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What can the NHS do to help staff speak up about concerns?

How do you ensure staff’s concerns are voiced and heard in a complex system like the NHS? A recent decline in doctor’s confidence to raise concerns about patient safety has led to renewed calls for stronger regulation of managers – but a broader approach is likely to be vital to encouraging staff to speak up.
Graham Martin
Professor Graham Martin
Director of Research
Healthcare professional walking down a brightly lit corridor in a hospital.

A recent survey of doctors by the British Medical Association (BMA) paints a worrying picture of their declining confidence in speaking up about patient safety concerns. Less than a third of doctors said they would feel confident in raising concerns – compared with 48% six years ago – and over 60% said they would fear reprisals if they did raise concerns. Addressing the union’s representatives, BMA chair of council Phil Banfield has warned of an emerging scandal around the fear and suppression faced by ‘whistleblowing’ doctors, and called for regulation of managers to improve accountability.

There’s good evidence that willingness to speak up is a good reflection of quality and safety in an organisation more broadly, and it’s also strongly correlated with indicators of staff wellbeing. But it’s clear that being open about patient safety and other concerns is a problem for the NHS – and not just for doctors. For some years the annual staff survey showed small but consistent positive shifts in responses to questions about speaking up, but in the last few years those improvements seem to have stagnated. In the most recent survey, only 62% of staff – not just doctors – said they felt safe to speak up about things that concern them in their organisation. Just half said they thought their organisation would address their concern.

So what can be done to improve people’s willingness to speak up about their concerns, and help to improve quality, safety and staff welfare? Some – including Banfield – say the answer lies in the performance and accountability of managers, particularly senior leaders. Proposals to regulate managers are firmly on the policy agenda: new Health and Social Care Secretary Wes Streeting has promised to implement measures to disbar senior managers if they silence whistleblowers.

Failures of leaders to heed concerns are undoubtedly a recurring feature of recent disasters in patient safety. Bill Kirkup’s investigation into maternity safety at East Kent Hospitals, for example, found no fewer than eight opportunities for the board to respond to concerns earlier, and potentially forestall much suffering. The trust ignored not only staff and families but also regulatory bodies. A critical Royal College of Obstetricians and Gynaecologists report was dismissed by the trust as “hearsay and uncorroborated comments,” while challenge from the Care Quality Commission and the Healthcare Safety Investigation Branch was “met with anger and defensiveness.”  

But in this case and others, many of the senior leaders implicated in the inadequate response to concerns were themselves members of regulated professions. Regulation here appeared to do little to prevent the silencing or disregard of concerns, even if it brings additional options for sanction after the event. The limited impact of the Fit and Proper Persons Test, as described in the Kark review five years ago, hints at the challenges that implementing a wider regulatory framework for managers would pose – not least exactly what competencies would be prioritised in such a diverse occupational group.

It’s clear, then, that improving voice in organisations is going to require more than regulation. And there are plenty of other ideas about how to make the NHS more receptive to bad news – and how to ensure its bearers are celebrated rather than castigated.

High-quality management, and high-quality systems, are central to many of these ideas. Crucial also is focusing on the whole-organisation response, rather than seeing patient safety concerns in isolation – since concerns about behaviour, quality and safety often overlap. For example, ensuring that organisations’ human resource functions have the capacity, the capability and the authority to respond appropriately when concerns arise is fundamental to giving people confidence to speak up and showing them that responses are meaningful.

Much has also been written about the importance of psychological safety in encouraging people to give voice to their concerns. But psychological safety is primarily a team-level property. Team leaders and colleagues can do plenty to achieve psychological safety, but this won’t help people who aren’t lucky enough to be part of a good team. Wider systems that support good management and respond swiftly and proportionately when things go wrong are vital – including rationalising what some have called the “maze” of “tangled, ill-coordinated” routes for raising concerns that often typifies healthcare organisations.

Encouraging people to raise concerns is crucial to patient safety. But focusing only on problems at the top of organisations, or modelling improvements on high-profile whistleblowing cases alone, will not address the more prosaic problems that stop people from speaking up. Addressing day-to-day issues through good management and systems is the way to ensure that voice becomes the norm in the NHS: a routine part of the job rather than a frightening, occasional exception.

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