Professional bodies (including Royal Colleges)

Introduction

3.5.1 The Review received written contributions from 11 Royal Colleges, including their umbrella organisation, and 5 clinical professional bodies. A number of these organisations also took part in our meetings and seminars.

3.5.2 There was a sense that staff raise concerns on a daily basis with their colleagues and managers and that these are resolved satisfactorily leading to better and safer care. It is when the process does not work and speaking up is discouraged that problems arise. There is a need for uniformity, consistency and fairness. The problems around raising concerns have been debated enough and the focus now needs to be on action. Processes are already in place for identifying, investigating and escalating concerns but they are not working well in practice. There is variability in how staff are treated after making a disclosure and whether the disclosure was acted on appropriately. Overall, concerns raised by staff should be given equal importance and respect to patient complaints. Overarching issues

Culture

3.5.3 As with other groups of contributors, culture and the need for culture change was commonly referred to. Whether procedures and policies on speaking up were effective or not depended on the local culture. Processes would never be fully effective while the focus was on blaming rather than learning. A culture of openness and transparency was a prerequisite for the delivery of safe, high quality care. This was most likely in organisations that valued fairness, honesty, communication and trust. Speaking up was more likely by people in organisations perceived to be responsive to complaints and concerns.

3.5.4 Culture change is a challenge, particularly in large organisations. Commitment at board, senior management and senior clinical level is necessary to facilitate such change as is good leadership and a more open and supportive attitude by senior management. Culture can be dependent on external influences such as financial and performance demands placed on trusts. Possible conflict between meeting government targets and addressing staff concerns was given as an example.

“ Ultimately, there needs to be a change in culture across the NHS which must start at the top. Significant pressure for positive results and good news stories from politicians and senior management often results in efforts to hide problems for fear of reprisals.”

3.5.5 The general view was that raising and addressing concerns needs to become normal practice. The NHS must normalise conversations about performance issues so that emerging quality and performance issues are routinely discussed before they become concerns. There needs to be a shared belief that raising concerns is positive, not a troublesome activity and that no detriment would occur.

Bullying

3.5.6 References to bullying were less common from this group although it was noted that a bullying culture is still perceived to be a problem and there should be no tolerance of bullying or undermining of staff. Some professional bodies are working together to address bullying. For example, the Royal College of Obstetricians and Gynaecologists (RCOG) is collaborating with the Royal College of Midwives (RCM) on a programme to address bullying and undermining in maternity services.

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Raising Concerns

The role of professional bodies

3.5.7 A number of these bodies produce guidance for their members on how to raise concerns at work (see 2.6) and some have initiatives in this area.

3.5.8 The Royal Colleges can become aware of concerns through a range of formal and informal routes including surveys, invited service reviews and direct contact from members. Some were proactive in this area such as piloting ‘regional conversations’ to offer members and fellows a safe space to raise concerns or recruiting ‘Workplace Behaviour Champions’ for trainees who need independent advice about unacceptable behaviour they are experiencing.

3.5.9 A number of the Royal Colleges stressed that their role was to signpost individuals with concerns to the appropriate source of advice and support rather than act as investigators. Some were reluctant to play an increased role seeing this as the role of regulators, unions and educational bodies. Students and trainees

3.5.10 Professional bodies stressed that healthcare students and trainees can provide important insights, bringing a fresh pair of eyes combined with experience gained through placements in multiple settings. They could be well placed to recognise instances of sub-standard care.

“ Students, through their comprehensive exposure to different healthcare environments during training, have a particular capacity to identify problems within the health service, and to develop solutions.”

3.5.11 They noted, however, that students and trainees can feel intimidated by the hierarchy within a hospital and fear the consequences of speaking up thus making them reluctant to raise concerns. Deterrents to Raising Concerns

3.5.12 Professional bodies highlighted a range of deterrents to raising concerns which were generally in line with those we heard from other groups. In addition, the Association of Surgeons in Training (ASiT) submitted the results of a survey59 _{of surgical} trainees to assess their experience in raising

concerns about patient safety. The majority had had concerns over patient safety yet a significant number had not felt able to raise these concerns due to perceived barriers and a lack of confidence in the process. Problems highlighted included: fear of personal vilification or reprisal; fear of impact on career; lack of confidence in the process; hierarchy of the surgical profession; and no response/

feedback or dissatisfied with response/investigation.

“ When doctors feel that they will not be penalised for speaking up and that their actions will have a tangible impact then the NHS will benefit.”

Awareness of process and procedure

3.5.13 The need for a common understanding of how concerns should and should not be raised supported by clear procedures was highlighted. Clear processes and guidance were a common suggestion for improvement.

3.5.14 Some of this group thought processes were in place but not working well in practice, whilst others stated there was no clear system to enable the reporting and raising of concerns.

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Raising concerns anonymously

3.5.15 Staff having the opportunity to report incidents and concerns anonymously was supported.

Seeking advice about concerns/raising concerns

3.5.16 Initiatives and approaches that enable and sustain staff engagement were supported including processes to access the chief executive officer (CEO), medical director and trust non-executives such as at open meetings. Some contributors were attracted to the idea of a local champion-type role. Some saw value in a board lead to oversee internal processes for raising concerns, ensure staff feel empowered to raise concerns, and to ensure lessons from concerns are shared across the organisation. Handling Concerns

Tackling concerns early

3.5.17 Professional bodies considered it was best to ensure problems did not arise in the first place rather than solely devise new arrangements for dealing with cases after the event.

“ We believe that a situation in which a person working in the NHS feels their only option is to become a whistleblower demonstrates a failure on the part of the organisation to put effective reporting and investigation systems in place, and to manage this by providing adequate support to their staff to follow the steps in these processes.”

3.5.18 Open discussion and seeking joint resolution were considered the ideal but required a strongly supportive, non-threatening, management structure. Complexity

3.5.19 Individual healthcare workers raise concerns for a wide variety of reasons. There is little reason to suppose that most are not genuine and represent a valid and justified exercise of the

individual’s professional duty to protect patients but sometimes reasons were questionable.

“ There are occasions on which the mantle of “whistle-blower” can be adopted for reasons which are not completely honourable.”

3.5.20 Some whistleblowing cases could be complex. Dissatisfaction with the escalation or investigation process could become conflated with the original concern about patient safety turning into a costly and time consuming debate about people and process, rather than patients and their safety. Simplifying HR frameworks within which individual medical performance are managed was suggested.

“ Cases are often not straightforward and can involve complex and long-standing professional and interpersonal difficulties between clinical colleagues. Cases can become a morass of claim and counter-claim with a toxic mixture of grievance and disciplinary activity where positions become quickly entrenched. Even if there is desire to resolve the issue, in many cases organisations may not have the expertise to do so.”

Detriment after Raising Concerns

3.5.21 Staff can be disadvantaged after raising concerns, for example, being told not to apply for promotion opportunities despite being qualified for them, themselves being accused of bullying and harassment, being suspended from work and having to defend themselves with little or no protection from their employer. Whistleblowing can also bring serious negative consequences for the individual including impact on mental health. Positively, however, the majority of surgical trainees who had raised concerns about patient safety responding to the ASiT survey (see 3.5.12) stated that this did not affect their career although a small number reported a negative experience ranging from feeling professionally isolated to having to move job or location.

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3.5.22 The overall view was that there was still a way to go for staff to be treated fairly, with respect and in a way that protects them from being disadvantaged in their career after raising a concern.

Training

3.5.23 There may be a lack of expertise within organisations to resolve issues. Training and

support for managers to understand their roles and responsibilities in the handling of, and responding to, concerns would be helpful. Senior clinicians can perceive criticism as a threat rather than an opportunity to improve ways of working and learning and become defensive. This could also be an area to cover in training.

3.5.24 Investment in high quality, joint training and leadership programmes for clinicians and managers to empower them to work in collaboration to respond in a timely, transparent and proportionate way to problems or concerns was needed.

Other suggestions included: emphasising raising of concerns as a key principle of medical professionalism through education; embedding raising concerns within the annual appraisal and revalidation processes; and, training and guidance for HR departments in how to deal with staff who raise concerns as their support was variable. Investigation

3.5.25 Objectivity and a full understanding of the facts of a situation and its background are key. Individuals close to a situation may form a particular view and any external assessment must take this into account. The truth can be elusive even with a fair, rigorous and comprehensive investigation of concerns.

3.5.26 Suggestions to improve the current process included: increasing clinical input into the ‘assessment’ stage of a concern; having a pool of trained internal investigators; use of independent mediation; and only suspending whistleblowers where there is evidence to show patient safety is endangered by not doing so. It was also noted

that teams needed to support each other through difficulties and respond to problems in a timely and constructive way.

3.5.27 A number of the Royal Colleges referred to the Invited Review Mechanism they offer. These reviews are requested by organisations rather than individuals and generally relate to the performance of a particular unit or department. The resulting recommendations go to the trust management although issues of serious concern can be referred to the professional or system regulator.

Feedback

3.5.28 Feedback to staff after raising a concern was important. Management need to trust and respect clinicians and invest time in explaining decisions. Support

3.5.29 Staff need practical or emotional support to navigate the steps in the process of raising concerns. The well-being of staff, both individually and as teams, needs to be considered. Partnership working between employers, trade unions and professional bodies should be promoted. Managers

3.5.30 Managers need to strike a balance between providing a safe and excellent service to patients and working within tight budgets with financial cuts. The rapid turnover of managers can lead to the same problems recurring and staff not wanting to raise the same issues again and again. There was some suggestion that regulation of managers might be useful.

“ The rapid turnover of managers in the NHS also works against investment, of both time and money, in long-term solutions.”

3.5.31 A number of professional bodies who wrote in to us signed an open letter to the Health Service Journal in December 2014 calling for a change in attitudes towards NHS managers.

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“ In our experience, NHS managers are as dedicated to the service as any other group of staff. We find it regrettable, therefore, that they are so often the subject of ill-judged criticism and made scapegoats when concerns arise. This is both unfair and damaging to the interests of patients since successful joint working between managerial and clinical staff is an essential ingredient of good care.”

Better data collection and analysis

3.5.32 This group was the most likely to refer to the need for better data collection, analysis and understanding to detect potential problems at an early stage and identify themes and trends that need to be addressed. The need to triangulate with other relevant information such as patient complaints and clinical outcomes data was noted as was the need to audit whether tangible action takes place. The need for regulators to actively seek information about staff concerns and culture was also raised.

3.5.33 Whilst the reporting of incidents and concerns had become easier and staff in many trusts are encouraged to report critical incidents and possible risks, it seemed that this was variable across organisations. It was suggested that more effective reporting systems were needed. Resolving Concerns

Closure

3.5.34 There can come a point in some cases where the individual becomes ‘fixated’ on what has happened to them and may need personal support to move on emotionally. In such a situation there may need to be stronger action to encourage them to move on when all concerns have been investigated and exhausted to prevent both psychological damage to the individual and demoralisation of the wider team.

3.6 Regulators