NHS Leadership, Performance and Patient Safety

The House of Commons Select Committee on Health and Social Care is examining the relationship between leadership in the NHS and performance/productivity as well as patient safety.

Prof Joy Warmington, brap CEO and Middlesex University Visiting Professor of Education, and Roger Kline, Research Fellow in the University’s Business School, submitted written evidence to the review arguing:

• Incivility and patient care and safety are intimately linked.

• Black and minoritized ethnic (BME) staff are particularly vulnerable to incivility and discrimination.

• A range of evidence shows BME staff are less likely to raise concerns, less likely to be listened to and more likely to be victimised if they do so

• Research consistently shows two main reasons why people do not raise concerns are, first, a belief that if they do the matter would not be rectified; and second, a fear of retaliation

• NHS boards must develop greater curiosity about the behaviours of staff, and be less concerned with reputation management

• A culture of openness can be cultivated by tackling the fear that makes (BME) staff reluctant to speak up and by being proactive and preventative rather than waiting for individual staff to raise concerns

You can read the full submission on the Committee website here.

Here's a quick summary:

What is the link between incivility, bullying, and patient safety?

Bullying and incivility are a common feature in almost every single independent review of systemic patient harm from Bristol to Francis to Ockenden. Thus, evidence commissioned by Lord Darzi (2008) concluded “the NHS has developed a widespread culture more of fear and compliance, than of learning, innovation and enthusiastic participation in improvement.”

Bullying and incivility impair patient safety for two reasons. Firstly, disrespect in medicine is a threat to patient safety because “it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices.”

Studies on incivility have concluded that:

• incivility erodes self-esteem, damages relationships, increases stress, contaminates the work environment, and may escalate into violence

• rudeness has adverse consequences on the diagnostic and procedural performance

• incivility has a negative impact on performance. Multiple areas can be impacted including vigilance, diagnosis, communication and patient management (even though participants may not be aware of these effects)

Secondly, bullying and incivility undermine inclusion and psychological safety. When either are impaired staff may be less willing to raise concerns or admit mistakes and both adversely impact communication. Research on adverse patient safety events found communication failure was the primary cause for medication errors, delays in treatment, and surgeries at the wrong site and the second leading cause of operative mishaps, postoperative events, and fatal falls.

Dixon-Woods et al (2014) noted that: “Managing staff with respect and compassion (is important) since doing so correlates with improved patient satisfaction, infection and mortality rates, CQC ratings and trust financial performance.”

Similarly, Dawson (2014) found that there is “a strong negative correlation between whether staff report harassment, bullying or abuse from other staff in the NHS staff survey and overall patient experience”. An environment of bullying and incivility is likely to deter staff from admitting mistakes or raising concerns.

Why are BME staff deterred from raising concerns?

Research consistently shows two main reasons why people do not raise concerns: first, a belief that if they do the matter would not be rectified; and second, a fear of retaliation. Thus, Sir Robert Francis (2015) found NHS staff in general may be reluctant to speak up because of fear of being:

• blamed or scapegoated

• discriminated against

• disbelieved

• seen as disloyal

• seen as disrespectful in a hierarchical system

• bullied

• and the wider consequences for their career

In their most recent report, the National Guardian’s Office (2023) found that:

• Almost two-third of respondents (66%) identified futility (i.e., the concern that nothing will be done) as being a 'noticeable' or 'very strong' barrier to workers in their organisation speaking up and this was an 8% increase compared to responses in the previous survey (58% 2021).

• Two-thirds of respondents (66%) identified retaliation/suffering as a result of speaking up as being a noticeable or very strong barrier to speaking up.
  

Research has reported the importance of hierarchy as a deterrent to raising concerns and BME staff are more likely to be found in junior and middle grades – or as agency and contractor staff – than White staff.

In research beyond the NHS, but including NHS respondents, Reitz and Higgins (2020) reported that respondents rated their own likelihood of speaking up and listening up more highly in most cases than they rated others. In other words, they felt that they spoke up and listened up, but others did not: a “superiority illusion”. Reitz found 88% of senior respondents said that race never or rarely affected how they listen to others. Ninety per cent insisted gender did not affect how they listen. The researchers comment:

“This is highly unlikely to be the case. Just because we don’t want these things to get in the way, doesn’t mean that they don’t. Leaders must face up to their own unconscious bias—one way to do this is to really notice their response to different people as they speak up.”

Hierarchy is compounded by the patterns of discrimination whereby BME staff are:

• more likely than their White colleagues to be bullied by their managers and colleagues

• more likely than their White colleagues to enter the formal disciplinary process

• much more likely to experience discrimination from managers and colleagues

What should be done?

A decade ago, research into organisational behaviour in the NHS concluded:

“The NHS exhibits too high a level of collective ego defences and protection of its image and self-esteem, which distorts its ability to address problems and to learn. Organisations and the individuals within them can hide and retreat from reality and exhibit denial; there is a resistance to voice and to ‘knowing’”.

This is exacerbated if the concern raised by BME staff is about racism or bullying. In Too Hot To Handle? (2024) our report found racially minoritised staff face common responses when raising concerns about race equality. These include:

• denial: often staff were subjected to ‘poor behaviours’ but neither managers nor subsequent investigations felt they could name the race discrimination that lay behind these behaviours

• reluctance or refusal to acknowledge race as an issue: connected with the above, employers tend to resist acknowledging poor treatment as race discrimination often, it seems, because of the stigma attached

• minimising of harm: organisations go to great lengths to downplay the impact of racist behaviours

• a lack of empathy: racially minoritised staff do not always receive compassion and understanding when raising concerns. Indeed, it is more common they are met with frustration, defensiveness, and exasperation

In addition, there are common shortcomings in race-related investigations:

• many employers set an unnecessarily high bar requiring staff to prove any allegation of race discrimination was ‘racially motivated’

• tackling racism is seen as too difficult and so is avoided

• the process of raising a concern and the time an investigation takes deters staff from raising a concern

• staff lack confidence investigatory processes and other responses will be fair

These findings correlate with findings from a number of Employment Tribunals we reviewed where BME staff had successfully sued NHS employers over their treatment when raising concerns, notably the successful landmark claim by Michelle Cox, a Black nurse manager, who whistle blew about the treatment of patients and was victimised for doing so.

As part of our response to these findings we critiqued existing approaches to addressing racism, and considered why racism is not better understood and considered what organisations could do if they were serious in their intentions to respond more effectively to both overt and covert forms of racism.

We suggest NHS organisations can create a culture freer from race discrimination by:

• developing an appetite for ‘race talk’ and setting standards of behaviour that challenge ‘everyday’ racism

• developing greater levels of comfort in staff speaking out about racism and ensuring concerns are acted on without retaliation

• acting on the early warning signs of racism by tackling racism more informally and being proactive when evidence would suggest there might be a problem

• imparting the skills that all staff need to get closer to genuine anti-racist practice, with particular development needed for boards, leaders, and professionals whose roles directly uphold the values of their organisations.

Crucially, there needs to be a learning culture where staff can be confident they will be heard, listened to, and their concerns acted on, without risk of resultant detriment. The culture and behaviours – the organisational deafness – of those with authority is the prime obstacle.

This is even more so with BME staff because organisations and managers become more defensive, placing individual and organisational reputational risk ahead of addressing concerns raised by BME staff, engaging in denial and avoidance and focusing on comfort-seeking rather than problem-sensing, even more than they do with staff in general. That is what our survey and the Employment Tribunal cases we considered show, even more so than generic recent whistleblowing research.

We suggest that whilst early informal resolution may be preferred to draw out processes that deter others and damage those involved, where this is not possible there needs to be assurance that attempts to prevent workers (including agency and contractor staff) or patients/relatives raising reasonably held beliefs about patient safety and worker wellbeing (including race discrimination), or any attempt to cause detriment to any such individuals, is regarded as gross misconduct. Boards need to end the protection and recycling of individuals engaged in race discrimination.

Doing so will make a very significant contribution to patient care and safety, alongside a recognition of the detrimental impact of unchallenged racism on NHS staff of BME heritage. We urge you to make explicit recommendations about this issue, far too long the subject of avoidance, denial, and collusion to the detriment of patient care and safety, organisational effectiveness, and staff health and wellbeing.

Full references are available in the complete submission. You can view the submission here or download a pdf below.

HSCCommittee WrittenEvidence KlineWarmington.pdf

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