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In this blog, Patient Safety Learning analyses the results of the NHS Staff Survey 2021, specifically focusing on responses relating to reporting, speaking up and acting on safety concerns. It reflects on the importance of staff feeling able to speak up about patient safety incidents and the implications when this is not the case.
It describes the NHS’s current approach to creating a patient safety culture and emphasises the need for NHS England and NHS Improvement, in partnership with the National Guardian and Care Quality Commission, to bring forward robust and specific commitments to drive this work forward.
On the 30 March 2022 the NHS published the results of its annual staff survey for 2021. 648,594 staff from 280 organisations took part in this, providing a snapshot of their experiences of working in the NHS.
This survey provides an important insight into attitudes and feelings towards reporting and acting on patient safety concerns in the NHS and how safe staff feel to speak up on these issues. At Patient Safety Learning we’ve previously highlighted the survey’s results in this regard in 2020 and 2021 and here we consider the most recent results and what they tell us about the safety culture in the NHS. 
The survey asked two questions relating to concerns about ‘clinical safety’, with the following responses:
The 74.9% response rate relating to security in raising concerns represents a positive nearly 5% increase over the last four years, up from 70.2% in 2017. However, given the number of the respondents, this still equates to an alarmingly high number of staff, over 160,000, who felt they could not say that they would feel secure raising concerns about unsafe clinical practice. In other industries, such as aviation and nuclear power, where the consequences of not reporting and acting on safety concerns can be critical, would we find similar results acceptable?
Likewise, it is very concerning that over 40% of staff cannot say with confidence that their organisation would address a concern about clinical safety which they raised. The percentage of respondents who feel that their organisation would address a safety concern that they raised has disappointingly stayed around the similar level over the last three years.
In the formal survey results briefing does indicate that this figure is somewhat higher in Mental Health/Learning Disability and Combined Mental Health/Learning Disability and Community Trusts, where 65% of staff say that their organisation would address a safety concern, up in those Trusts from 59.1% in 2017. Which begs the question, what is being done differently to improve this, and can we take the lessons from these Trusts to apply them elsewhere in the NHS?
Separate to clinical safety, another section of the survey focused on workforce pressures produced the following responses:
These results understandably reflect the significant workforce pressures and staff shortages currently faced by the NHS. Given the responses on clinical safety concerns, it is a serious point of concern that on these issues staff may also feel unable to highlight how these pressures may impact on safe practice. This is particularly concerning in the context of the recently published Ockenden Review into newborn, infant and maternal harm at Shrewsbury and Telford Hospital NHS Trust, which highlighted the serious patient safety impact that shortfalls in staffing can have on services.
The survey asked two questions relating to staff views on speaking up about concerns, with the following responses:
When asking if you would feel safe to speak up about concerns, it is simply unacceptable that 38% of respondents, over 240,000 NHS staff members, felt they could not say that this was the case.
This figure is slightly worse than the 2020 score, where 65.6% of staff answered that they felt safe to speak up about concerns. This decline is reflected in the recently published Freedom to Speak Up Guardian Survey 2021, which reported that “the proportion of guardians who reported a positive culture of speaking up in their organisation has dropped by five percentage points on last year, to 62.8%”.
These figures are a clear indication of the continuing influence of the blame culture in healthcare. This is reinforced by the experiences and testimonies of many whistleblowers in the NHS, and their subsequent treatment when they tried to raise concerns. 
Organisational cultures that seek to assign blame when things go wrong make avoidable harm more likely to happen again. Blame culture incentivises people to cover up errors and avoidable harm, rather than reporting them, and often singles out individuals rather than tackling the systemic causes. Further to this, it is perhaps inevitable but equally concerning that less than half of respondents asked in the survey had confidence that any concern they raised would be acted upon.
The latest Staff Survey results highlight that there are still significant numbers of staff in the NHS who feel unable to report safety incidents, speak up about concerns and lack confidence that these will be acted on by their organisations. It is widely acknowledged that to ensure patient safety incidents are consistently reported and acted on, staff need to feel safe to do so. This clearly is not the case for many NHS staff.
We need to create an environment in healthcare that supports raising, discussing, and resolving of concerns, with incidents of avoidable harm responded to with empathy, respect, and rigour. At Patient Safety Learning we believe that this will involve:
The NHS Patient Safety Strategy identifies building a patient safety culture as one of the two foundations that underline its vision to continuously improve patient safety. It states that:
“Progress on developing a safety culture will be supported by the introduction of the national patient safety syllabus and the designation of patient safety specialists, as well as wider mechanisms. Progress will be monitored through NHS Staff Survey metrics about fairness and effectiveness of reporting, and staff confidence and security in reporting. The introduction of proxy indicators for problematic cultures, such as levels of staff suspension and of anonymous incident reporting, will also be explored.”
The last three years of NHS Staff Survey results indicate that a blame culture continues to persist in too many healthcare organisations, undermining our efforts to improve patient safety and reduce avoidable harm.
The NHS has obviously faced two incredibly challenging years working with the ongoing pressure of the Covid-19 pandemic and now tackling the growing backlog of care and treatment. However, we believe that now must be the time when NHS England and NHS Improvement, working in partnership with the National Guardian and Care Quality Commission, bring forward as a matter of urgency robust and specific commitments to drive forward the work of improving the safety culture in the NHS.
 NHS Staff Survey, NHS Staff Survey National Results, 30 March 2022. https://www.nhsstaffsurveys.com/results/national-results/
 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
 Patient Safety Learning, Tackling the blame culture? NHS Staff Survey Results 2020, 22 March 2021. https://www.patientsafetylearning.org/blog/tackling-the-blame-culture-nhs-staff-survey-results-2020
 NHS Staff Survey, NHS Staff Survey 2021: National results briefing, 30 March 2022. https://www.nhsstaffsurveys.com/static/423ee2faa3495b47585ce70d25dc4a92/ST21_National-briefing.pdf
 Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, 30 March 2022. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2022/03/FINAL_INDEPENDENT_MATERNITY_REVIEW_OF_MATERNITY_SERVICES_REPORT.pdf
 National Guardian, Freedom to Speak Up Guardian Survey 2021, 31 March 2022.https://nationalguardian.org.uk/2022/03/31/2021-ftsu-guardian-survey/
 Hugh Wilkins, Crossword Counterpoint: glimpses of NHS whistleblowing terrain, 16 March 2022. https://www.pslhub.org/learn/culture/whistle-blowing/crossword-counterpoint-glimpses-of-nhs-whistleblowing-terrain-r6284/
 Hugh Wilkins, The right – and duty – of NHS staff to speak up, 22 June 2020. https://www.pslhub.org/learn/culture/whistle-blowing/the-right-%E2%80%93-and-duty-%E2%80%93-of-nhs-staff-to-speak-up-r2340/
 NHS England and NHS Improvement, The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. https://www.england.nhs.uk/patient-safety/the-nhs-patient-safety-strategy/#patient-safety-strategy
 NHS England and NHS Improvement, NHS Patient Safety Strategy: 2021 update, February 2021. https://www.england.nhs.uk/wp-content/uploads/2021/02/B0225-NHS-Patient-Safety-Strategy-update-Feb-2021-Final-v2.pdf