hsj.co.uk 16 Health Service Journal 16 May 2014

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When it comes to supporting healthcare staff to raise concerns, sometimes a simple approach can be best.

“It doesn’t have to be something formal or really complicated,” says Nyla Cooper, programme lead for professional standards with NHS Employers. “It’s about the board being visible, managers engaging with staff, and being responsive to what they are telling them.”

Raising concerns, or whistleblowing as it’s often called, should be seen as an early warning mechanism to prevent bad practice from escalating.

Protecting patients from harm and ensuring dignity of care requires a system and a culture where staff feel empowered and supported to raise concerns safely and confidently.

So where are we now? The latest NHS Staff Survey (see hsj.co.uk/whistleblowing) presents a mixed picture: 89 per cent of staff know how to report any concerns they have about fraud, malpractice or wrongdoing. However, just 71 per cent would feel safe raising these concerns, and only 54 per cent would feel their organisation would address them if they did.

The overall impression is just as unclear on reporting errors, near misses and incidents. While 85 per cent felt encouraged by their organisation to report them, less than half (44 per cent) felt informed about errors, near misses and incidents, and the same proportion felt they were given feedback on changes made as a result.

Ms Cooper, whose remit includes raising concerns, says there’s a strong recognition of

the need to drive up public confidence. The Francis and Berwick reports talk about openness, transparency and candour which are great aspirations to work towards, and there is a real commitment to affecting a change in culture in the NHS to enable that to happen. “There’s a wealth of guidance, and regulation which is targeted at driving up the quality of care and patient safety,” she says. “But we just need to ensure that it fully supports people to be responsive and do the right thing.”

Developing a system and a culture where staff feel confident about raising concerns is important, but Ms Cooper acknowledges that getting it right isn’t quite so simple. “Some of the issues presented are complex and rely on employers and managers to make the right judgment call,” she says. “Sometimes they get it wrong. Organisations need to get better about communicating the lessons learned. Building staff morale after something has gone wrong and it hits the public eye can pose a huge challenge for employers.

“The real aim should be that staff feel empowered and supported to have those open discussions without the need to invoke formal whistleblowing procedures.”

Christina McAnea, UNISON national secretary and trade union side chair of the national Social Partnership Forum (representing 15 NHS unions), believes that the trade unions have an important role to play in helping to develop a culture where staff feel confident in

How can we make staff feel that they can speak out about their concerns? Jennifer Trueland reports

SEE, TOucH, HEar

SpEcIaL rEpOrT: WOrkfOrcE

‘I believe that if you don’t provide the spanners, people may take a hammer to try and fix it instead’

dEaN rOyLESON LISTENING

Of all the recommendations, analysis, commentary, follow up reports and actions that have come out of the review in Mid Staffordshire, the area that seems to get most press attention is raising concerns and whistleblowing. There have been parliamentary questions and debate, health select committee hearings, public accounts committee sessions and almost

daily press coverage.The debate about it has been

generally healthy. Everyone recognises a problem, everyone knows that guidance will only take us so far, and everyone accepts that not resolving underpinning cultural issues is bad for patient care.

Some of the analysis is wrong though. For example the belief that every compromise agreement (now referred to as “settlement agreements”) costs the NHS millions and were all used to gag people.

The National Audit Office report reflected that none of the NHS agreements it reviewed contained “gagging clauses”. We also know that compromise agreements were used in many cases of mutually agreed resignations at the time of the reorganisation of our health care system.

The effect was that staff took half the amount of contracted redundancy from employers –saving millions, and with no

question of patient care issues. It is clear though, the legal

language of the agreements and wording will have led some to believe they were gagged.

Since April 2013 there has been a requirement for employers to have a specific clause, making it explicit that any agreements do not prevent employee disclosure about patient safety issues.

In the last year we, as an organisation that represents employers in the NHS, have hosted a number of debates, webinars and seminars on raising concerns in the workplace. We have updated guidance and templates, as well as produced informative podcasts and videos – all aimed at raising awareness of good practice in relation to affecting cultural change.

I know guidance isn’t sufficient in itself. When I posted an update on Twitter recently, someone responded to a discussion about culture by saying: “Lots of shiny spanners doesn’t mean you know how to fix the engine.”

True – good point. However, I believe that if you don’t provide the spanners, people may take a hammer to try and fix it instead. I hope you find the “spanners” in this special report helpful, as you review your local practices. ●Dean Royles is chief executive of NHS Employers.

Special report editor Claire Read

In association with

Tools to mend the culture problem

First steps: the board must be visible, managers engage with staff and leaders have to be responsive to what they are telling them

hsj.co.uk 16 May 2014 Health Service Journal 17

‘I remember going to bed that night, and thinking ‘my career is over’. But there was nothing else I could have done. I felt patients were at risk’

raising any issues of concern and where they know that those concerns will be properly addressed.

Working in partnership with employers at a local level can ensure that robust reporting arrangements are in place, and that the staff are clear about how to use them. “NHS staff are the eyes and ears within every workplace, they must be encouraged to voice their concerns whenever and wherever they feel that patient safety could be at risk,” she says.

NHS Employers provides advice and guidance to employers on developing processes which support staff to raise concerns (visit www.nhsemployers.org/raisingconcerns for more information).

It also supports organisations, such as the Care Quality Commission, which take steps to encourage people to raise concerns, promote good practice and share learning.

Kay Sheldon, non-executive director at the CQC, previously raised concerns regarding the CQC culture and the inspections

it was conducting. Although this was not an easy process, Ms Sheldon felt she had to do the right thing. “I felt that I had to keep raising these concerns as it was my job and duty to speak up against things that could affect patient safety. Not pursing this was not an option – it was the right thing to do.”

Since raising her concerns the CQC have implemented changes and are also planning to hold two reviews on whistleblowing within the CQC and how the CQC can also support and protect whistleblowers within their remit.

“What we should be aiming for, is a culture where staff are able and expected to raise any concerns they may have.” (For more information on CQC’s approach visit www.nhsemployers.org/raisingconcerns.)

Although there has been some progress with raising concerns within the NHS, there is still a long way to go, says Jennie Fecitt, lead nurse with Patients First, a lobbying and campaign group which works to protect whistleblowers – and to create

an NHS where they are no longer necessary

Ms Fecitt herself suffered bullying and intimidation from colleagues after she repeatedly raised concerns about a member of staff ’s qualifications. She eventually invoked her trust’s whistleblowing procedures because she had a reasonable belief – subsequently confirmed – that there had been a management cover-up over the issue.

The decision to blow the whistle wasn’t made lightly. “I remember going to bed that night, and thinking ‘my career is over’,” she says. “But there was nothing else I could have done. I felt patients were at risk.”

Ms Fecitt and two colleagues were affected. Two were moved to different workplaces, and one, an agency nurse, found her hours dried up.

“The team were getting one-sided information because we couldn’t discuss it, so decided that we were on a witch hunt,” she says. “It was bullying – they were ignoring me, there was real insubordination, and my daughter had a threatening phone call. I felt very isolated.”

Her advice to staff who have concerns is to raise them verbally and try to deal with them informally.

“Most people don’t consider themselves whistleblowers – they just think that they have a concern and that they should raise it. Trusts should support staff to do this and should act quickly. After all, we’re talking about patient care, and things that have an impact on patient safety – what could be more important?” l

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hsj.co.uk 18 Health Service Journal 16 May 2014

BIrmINGHam aNd SOLIHuLL mENTaL HEaLTH fOuNdaTION TruSTLike other organisations, Birmingham and Solihull Mental Health Foundation Trust has formal whistleblowing procedures. But the executive team wanted to find other, less formal ways of encouraging staff to raise concerns.

The fact that the chief executive is called John (Short) may have suggested a way forward – and the Dear John initiative was born.

This system allows staff to submit concerns directly to the chief executive via a stand alone Dear John website at any time, and from anywhere there is an internet connection. The reports can be anonymous if the sender wishes. Those who do give contact details receive an initial response within 24 hours. Concerns are expected to be investigated within a week of being submitted, or sooner depending on how serious they are, and a record is kept of each and their outcomes.

In the first year, around 130 submissions have been received. “As a trust we are clear that providing high quality services to our service users and carers is at the centre of everything we do and this is the focus of our corporate strategy and business plan,” says Mr Short.

“We therefore think it’s important that, when a staff member in any position in the

trust has concerns that something isn’t quite right, they have a number of ways in which they can raise them to ensure that we are aware of anything that is compromising quality.”

The initiative responds to the recommendations of the Francis report with respect to highlighting the importance of reporting incidents of concern, as well as the Keogh review, which talks about the positive impact of staff engagement on patient outcomes, he adds.

Importantly, it doesn’t stand in isolation. “Dear John sits alongside existing reporting mechanisms and policies such as whistleblowing and serious incident reporting. It is a slightly more informal mechanism for staff to use to raise a concern even if they are not sure whether something is actually wrong. They can do this anonymously if they wish and know their concern goes direct to the chief executive. As such it has proved effective in connecting staff with the executive team and in tackling some issues that might otherwise have escalated further and taken longer to come to our attention or have been ignored.”

The initiative adds to the information received via more formal channels and other staff engagement, giving a more comprehensive view of what’s happening across the trust. “It also allows staff to suggest solutions to these, for example how they think we can improve processes or procedures.”

The trust has a number of ways of ensuring it listens to staff, and Dear John is an important part of this. “We do have some evidence that the very existence of Dear John has contributed to a perception of a more open culture, for example its introduction has also coincided with other routes to raise concerns being used more frequently, such as local counter fraud referrals.”

Around a year in, Mr Short can point to specific examples of improvement generated by Dear John, including changes to patient environments and to how specific care is delivered. “Dear John has been wholly or partly responsible for actions such as the purchase of new equipment for patient areas, re-examination of staffing numbers in certain wards, changes to processes such as recruitment and selection, and investigations into bullying and harassment and fraud,” he says. “As well as this, it has contributed to wider trust initiatives already in place such as a review of inpatient numbers and how statutory and mandatory training is delivered.”

His advice for others thinking of setting up a similar initiative is to make it part of a wider staff engagement strategy which focuses on quality, rather than a stand alone initiative.

“We triangulate the information and themes gathered from Dear John with other sources such as the staff

survey and complaints, as this gives a more complete picture of what is concerning staff and indicates wider patterns or common themes that need investigation,” he says.

“The key is that it is seen as a direct and more informal route for staff to contact the chief executive and the ability to raise concerns anonymously is an important factor in its success. For a system such as this to work, staff need to really believe that the chief executive is interested and that things will change as a result of them raising something.”

EaST LONdON fOuNdaTION TruSTEast London Foundation Trust has embarked on a quality improvement journey with the aim of changing organisational culture to one that places patients and families at the centre.

Importantly, says associate medical director for quality improvement and consultant forensic psychiatrist Amar Shah, it aims to embed listening to and learning from patients and staff at every level. That means that

How two trusts are encouraging staff to speak up, with a system that lets staff send anonymous missives to the chief executive and a campaign to create a listening culture

LETTErS Of NOTE

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Urgent letter: chief executive John Short has set up the ‘Dear John’ initiative, a website to ensure he hears staff concerns

hsj.co.uk 16 May 2014 Health Service Journal 19

staff are encouraged to raise concerns – and can be sure that they will be listened to, and the results fed back to them.

“Our quality improvement programme is all about rebalancing the power and autonomy, to give frontline staff much more freedom, space and skills to test out small changes to their workplace in order to improve the quality of care we offer,” says Dr Shah.

“We feel [it] is crucial to enable us to move from being an organisation that provides generally good quality care, to one that aspires to excellence at every encounter and one that truly values the skills and ideas of its frontline staff.”

An important part of this is a review of all of the trust’s support systems, from incident reporting, to making data open and transparent throughout the organisation. It has also included reviewing all HR policies and embedding listening in organisational structures at every level.

For example, following extensive staff consultation, the trust has introduced changes to its Datix system for incident reporting to make it more useful. Improvements have included giving feedback to the original reporter about actions taken to address their concerns, setting up dashboards in Datix to allow services to view trends in incidents over time, and integrating incident data with other quality data, which staff

will be able to access from any computer. Further improvements suggested during the consultation process will be implemented in due course.

The trust wants to embed listening and learning into its DNA, says Dr Shah, adding that it is making an “unprecedented” investment in quality improvement.

As part of this, senior management hold regular listening sessions which include a frequently held chief executive open forum. Executive “walk rounds” take place three times a week and key findings are passed back to the clinical team, shared at internal quality and safety committees, and published each month as part of trust board papers.

Clinical teams are also being supported to ensure there is a regular space where staff can come together to think and talk openly about the quality of care, share improvement proposals and test out new ideas.

Individual directorates are also being supported to encourage listening and acting on staff suggestions and comments, and feeding back on positive changes that have happened as a result under the banner of “you said, we did”.

Dr Shah says the main barrier has been finding ways of releasing nursing staff from wards to attend the listening to improve sessions. But, he adds, the enthusiasm of frontline staff to be part of this change has

been wonderful.Asked to point to examples of

positive change resulting from staff feedback, and Dr Shah says: “There’s so many examples of ideas from staff that have led directly to improvements in patient care that I wouldn’t know where to start.

“Our view is that the route to providing care of consistently excellent quality, with patients and families receiving the experience of care that we would want for ourselves and our loved ones, relies on us putting much more weight on the ideas, views and concerns of frontline staff. And our quality improvement programme, which is our core business strategy, will help us to achieve this.”

The trust has set up a QI website which includes resources such as a library of useful documents, as well as advice on how to get involved. It also contains news of quality initiatives, such as an electronic patient board that allows the City and Hackney home team to better manage their workload.

The trust has also been running QI roadshows, which staff are encouraged to attend, and is running a QI newsletter which also has links to learning resources. l

FIND OUT MOREFor more information about East london project, see the trust’s quality improvement website, http://qi.eastlondon.nhs.uk, or email qi@eastlondon.nhs.uk

‘We think it’s important that, when a staff member has concerns something isn’t right, they have a number of ways they can raise them’