On Thursday 30 July 2020, NHS England and NHS Improvement published the NHS People Plan for 2020/21.[1] Building on the Interim NHS People Plan released in 2019, it describes itself as focusing on “how we must all continue to look after each other and foster a culture of inclusion and belonging, as well as action to grow our workforce, train our people, and work together differently to deliver patient care”.[2]
With the Covid-19 pandemic having placed NHS staff under immense pressure in recent months, understandably much of this Plan places a strong emphasis on providing support for staff physical and mental health. This is welcome at a time where staff safety has become such a pressing concern, and it references important issues, such as effective infection control, providing appropriate personal protective equipment and the need for safe rest spaces.
However, the Plan makes surprisingly limited references to another major problem facing staff in the NHS – the blame culture. Blame culture continues to present a serious threat to patient safety. Assigning blame when things go wrong deters staff from speaking up, reduces the likelihood of incidents being reported and therefore makes it less likely that we learn and take action to prevent unsafe care. And patient harm is more likely to happen.
In this blog, we consider how organisational culture is a significant factor in the safety of patients and staff. We highlight where the People Plan has not addressed these concerns and the action that needs to be taken urgently.
What impact does culture have on patient safety?
The influence of culture on patient safety is not a new concept; there is significant research in this area in healthcare and other safety critical industries.[3] At Patient Safety Learning, we recognise the crucial role culture plays in patient safety, identifying it as one of the six foundations of safe care in our report A Blueprint for Action.[4]
To improve patient safety, it is important to move towards a Just Culture; a culture less focused on blame and which “considers wider systemic issues where things go wrong, enabling professionals and those operating the system to learn without fear of retribution”.[5] This has a positive impact on patient safety, creating an environment where individuals are supported in raising and resolving concerns, addressing incidents of unsafe care with empathy, respect, and rigour.[6]
In the NHS, following the Public Inquiry into the serious failings at the Mid-Staffordshire NHS Foundation Trust, Professor Don Berwick was asked to carry out a review into patient safety problems.[7] This identified blame culture as a key patient safety issue, requiring a culture change.[8] Making the case for this, he noted:
“When people find themselves working in a culture that avoids a predisposition to blame, eschews naïve or mechanistic targets, and appreciates the pressures that can accumulate under resource constraints, they can avoid the fear, opacity, and denial that will almost inevitably lead to harm.”[9]
The reluctance to speak up is still a serious issue for the NHS, reflected its most recent NHS Staff Survey results.[10] 40.3% of survey respondents did not agree with the statement that “their organisation treats staff who are involved in an error, near miss or incident fairly”.[11] While this is an unacceptably high level itself, it can vary from organisation to organisation; in the lowest scoring trust, 59.7% of staff did not agree with the statement.[12] In addition to this, nearly 30% of all survey respondents also indicated that they would not feel secure raising concerns about unsafe clinical practice.[13] From the 569,440 number of staff who responded, this means that more than 220,000 staff didn’t feel that their organisation treats staff fairly and approximately 160,000 staff did not feel secure in raising concerns about unsafe clinical practice.[14]
We also see the impact of the blame culture reflected in our own work to share learning for patient safety on our online platform the hub. We regularly see a reluctance from staff in sharing examples of good practice as well as concerns about unsafe care. Even when documents are anonymised to shield the identity of those involved, these concerns continue to weigh heavily on those involved. Staff express their fear that they will be ‘found out’ and do not have permission to share good practice.
The blame culture is acknowledged as a key patient safety issue for the NHS in its Patient Safety Strategy, which states the need to “embed the principles of a safety culture within and across local system organisations”.[15] Despite this, however, the new People Plan has only limited references to addressing this issue.
Speaking up: listening and responding to staff on safety matters
“NHS England and NHS Improvement will work with the National Guardian’s office to support leaders and managers to foster a listening, speaking up culture. Board members of NHS trusts and foundation trusts already have specific responsibilities under the NHS Improvement board guidance published in July 2019.”[16]
This quote is the main reference to improving the speaking up culture in the People Plan. While it reaffirms a commitment to fostering a speaking up culture, Patient Safety Learning believes that there is a need for a more robust set of measures to deliver this in practice. Reminding NHS organisations that they have responsibilities is just not enough. We want to hear how NHS England and NHS Improvement will contribute to the development of a Just Culture across the healthcare system. If Boards already have specific responsibilities to create a speaking up culture, why are there still major challenges in delivering this? What further resources, guidance, support, and direction are needed?
Given that such a significant number of healthcare staff have expressed fears that they would not be treated fairly when speaking up about patient safety concerns, Patient Safety Learning believes there is a huge missed opportunity in the People Plan to acknowledge and tackle these issues.
We call for an urgent indication about how NHS England and NHS Improvement, the National Guardian and the Care Quality Commission intends to:
- Provide resources, guidance, support, and direction for organisations wanting to encourage staff speaking up.
- Proactively share examples where improvements have been made to speaking up cultures so lessons learnt can be shared widely and best practice implemented.
- Identify poorly performing organisations and intervene to make improvements.
- Report publicly on progress and the impact that speaking up has had on patient safety and staff safety.
The action needed to create a Just Culture
“We will also promote and encourage employers to complete the free online Just and Learning Culture training and accredited learning packages to help them become fair, open and learning organisations where colleagues feel they can speak up.”[17]
The need to create a Just Culture in the NHS is also limited to a reference in the “Ensuring staff have a voice” section. The above quote links to online learning the NHS has made available in this respect, with a specific example of good practice at the Mersey Care NHS Foundation Trust.[18]
While guidance and examples of good practice are a crucial element needed to create a Just Culture, given the complexity of the organisations involved, we feel that a serious commitment to this requires a greater degree of rigour. Reflecting on culture in the NHS in a recent blog on the hub, a healthcare professional noted that “we are told to adopt a ‘just culture’, however fostering a culture of safety is not that simple, following a guide doesn’t work”.[19]
We call on NHS England and NHS Improvement to set out more detailed measures to achieve a Just Culture, such as:
- Asking organisations to develop and publish goals to create and sustain a Just Culture.
- Ensuring organisations measure and report on their progress in an open and transparent way.
- Enabling organisations share good practice for wide dissemination and implementation.
If this is not the role of NHS England and NHS Improvement, then whose role is it? If the answer is no one, can we really claim to be serious about creating a Just Culture in our healthcare system?
What needs to change
At Patient Safety Learning, we think it is vital that the health and social care system develops programmes and goals to eliminate blame and fear, introducing and/or deepening a Just Culture in organisations. There needs to be a real commitment from the leadership of the NHS to implement, measure and monitor performance on these issues if we are to see the change that is needed and deliver safer care. Without this, our efforts to improve safety in other areas are likely to be undermined, as noted by Professor Don Berwick:
“In the end, culture will trump rules, standards and control strategies every single time, and achieving a vastly safer NHS will depend far more on major cultural change than on a new regulatory regime”[20]
We call for the NHS People Plan to be a rallying point for the long-needed improvement in culture in the NHS. And if not now, then when?
[1] NHS England and NHS Improvement, We are the NHS: People Plan 2020/21 – action for us all, July 2020. https://www.england.nhs.uk/publication/we-are-the-nhs-people-plan-for-2020-21-action-for-us-all/
[2] NHS England and NHS Improvement, Interim NHS People Plan, June 2019. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/05/Interim-NHS-People-Plan_June2019.pdf
[3] A range of different articles and studies looking at issues concerning patient safety and culture can be found on Patient Safety Learning’s the hub: https://www.pslhub.org/learn/culture/
[4] Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019. https://s3-eu-west-1.amazonaws.com/ddme-psl/content/A-Blueprint-for-Action-240619.pdf?mtime=20190701143409
[5] Professor Sir Norman Williams, Gross negligence manslaughter in healthcare, June 2018. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/717946/Williams_Report.pdf
[6] Sidney Dekker, Just Culture: Restoring Trust and Accountability in Your Organization. 3rd ed. Routledge; 2016.
[7] Don Berwick, A Promise to Learn – a Commitment to Act – Improving the Safety of Patients in England, August 2013. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf
[8] Ibid.
[9] Ibid.
[10] Patient Safety Learning, Results of the NHS Staff Survey 2019, 18 February 2020. https://www.patientsafetylearning.org/blog/results-of-the-nhs-staff-survey-2019
[11] NHS Staff Survey Results, Results Summary 2019, Last Accessed 18 February 2020. http://www.nhsstaffsurveyresults.com/homepage/results-2019/
[12] National Guardian for the NHS, Freedom to Speak Up Index Report 2020, July 2020. https://www.nationalguardian.org.uk/wp-content/uploads/2020/07/ftsu_index_report_2020.pdf
[13] NHS Staff Survey Results, Results Summary 2019, Last Accessed 18 February 2020. http://www.nhsstaffsurveyresults.com/homepage/results-2019/
[14] Ibid.
[15] NHS England and NHS Improvement, The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. https://improvement.nhs.uk/documents/5472/190708_Patient_Safety_Strategy_for_website_v4.pdf
[16] NHS England and NHS Improvement, We are the NHS: People Plan 2020/21 – action for us all, July 2020. https://www.england.nhs.uk/wp-content/uploads/2020/07/We_Are_The_NHS_Action_For_us_all-1.pdf
[17] NHS England and NHS Improvement, We are the NHS: People Plan 2020/21 – action for us all, July 2020. https://www.england.nhs.uk/publication/we-are-the-nhs-people-plan-for-2020-21-action-for-us-all/
[18] Mersey Care NHS Foundation Trust, Just and Learning Culture – What It Means for Mersey Care, Last Accessed 6 August 2020. https://www.merseycare.nhs.uk/about-us/just-and-learning-culture-what-it-means-for-mersey-care/
[19] Anonymous, We all want a culture of speaking up, don’t we? So, why isn’t it happening?, Patient Safety Learning’s the hub, 22 June 2020. https://www.pslhub.org/learn/culture/bullying-and-fear/we-all-want-a-culture-of-speaking-up-don%E2%80%99t-we-so-why-isn%E2%80%99t-it-happening-r2318/
[20] Don Berwick, A Promise to Learn – a Commitment to Act – Improving the Safety of Patients in England, August 2013. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf
