives depends on having a a working environment that radically improves the experience of staff, emphasises a preventative approach to identifying concerns, ensures that staff who do raise concerns will not be victimised and will be listened to with the urgency their concerns demand. It demands relentless challenge to bullying and discrimination (not enough attention is paid to racism towards BME staff in the report).

Culture, Teamwork & Psychological Safety. Ockenden demands that “all Trusts must actively foster a culture of safety, compassion, and respect across all maternity services. Staff must feel supported to speak up and raise concerns without fear of reprisal. Women must feel listened to, respected, and fully involved in decisions about their care. Trusts must promote compassionate leadership, a civil and kind workplace, and the use of positive feedback as a tool to reinforce good practice and drive continuous improvement.”

She is absolutely right, but how many trusts are prepared to acknowledge how far they are from this goal and take the steps across all aspects of employment relations to ensure this happens? The environment she rightly seeks depends on evidenced-based and equitable disciplinary processes and performance management, recruitment and career progression. It require3s determined evidence based approaches to bullying, harassment and discrimination from leaders who personally commit to it and are held to account for it.

Learning is indeed crucial. Half of the senior leaders asked for an interview b y Ockenden refused to agree to one. But a just and learning culture is not an alternative to accountability. What happened in Nottingham is not an isolated example in maternity or elsewhere, and the failure of Boards, managers and HR to ensure a healthy working environment means abandoning the performative measures too many organisations have taken and adopting measures that are, focussed on learning but sanctioning those whose behaviours remain unacceptable, whether they are Board members who look the other way, leaders who place reputation ahead of care, or those at any level who fit Mary Dixon-Woods’ recent conclusion that “Some of the biggest scandals involving avoidable harm are due to transgressive behaviour and not classic medical error like giving a patient the wrong drug. This is something we’ve learned many times over, from Shipman onwards.” https://www.thisinstitute.cam.ac.uk/blog/mary-dixon-woods-calls-for-fresh-thinking-on-patient-safety-at-appg-event/

Finally, what steps did senior HR staff take to urge the Board to intervene, to challenge managers, to investigate the widespread bullying, the victimisation of staff raising concerns, and the concerns about staffing levels? It is not possible these were not widely known at senior level.

Note. The recommendations are for England as a whole and Ministers will respond in September.

Questions for Ministers

• Will the workforce and workforce culture recommendations be adequately funded? If not, everything else is waffle.

  
  

• Will Ministers insist on evidence-based measures to improve workforce culture and equity rather than the performative measures which have been so common?

  
  

• Will those who sought to prevent staff raising concerns, or minimised those concerns, or victimised staff who did raise concerns, be referred to professional regulators and face appropriate sanctions wherever they now work? Will that include Nottingham Board members from that period including professional leads and HR unless they can demonstrate they sought to intervene? Will those leaders who refused to even be interviewed be sanctioned? Will it include all those senior managers who refused to even be interviewed?

  
  

• Should those leaders at DHSC, NHS England, CQC or professional regulators who knew of the unfolding scandal and sought to suppress or ignore evidence of it be reported through the Fit and Proper Persons process if that has not already happened, whether or not there are criminal prosecutions?

  
  

• What consequences should there be for individual managers and frontline staff who were aware of the scandal, failed to protect staff and patients who had raised concerns and personally victimised those who did raise concerns – and with support for those determined to improve their behaviours?

If not, why not?