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Interview: How do we fix speak up in the NHS? With Georgina Charlton

After the shocking findings of the Ockenden Review into the Shrewsbury and Telford NHS Trust about the state of maternity services, many have questioned the merits of the whistleblowing system in the NHS and demanded change to improve patient safety and workplace conditions. For World Whistleblowers’ Day, our CEO Liz Gardiner interviewed Georgina Charlton, a former FTSU Guardian to discuss the poor speak up culture in parts of the NHS and share ideas on how to bring about positive cultural change

Liz: As a former FTSU Guardian, how deep rooted would you say the issues facing the NHS are and what would you say were the main challenges the NHS faces when it comes to preventing victimization and the blame culture issues that we hear so much about?

Georgina: The NHS has been subjected to a prolonged period of pressure, accelerated and deepened by the pandemic. These include pressures generated from our regulators around financial and performance targets. Of course, some of these were also prior to the pandemic but many organisations are seeing  internal pressures such as high vacancy rates and staff sickness.

When you combine all of these operational and financial pressures with an exhausted workforce struggling to feel valued and motivated then unfortunately that’s where poor behaviours start to bubble to the surface. My reflection is that they become more prominent in more recent times. I’m not saying that these behaviours weren’t there before the pandemic, but they have certainly become more visible.

There is a growing pool of evidence that demonstrates the damaging and negative impact of poor and uncivil behaviours on patient safety and staff morale. There’s a great bit of work being done by the project called ‘Civility Saves Lives’ which highlighted how acts of incivility have huge effects on recipients and bystanders including a significant reductions in their cognitive functions and quality of work. We need to acknowledge this and take action in calling out when poor behaviours occur.

I empathise with middle managers within the NHS, having to respond to the top-down pressures of an organization both internal and external and the bottom up frustrations from staff. All this pressure meets in that middle and often falls on the heavy shoulders of middle managers who are doing their best during these challenging times.

I was a speak-up guardian for four years in a large and complex organization and my experience is that when it comes to victimisation there is a spectrum from being really obvious to be extremely subtle, but both are still damaging to those who are subjected to these acts . Victimisation can be as subtle as giving people less favourable shifts on a rota and sometimes people don’t even know that they’re doing it.  At times I do think that victimisation can be unconscious and therefore even more important to challenge when this is seen and felt.

So yes, we have to be open about what victimization looks like in practice. This is why I helped Protect develop the Preventing Whistleblower Victimisation guide for employers, which tried to articulate a little bit about that and clarify what we mean when we say words like victimization and detriment as it means different things in different organizations. I think it’s really important that we are open about what that looks like in reality.

There are difficulties with challenging and toxic culture, I like to describe culture as the written and unwritten rules of an organisation or a team.  The written elements of a culture are really important to have like a whistle-blowing policy but it’s never enough on its own.

However we need to reflect on the unwritten rules, You have to ask, what is happening in reality? What is happening in teams and what is that lived experience and narrative that goes with that so that. I speak to teams where somebody raised a concern and they were treated differently. As a result of this everybody else in the team is discouraged from speaking up. There may be a policy but the actual culture that’s underpinning that can be an automatic shutdown if its hostile to whistleblowing. In situations like that I’m sure there will always be individuals who think ‘oh I don’t think I can do that because look how this person is being treated’.

Equally, it’s important to say that not all parts of the NHS have a negative speak up culture. In those workplaces that have got it right speak up has such a positive impact. If someone raises a concern and they feel listened to and they can see the action was taken that sends that ripple effect out to the team actually it’s okay to speak up here. We all have the same purpose in healthcare and other sectors to do the right thing for the people that we look after and we care for so why would you not want to know if something’s not going to plan.

I always quote at this point something the aviation industry talks about which is that ‘speaking up should be seen as a gift, a valuable gift of information. It should be seen in a positive light rather than a negative.

 

Liz: Now that’s a really powerful thought as well that you you’re bringing a gift of information but in return the employer has to be a good receiver of bad news because quite often you know almost inevitably whistleblowing raises something that’s really hard for employers to hear. It’s a natural human reaction to respond badly to criticism and we need to explain to people the importance of listening and the impact that can have. What would your top tips be for employers if they’re starting on this journey to change how they respond to people speaking up. What first steps would you get an NHS trust to take? 

Georgina: There’s so many good top tips I feel like I can share having done this for a period of time and also led the London region of Speak up Guardians.

Having a safe, independent and impartial person within an organisation where you can go to raise concerns is really beneficial and this role in the NHS has been mandated since 2016. The independent person helps provide protection and confidentiality for whistleblowers. Sometimes I’ve raised concerns on behalf of individuals anonymously and it can really act as an additional layer to protect whistleblowers from victimisation. Having an independent person to speak up to also sends a really strong message to staff that speaking up is really important and welcoming and that the organisation is putting resources into supporting that cultire

However just having an individual speak up guardian isn’t enough in large organisations. A guardian is just one person and it often becomes too much to handle alone.

So, what did was build a team of what we call ‘speak up advocates’ and ‘inclusion agents’ which are people that sit within teams and departments who have had special training about how to raise concerns including how to connect with the guardian. Employees need to have people that are approachable and that they feel safe talking to. The idea is that not only do you have this individual who sits and works at a senior level you have people infiltrated all the way down to the front line.

Another thing I suggest is multidisciplinary speak up training rather than training just management. The recent Ockenden Review of maternity services in Shrewsbury made very difficult reading about the speak up culture there, but one of the recommendations in the report was that there should be multi-disciplinary training. This is something that I did a couple of years ago within a clinical service where I taught how to escalate concerns and respond to concern, but the critical thing is that it was multi-disciplinary so you have staff that are speaking up, alongside those that are going to answer concerns in the same room.  This style of training helps agree a common language for speaking up and a collective agreement to welcome this in the team. It’s obviously great to train managers on how to handle speak up concerns but it’s much better to also train the people that may be speaking up with a training which is more Inclusive. I’ve have personally seen real benefits.

Similarly, employers should also look to increase the visibility and accessibility of speaking up and to try to promote a more humane response. Every PC and laptop in my organisation has details of how you can speak up on there permanently. Every so often you’ll see a photo of the speak up guardian on computers and also permanently on notice boards throughout the hospital. Staff who want to speak up are no longer just contacting a faceless email address or phone number but can see the name and a face bringing a more human approach to speaking up.

Capturing information in every part of your organisation is key, so that you can collate a proper picture of your speak up culture.  The NHS has annual staff surveys and pulse surveys that help build a picture on speak up culture but also the Speaking up guardian keeps a log of concerns raised to look for key themes and learning from the organisation.

I also want to emphasise the important of the integrity of senior leaders and I always quote Brené Brown when I talk about integrity. She says, “Integrity is choosing courage over comfort; choosing what is right over what is fun, fast or easy”. If you can get this behaviour at all levels of leadership within an organisation it has so much opportunity to bring a positive impact.

Finally, Psychological safety I think is absolutely critical in teams to bringing together a respectful and trusting working environment where they feel included and where they can bring their whole selves to work.

We need to create that learning environment that it’s okay to make mistakes and learn and to also challenge when things aren’t right. The Aristotle project at Google concluded that psychological safety was a key pillar of creating really highly effective teams.  But creating psychologically safe environments is a long game but absolutely worth the commitment as these environments tend to be more effective and productive with better outcomes for the service users.

So, I have shared a whole array of different top tips and ideas that depending on your organisation and what resource you have can be adopted.

 

This interview was adapted from our World Whistleblower Day Webinar on 23 June. You can view the full video here.

 

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