My career spans over 30 years, working either for or with the NHS, in roles varying from head of I.T.; management consultant to a mental health nurse in an assertive outreach team.
I have seen first hand how the wide variation in healthcare organisational leadership styles, links directly to the quality of services, and how this can be improved by reflection and actions on the culture.
The following ‘culture barometer’ is based on my thoughts in the light of the Francis report into the whistleblowing process and recent changes to regulation. It’s designed to be simple, using information which should be readily available and which is less likely to be influenced by ‘spin’ or ‘gaming’. It isn’t designed to give a definitive answer but to enable a picture to be built up, highlighting key areas of success as well as difficulties.
Maybe the best way to use this is to ask organisations to reflect on these measures themselves and then discuss this.
This blog is largely based on personal experience.

1. Compare the organisation’s whistle-blowing policy with a best practice example.

  • Is there support for whistle blowers?
  • What can staff do if they want to complain about member of the Executive Team?
  • Has the organisation signed up to a safety campaign such as the Nursing Times Speak Out Safely campaign or NHS England’s Sign up to Safety campaign.
  • If so what pledges have they made as a result of signing up, and are they keeping to them?

2. Does the organisation have statement/ policy on transparency?

  • Is this open for all to see? (e.g., not just on the intranet)
  • It may be part of the engagement or leadership strategy.

This is how the Freedom to Speak up Report summarises ‘transparency’ (p.208)
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‘Good Practice Transparency (section 7.4)
Transparency for individuals (see also good practice on investigations 6.4)
The findings of any investigation are shared with the person who raised the concern and any other staff involved, redacting or editing only what is essential to respect the confidentiality of other individuals involved.
Transparency by organisations
NHS organisations:

  • collect and analyse information related to staff concerns and triangulate it with information from other sources to help identify trends for further investigation and learning to share
  • publish in Quality Accounts (or equivalent) quantitative and qualitative data about formally reported concerns such as number of concerns raised, action taken and outcome, taking into account patient confidentiality and data protection.
  • share information about formally reported concerns or incidents with disputed outcomes with the NRLS, INO (see Principle 15) and relevant regulators and commissioners.

Confidentiality clauses
Confidentiality clauses are:

  • not automatically included in settlement agreements
  • approved by the CEO to confirm they are consistent with the public interest in transparency and when used written in plain English.’


3. Incident and near miss reports (and outcomes).

  • A low number of reported incidents / near misses is a cause for concern.
  •  Have the incidents / near misses resulted in learning?

4. Number of people having capability assessed; been referred to professional bodies or who have been dismissed (and the outcome).

  • In a medium to large organisation low numbers of people undergoing capability assessments may indicate a failure of accountability.
  • Are staff winning unfair dismissal cases or professional bodies throwing out referrals with ‘no case to answer’?

5. Number of people suspended (or on special leave) and what for

  • Look for ‘bringing the organisation into disrepute’ and follow up what this means.
  • ‘Special leave’ can be used to disguise a culture of fear and preventing people from speaking out.

This is how the Freedom to Speak up Report summarises good practice around ‘suspensions and special leave’ (p.204)
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‘Good practice – Suspensions and special leave
(section 6.5)

  • Suspension of staff involved when concerns are raised is a last resort, where there is no alternative option to protect patient or staff safety, or to maintain the integrity of any investigation or for another compelling reason.
  • Alternatives to suspension or special leave are always considered including restricted practice, mediation and support and temporary redeployment to a non-patient facing role or to another site.
  • A decision to suspend or give special leave to someone who has raised a concern is only taken by a nominated executive director or directors with the authority of the CEO.
  • Any decision to suspend or grant special leave is accompanied by an explicit and recorded consideration of all reasonable, practicable alternatives that have been considered and the reasons
    they were not appropriate.
  • The number of suspensions or special leave resulting from raising concerns and their ongoing justification is regularly reviewed by the board.
  • The number of suspensions and special leave resulting from raising concerns is shared with regulators and used as an indicator by both the board and the regulators to consider how concerns are handled in the organisation.
  • Staff who are suspended or on special leave following raising a concern are given full support in line with Principle 11 in 7.2’.


6. Outcomes of previous suspensions (periods of absence on special leave)

  • It’s not that suspension shouldn’t happen, but repeated outcomes where the person was vindicated could be cause for concern.
  • Are there problem areas?
  • Which staff groups appear most?

7. Content of the (public) Board Meeting minutes

  • How long are the papers?
  • Are they easily accessible to patients and public?
  • How much clinical content?
  • Are key safety issues discussed?
  • Are these discussions fully minuted (e.g. not just ‘there was a lengthy discussion on…’)
  • Are serious incidents and major complaints and plaudits discussed in detail?
  • Are the staff survey results discussed in detail?

Personal views of Steve Turner.
Photo: Amanda Mills

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