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Learning from Francis: Culture change and staff involvement in the NHS

Brendan Martin, 12 February 2015

See also:

The Best Workplace: building team work through staff involvement

Staff wellbeing and engagement will make or break NHS England’s Five Year Forward View

Care-at-home for the 21st Century -- how we are applying the Buurtzorg principles in England

The Duty of Care of health care professionals -- our free online handbook


In recent months I have been helping an NHS Foundation Trust respond to complaints raised by some staff about bullying, in a few cases linked to concerns about management behaviour or patient safety.

I have also been working with the Society of Radiographers, training their reps to support members with concerns, many of which relate to the dehumanising effect of treating patients like objects on a ‘conveyor belt’.

So the evidence outlined in Sir Robert Francis’s Freedom to Speak Up report yesterday didn’t shock me, but I was amazed this morning to receive an email about it from Jeremy Hunt and Andy Burnham, apparently intended for NHS England chief executive Simon Stevens.

How on earth they mixed me up with him I don’t know, and the honesty and collaborative commitment expressed in their message was also a surprise. But as an eternal optimist, I don’t want to believe it’s a hoax. What do you think? Here’s what it said:

Dear Simon,

You won’t be surprised any more than we were by the grim picture painted by Sir Robert yesterday, and of course we have both promised to implement his recommendations while hoping the electorate blames the other for the problems.

But what we really believe is that we must show the culture change he makes clear is so desperately needed. And we mean ‘show the change’, not just talk about it.

So after our initial ritualistic statements we are going to pause to reflect on our own responsibilities for the cultures of blame and fear he describes, and for the way in which many staff who should feel cherished actually feel bullied and hopeless.

We hope that will enable us to really hear what dedicated NHS workers and many more in the communities they serve have been trying to tell us for years, and to understand why some responses to yesterday’s report were more lukewarm than others.

Take the rather defensive response of NHS Providers, for example. How easy it would be to attack them for it, as some of have done. But rather than do that, perhaps we should try to understand why managers in NHS Trusts feel caught between a rock and a hard place.

Pressured from above to reach ever tougher targets with every tightening budgets, they also feel the increasing desperation of their staff. Perhaps part of the answer lies in a key paragraph (1.118) of Sir Robert’s Mid Staffs report two years ago, which stated:

“The patient must be first in everything that is done: there must be no tolerance of substandard care; frontline staff must be empowered with responsibility and freedom to act in this way under strong and stable leadership in stable organisations.”

Do we empower NHS staff with “freedom and responsibility”? Are their organisations stable? Do we mistake command-and-control for ‘“strong leadership”.

I think all three of us know the answers to those questions, and Sir Robert’s emphasis on culture change yesterday showed we can’t avoid them any longer.

So here’s our proposal. On 11 March, a month to the day after Sir Robert’s report, we will have NHS Change Day, when thousands of staff will once again pledge to take initiatives that will contribute to the change we need.

That’s great, but we all know there is a limit to the difference those pledges can make unless they are matched by systemic change, and it is down to us to enable that.

It will mean accepting that the culture criticised by Sir Robert remains dominant in many organisations, despite the efforts of some quite heroic leaders to place staff engagement at the heart of their everyday organisational practice.

And it will mean accepting -- and learning from experiences such as Buurtzorg in the Netherlands -- that the route to better service and more efficient use of resources is to create trusting and transparent environments for health care teams to do their jobs.

‘“Freedom and responsibility”, as Sir Robert said — not one or the other, but crucially the creative power that comes from linking the two.

I know it’s not the kind of leadership we’re used to, and it involves changing attitudes and learning new skills. But it’s essential, and it’s time we set the right example.

So, Sir Simon, could we work together to listen, consult and start planning along those lines? Because, let’s face it, none of our statements yesterday — yours included — came even close to what is required.

Of course we must enable staff to speak up about their concerns, and protect them when they do.

But that's not enough. We'll know the culture has really changed when whistleblowing is no longer necessary because everyday staff involvement solves problems as they arise, and politicians and bureaucrats provide the support needed to do that.

Yours sincerely,

Jeremy and Andy.

  • Brendan Martin is managing director of Public World
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