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The challenges of fostering openness in the NHS: a conversation with Graham Martin

The challenges of fostering openness in the NHS: a conversation with Graham Martin
Daniel Punch
Communications Manager

It has been more than a decade since reports about patient safety issues at Mid Staffordshire NHS Trust first came to light. But ten years, two inquiries, at least five official reports later, the English NHS is still feeling reverberations from the scandal.

No one wants to see a repeat of ‘Mid Staffs’, nor any of the other failures in patient safety from recent years. So there has been a concerted effort to learn from these mistakes.

Part of that effort is a push to encourage openness and candour in healthcare organisations. NHS staff are the eyes and ears of the healthcare system – if something is going wrong with patient care, they’re the ones who know it. To function the way it should, the NHS needs them to speak up when they have concerns. But evidence shows that isn’t always happening.

In response, the NHS has rolled out a number of policies aimed at encouraging employees to speak up. These range from the duty of candour – a regulation requiring healthcare providers to inform patients when something goes wrong in their care and they suffer harm as a result – to the Freedom to Speak up Guardians – hired by each NHS provider organisation to support staff speaking up.

But have these policies changed anything? Do NHS staff feel more comfortable speaking up?

In a study commissioned by the Department of Health and Social Care, a team of researchers – include THIS Institute’s Graham Martin and Mary Dixon-Woods – tried to answer those questions by interviewing 51 senior leaders from across the NHS. The team’s paper in the Journal of the Royal Society of Medicine showcases what they found.

We recently had a chat with lead author Graham Martin, who shared some unique insights into the study.


Your team interviewed many of the people responsible for implementing these policies. What did they have to say about the push to foster openness?

For the most part, they were very receptive to the need for these kinds of changes. In any big, complex organisation, you don’t necessarily know everything that’s going on a couple of blocks away, or in the next ward along. So you need sources of intelligence that can tell you the right places to look if there are issues.

The people we spoke to didn’t consider Mid Staffordshire exceptional or completely alien from their own experiences. Quite a few of them recognised that some of the things that went wrong at Mid Staffs could go wrong in their own organisations. So they were keen to do whatever they could to try and prevent that.

As keen as they were, your paper makes it clear that encouraging voice is no easy task. From what your team found, why do NHS staff not speak up about patient safety issues?

There are a whole range of reasons that aren’t unique to healthcare, or to the UK. For one, daring to speak up is brave. You might not be listened to, and you might be wrong. And if you’re wrong, you might be compromising your credibility with your colleagues. If you’re right, you might be opening yourself up for informal retribution from them. You might even be subjecting yourself to more formal punishment from managers. There are relatively recent examples in the NHS where people who have ‘blown the whistle’ have basically found themselves forced out of organisations.

There is also scepticism about how organisations deal with concerns raised by staff and the likelihood that they will actually lead to change. So there aren’t a lot of reasons encouraging you to report concerns, and an awful lot of reasons not to.

How did the leaders you interviewed go about overcoming these perceptions?

We found that changing people’s minds about speaking up goes beyond implementing a policy. You have to dig deeper to change the organisation’s culture.

Listening is big part of that. People told us about chief executives working shifts as care assistants, or doing walk-rounds where they listened to issues from staff. They also made sure those conversations translated into tangible improvements.

They told us, for example, about having small pots of money they could use quickly to address staff concerns. That helped them build trust and reinforce that all sides benefit when someone speaks up. It doesn’t just create a report that gets a gold star from management somewhere.

Changing people’s minds about speaking up goes beyond implementing a policy. You have to dig deeper to change the organisation’s culture.

The idea of words vs. actions comes up a lot in the paper. Why is that distinction so important?

Negative perceptions about speaking up run deep. They become part of an organisation’s “shared lore” and they’re very difficult to overcome through words. In our interviews, there was a sense that if the words of a policy weren’t backed up with actions, it could breed cynicism – especially when staff have heard so much about the negative consequences of speaking up. Staff needed to see that speaking up led to real changes, so they didn’t feel they were just shouting into a vacuum. Words are important, but actions speak louder.

Going forward, what’s needed to help these policies achieve their goals and foster more openness and candour in the NHS?

Healthcare leaders have to make sure they implement the spirit of the policy, as well of the letter of it. And that takes a lot of discretion and hard work. The people we interviewed had a lot of creative ideas on how to do that, and their notion of connecting the sharp end with the blunt end of care is really fundamental. But the extent to which they had an impact in practice, it’s too early to say.

There has also been a lack of any real infrastructural investment to support these kinds of changes. A lot of these things were being done on a shoestring. In other places, we’ve seen that you need coordinated and very well-resourced initiatives to make a difference at that level, because views about the risks of speaking up are so deeply held.


Learn more by reading the full paper in the Journal of the Royal Society of Medicine.

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