To hear and be heard: will whistleblowing achieve culture change?

Culture is such a difficult thing to pin down, isn’t it? Yet we can’t help but contribute to it in all that we do and don’t do – ‘what we walk by we tolerate’ as they say. But while we can’t help but contribute to culture, the act of changing it – creating it – is more difficult. 

In our leadership development programmes at the Fund we are explicit in our view that one of the primary tasks of leaders – perhaps the single most important task – is to create the right culture. In a health care context this means creating the conditions in which high-quality, compassionate care can flourish – and it’s a collective responsibility. In my work with leaders I have never once had this view challenged. 

Yet here we are, two years after Sir Robert Francis published his findings into the failings at Mid Staffordshire NHS Foundation Trust, getting to grips with his latest report on the need to support staff who speak out about poor-quality care. This is in the same week that the Ombudsman and Healthwatch have shone an uncomfortable light on how the NHS deals with patient complaints

Secretary of State for Health Jeremy Hunt has made his response clear, emphasising the need for greater transparency, protection for staff who whistleblow and a renewed focus on changing the culture in the interests of patient safety.

Providing more training for medical students in raising concerns would definitely be a step in the right direction. Our own work with emerging leaders suggests that they frequently find themselves at a loss to know how to best escalate a concern or risk. Equally I can think of very experienced clinical leaders who have found themselves inexplicably silenced by the fact that they don’t know how to navigate the organisational bureaucracy when raising concerns over aspects of care within their own service, for which they are directly accountable. The experience seems to leave many feeling angry, anxious, powerless and professionally compromised. 

This week’s reports have been accompanied by the usual statements about the actions that will need to be taken by organisations at a local and national level. But the emphasis from both Robert Francis and the Secretary of State on getting the underlying culture and expectations of behaviour right (not just the processes) is very positive. In Francis’s own words, his recommendations ‘are largely about doing better what should already be done’. My hope is that this time we don’t once again hit the target but miss the point. Culture change is about tackling something that is deeply ingrained. 

I think fundamentally it is about power – how power might be used to enable rather than constrain and how it can be shared to ensure leadership and expertise are aligned at every level, as our approach to collective leadership describes. However, conversations about power aren’t easy.

Re-reading my colleague Nicola Hartley’s blog on whistleblowing shortly after the publication of the Francis report in 2013 got me thinking again about this issue. A glance at this week’s headlines on the banking sector reveals once again the extent to which whistleblowers can divide opinion – hero or villain? What do we give away to the whistleblower in terms of our own power and sense of collective responsibility? The health sector abounds with examples and careers lost or sacrificed in the name of patient safety. But, as Nicola writes in her blog, by the time it gets to whistleblowing isn’t it already too late? Surely there must be a better way?

On one level the act of whistleblowing could be seen as a last-ditch attempt to be heard. At a more existential level I see it more as a primitive, distressed cry for help. In this context the ability to hear that which might be difficult – sometimes even unbearable – seems to me to be a key leadership practice for leaders at all levels who are serious about culture change. It’s the very antithesis of the collusive avoidance of responsibility described by Isabel Menzies-Lyth and would mark a real shift to the genuine sharing of collective leadership responsibility for organisational success described by my colleague Michael West. Collective leadership is necessary to really listen and learn from the experiences of patients and service users, but applies equally and importantly to really hearing the experiences of staff. 

How do we create cultures in which it becomes possible to hear and be heard and without resorting to a whistle. It’s that simple. Isn’t it?

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Comments

#542241 Roger Kline
research fellow
middlesex university

Mathew. Hard to disagree with most of what you say but it doesn't really address what happens in the NHS in the next year , or indeed much longer, until we create a better leadership and workplace culture.

The institutional and cultural barriers to safe care are not difficult to understand but for reasons you touch on - and there are othe5r4s - some of these turkeys are not going to vote for Xmas.

So what should be said to staff now - those who raise concerns, those who don't as they are afraid and those who have raised concerns and had their careers destroyed?

We should indeed work for culture change, but what do we also do in the next couple of years and more to limit damage to staff and patients?

One final point. The current NHS culture and its approach to whistleblowing is, as in many other things, especially sharp for BME staff as Francis recognises. Time to recognise and act on that too.

#542579 Matthew Rice
Senior Consultant
The King's Fund

Thank you Roger. I don't disagree with anything you've said. There is much for the system to do in this area. We will continue to work with you and others to ensure that the issues for those staff and patients from black and minority ethnic groups are recognised.

#542717 John Bamford
Patient Safety Campaigner
Private individual trying to make a difference

Agree with Nicola Hartley's blog that if left to whistleblowers its a sign that the culture in an organisation is not the open transparent culture that is needed to empower and enagage Staff. The cultures set by leaders both at Organisational level and local Workface level is critical. It's Staffs' perceptions of what their boss wants them to do based on how the boss reacted to difficult situations in the past which influences Staffs' behaviour.
I'm privately funding some engagement and culture change work at Blackpool and Wrightington, Wigan and Leigh Hospitals. The approach, called Talksafe, has a big evidence base from work in Industry. One of the best ways of changing culture is by face to face conversation and enquiry. Praising Staff when they are doing the job right. Asking Staff where they are not doing the job right why they feel they have to do it that way. Early days but a promising start.

#542874 Barbara Bradbury
Director
Halland Institute

It would help if CEOs and Board Directors were not just fixated on the numbers - finances seems to be the key driver.Of course, the finances are important. However, the business of the NHS is Health Care. The service used to revolve around the professionals. Now, that focus has changed to general management. A client of mine, clinician by background with responsibility for safe guarding and quality, summed it up well the other day: "I am never going to work again for a Director of Quality who does not have a clinical background". After two very bad experiences, reporting into people who, I would assert, hold one of the most important positions on a HEALTH SERVICE Board, i.e. the ultimate accountability for quality of patient care, it does not make sense to me to be appointing people who do not know how to provide high quality patient care. Worse still, do not listen to those who do, for fear of losing face.

I, too, stress on leadership programmes the importance of culture and distributed leadership. The reality is that too many managers are inexperienced and, subliminally, fear being exposed by their subordinates. Instead of working with them, they set themselves apart from them by their lack of ability to engage appropriately. If they had the skills to develop their staff, build high-performing teams and lead by exemplary role-modelling, we wouldn't need to be discussing this issue.

#545785 Jennifer Brown
was night carer in LA reidential home
No organisation just an unfairly dismissed whistleblower

Every time whistleblowing is described as something different to raising concerns but as something which happens only when those concerns are ignored damages the concept of whistleblowing for good! Where leadership is good and concerns are listened to and acted on whoever blew the whistle can just get on with their work no stress no need to keep passing concerns up ladder etc. Whistleblowing is not just what is brought to the public attention; it is concerns raised by any employee who witnesses a problem (not only abuse etc.) and discloses it to their employer. A whistleblower is not just an employee who has not been listened to or suffered detriment from employer; to insist employees who raise concerns which happen to be acted on are anything other than whistleblowers is a way of somehow devaluing the act of raising concerns as though "whistleblowing" is a shameful act. A whistleblower is a right thinking employee who cares, raises concerns and who wants their employer to act in the public interest by listening and taking action! Good employers value employees who shine a light on problems by drawing them to their attention. Bad employers will act against any employee who raises concerns as cover up and reputation is more important than actually sorting out a culture which allows wrongdoing to persist. The latter causes whistleblowers to become newsworthy! The last thing a whistleblower wants is that. So please take on board a whistleblower in the news is no different from the whistleblower who's concerns were acted on appropriately they just had to keep disclosing higher and higher up the ladder until finally they may have had to go to regulators ombudsmen or even the media. Of course if treated so badly because they could not be silenced when concerns were not acted on they find themselves suspended and dismissed and have to try and find redress in the Employment Tribunal that is another way their actions become media news even if they had not gone to them before. We whistleblowers want action to be taken not notoriety!

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