Power and the sound of silence

RogerKline
Mar 11
5 min read

This blog first appeared on the Patient Safety Learning Hub.

Content

A critical characteristic of effective teams is whether every member is willing to speak up to share thoughts and ideas to improve processes, to raise concerns and admit mistakes. In healthcare, the failure of those to whom concerns are raised to listen and act on them decisively is a major factor in unsafe and suboptimal care delivery.

NHS inquiry findings and recommendations are remarkably consistent on this issue. The Ely Inquiry (and other inquiries in the 1970s),[1] the Bristol Inquiry (2001),[2] the Mid-Staffordshire Hospital inquiries in 2010 and 2013,[3][4] and more recently Ockenden (2022),[5] all highlighted the failure to listen to staff who raised concerns and, worse, the victimisation of some of those who did raise concerns.

Yet when the voices of healthcare staff are listened to and acted upon they can improve the safety and quality of services—as well as staff wellbeing.[6]

Following the Francis Reports,[7] there was some limited improvement in NHS staff survey responses on whether NHS staff felt willing to raise concerns, whether they would be treated fairly if they did, and whether they felt their managers and employers would listen and act on those concerns. After Covid-19 that limited improvement stopped.

Despite the raft of legislation, NHS regulation and exhortation, the 2023 National Guardian Office report entitled 'Fear and Futility' noted a “sharp decline in Freedom to Speak Up Guardians’ perception of the improvements in the Speak Up culture of the healthcare sector…” It noted that: “there is a growing feeling that speaking up in the NHS is futile – that nothing changes as a result.”[8]

Staff safety is key to patient safety, so the fact that the majority of concerns raised are about staff safety is not a separate issue from patient safety but intimately linked.[9]

So, when staff ought to - and often do - raise concerns what goes wrong?

First, it has been repeatedly found by Francis (2015),[7] Kline and Warming (2024)[10] and others, that NHS staff are sceptical that raising concerns is effective and believe that by doing so it makes things worse for them personally due to victimisation.[11]

Second, some staff groups are particularly sceptical of the effectiveness and/or safety of raising concerns. Kline and Warmington found that of Black and Minority Ethnic (BME) staff who did raise concerns, only 5.4% said they were taken seriously and that their problem was dealt with satisfactorily.[10] The most common outcome, in 42.7% of cases, to a race discrimination concern was nothing happening.[12]

Begeny et al. (2023) revealed that within the UK surgical workforce, two-thirds of women medics (63.3%) had been subjected to sexual harassment, sexual assault and rape from colleagues, but only 16% of those impacted by sexual misconduct made a formal report.[13]

Surviving in Scrubs (2023) noted a serious resulting risk to patient care from the silencing of female staff voicing concerns about such behaviours, as female staff reported that their clinical judgements were questioned, decisions were not taken seriously, clinical requests were ignored and referrals were refused.[14]

Third, Mannion emphasises the importance of hierarchy in shaping behaviours:

"Effective voicing of concerns is but the first stage in reshaping better safer healthcare: those with influence have to hear, and they have to act… In an intensely hierarchical organisation such as the NHS, entrenched status and power differences between professional groups can harm the development of open reporting cultures. Any attempt to address speaking up in the NHS must deal with the challenging organisational dynamic of resistance to bad news."[15]

Reitz and Higgins (2020) suggest:

"...power imbalance in organisational roles (as) perhaps the most important factor that makes employee silence such a common experience."

They conclude that:

“...instigating whistleblowing lines and training employees to be braver or insisting that they speak up out of duty, will achieve little therefore, without leaders owning their status and hierarchy, stepping out of their internal monologue and engaging with the reality of others."[16]

Fourth, reputation continues to trump candour. Francis (2013) concluded that:

“There lurks within the system an institutional instinct which, under pressure, will prefer concealment, formulaic responses and avoidance of public criticism’; and an institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern”.[4]

Finally, alongside the refusal to adopt evidenced-based proactive interventions goes a lack of accountability for those whose power creates silence. Ministers have spoken strong words:

“NHS managers who silence whistleblowers could be barred from working in the NHS, under proposals being announced this week.” [17]

But such statements will only be effective if they are part of a wider evidence-driven strategy. In the meantime, victimisation of those raising concerns remains widespread, as recent reviews of the treatment of whistleblowers by both employers and the largest professional regulators have found.[18][19] Moreover, advice from professional regulators, as with NHS England, is very focus

ed on individual professional accountability rather than system abuse of power.[20]

Unfortunately, despite the best efforts of some NHS organisations, the conclusion Pope and Burnes reached a decade ago still stands:

“The NHS exhibits too high a level of collective ego defences and protection of its image and self-esteem, which distorts its ability to address problems and to learn. Organisations and the individuals within them can hide and retreat from reality and exhibit denial; there is a resistance to voice and to “knowing.”[21]

Power and the sound of silence

Content

So, when staff ought to - and often do - raise concerns what goes wrong?

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