The canary in the mine and “the whiff of Mid Staffs”

Every time there is a scandal in the NHS – whether about clinical concerns or staff behaviours - those whose office doors say they are “leaders” deplore the fact that staff failed to raise concerns in a timely or effective manner or that leaders failed to act on them.

After the Lucy Letby publicity, NHS England issued new “refreshed” speaking up guidance which was about as useful as a chocolate teapot. Last November Wes Streeting announced a consultation on whether (or how) NHS managers who silence whistleblowers could be barred from working in the NHS, under proposals being announced this week. https://www.gov.uk/government/news/new-protections-for-whistleblowers-under-nhs-manager-proposals

Yet every single one of the numerous staff – from Trust chairs to front line staff – that I have spoken to in recent weeks and months simply don’t believe things are improving.

A recent CQC research paper confirmed what researchers for the last fifteen years have been saying – staff fail to raise concerns because they believe the current speaking up process frequently doesnt work or, worse, that it is seen as dangerous by those wishing to raise concerns. https://www.employment-studies.co.uk/system/files/resources/files/CQC%20Tackling%20inequalities%20final%20report.pdf 

It is no wonder that the 2023 National Speaking Up Guardian report was entitled “Fear and Futility” https://nationalguardian.org.uk/2023/06/08/fear-and-futility/

Earlier this year a dollop of NHS money was provided to support a consultation on a Code for NHS Managers which might say something about raising concerns. I saw an advanced draft. The kindest I can be is to say it was not inspiring.  Indeed, I was prompted to suggest an alternative draft Code. https://www.rogerkline.co.uk/post/a-management-code-of-conduct-must-contain-more-than-good-intentions

So why does this matter?

NHS staff (and social care staff) have to be able to raise concerns, informally whenever possible, in the moment, and be taken seriously even if their concerns turn out to be less serious than they initially thought. If staff don’t feel they can raise concerns that it is tantamount to removing the canary from the mine. In which case patient safety and staff wellbeing will certainly suffer.

Ever more sophisticated (or at least complicated) NHS policies and procedures only work if the culture of the organisation from the very top to front line managers welcomes staff raising concerns. If that happens then Freedom to Speak Up Guardians may be helpful, sometimes very helpful.

But organisations often prefer to go comfort seeking, not problem sensing. Concerns raised are ignored or trundle through labyrinthine processes, or the person raising the concerns is seen as a problem. As Francis put it 12 years ago

“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’. https://www.gov.uk/government/publications/report-of-the-mid-staffordshire-nhs-foundation-trust-public-inquiry

If anyone suggests I am exaggerating, I can say that in every meeting I join, someone tells me this is still so.

There is an astonishing difference between whether leaders think they listen and whether staff think they do. Megan Reitz and John Higgins, who have examined this, concluded their research with this insight:

“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.’” https://bmjleader.bmj.com/content/leader/early/2020/11/06/leader-2020-000394.full.pdf

It is even worse when racism or sexism are a factor. Begeny found just 16% of women surgeons who had experienced sexual misconduct even raised a concern https://academic.oup.com/bjs/article/110/11/1518/7264733?login=false

When Joy Warmington and myself surveyed 1300 NHS BME staff we found just 5% felt their concerns were effectively responded to, whilst 42% said nothing happened and many staff believed raising concerns as a Black and Minority Ethnic staff member was dangerous as well as pointless. https://www.brap.org.uk/post/toohottohandle

Why does this especially matter now?

Because when Ministers sets targets for more output with less staff, the fear of raising concerns will increase too, because Trust leaders will be under immense pressure to deliver and staff raising concerns risk being seen as a distraction from doing so.

For many staff, whether they act on their duty of care and professional codes is not straightforward. It will often depend on their personal calculation on whether doing so will be safe or effective. As two senior nurses have put it to me in the last couple of weeks “there is a whiff of Mid Staffs in my organisation”. I suggest  we may expect more scandals, not less, in the near future.

So, Wes, can we please have a clear message, along the lines of the one you set out last year: that anyone who prevents staff raising a protected disclosure, or victimises someone who raises such a concern should not be working in the NHS.

No waffle please. Such detriment should be seen as “never events” however senior the

person is who is responsible.