Towards a Better NHS

Edmund BurkeThe only thing necessary for the triumph of evil is for good men to do nothing

Confucius – If you know what is right, and do not do it, that is the worst form of cowardice

Martin Luther King – Our lives begin to end the day we are silent about the things that matter

I have listed below a 20-point plan for a better NHS. An article related to this plan, published in the Health Service Journal in August 2018, can be found here. Running a successful NHS could be seen as managing a ‘Triangle’ that consists of Patients, Resources and Staff. There has rightly been a major focus on two sides of the triangle – Patients and Resources, but we must do more for the Staff side of the NHS Triangle.

  1. There should be a major review and overhaul of NHS disciplinary procedures, with an end to the current ‘apartheid system’ in NHS HR procedures – one law for doctors, but another law for nurses, psychologists and other healthcare professionals. Disciplinary panels should be constituted according to PIPE principles –
  •  Plurality (more than one decision maker).
  •  Independence (some members on the panel external to the employer).
  •  Panel training to prevent conscious and unconscious bias and training in principles of investigation (cf. D Simon. (2012). In Doubt. Harvard University Press, and his website, www.indoubt.net).
  • Relevant Expertise, as related to the specific professional, technical, cultural, language, etc attributes of the staff member in question. Where an investigation of a member of staff is conducted on a matter that is serious enough to include the possibility of the member of staff being severely disciplined or dismissed, the investigation process should be carried out according these same PIPE principles.

The outcome of hearings should be subject to PRIME principles –

  • Ensuring that any punishment is Proportionate.
  • Exploring how Remediation could help the individual.
  • Carrying out an Impact assessment of any punishment.
  • Ensuring that Mediation is fairly and thoroughly explored where there are issues of an alleged breakdown in relationships
  • External, expert assessment of these four principles being fairly and robustly implemented.

2. What happened to staff such as Nurse Amin Abdullah has happened to NHS staff up and down the country. Therefore, NHS Improvement together with Trusts should set up independent inquiries into other cases of unfair dismissal and similar management-mediated injustices which have taken place in the NHS over the years. At its inspections, the CQC should examine all cases of staff dismissal for fairness, and for future inspections have this as a rolling feature for new dismissals since the last inspection. Where NHS staff have clearly been victimised by an NHS employer, the CQC should use its powers to fine that employer, with a portion of the fine given as compensation to the victimised employee.

3. There should be a properly funded employment-support scheme for sacked whistleblowers and other victimised NHS staff, in the form of three-year re-entry fellowships, to help them get back into NHS work again. This would also help to give confidence to those who wish to stand up and speak out that if they do lose their jobs there would be properly resourced systems in place to support them back to work.

4. Healthcare regulatory bodies should review guidance for healthcare professionals who take on management roles, and examine those cases of dismissal of healthcare staff where similar forms of unjust management procedures were adopted and where members of those regulatory bodies played a key part in the victimisation of staff. There should be an automatic thorough investigation if the victimised staff member suffered harm or was a whistleblower.

5. There should be a review of the selection and training of NHS managers, and the establishment of a regulatory system for NHS managers. They remain the only healthcare professionals who are not subject to any form of regulation, and this inexcusable flaw in the system needs to be rectified. Chief executives should sanction every case of a dismissal of an NHS employee and take ultimate responsibility for dismissals.

6. Consideration should be given to the setting up of a Staff Support Commission, since it is clear that staff wellbeing and staff morale, and issues such as those relating to whistleblowing, need a dedicated body, with dedicated expertise and resources. Such a Commission could oversee independent inquiries, such as that carried out in the case of Nurse Amin Abdullah. (See my Health Service Journal article on a proposed Staff Support Commission).

7. It is clear that human factors play a key role in clinical events, and the Healthcare Safety Investigation Branch recognises this by employing staff with Applied Psychology expertise. Psychological factors such as cognitive bias also play a key role in staff-related events, and more generally impact on the morale of the NHS workforce. Every NHS Trust should employ an Applied Psychologist / Human Factors Specialist whose role would be to advise and help investigate both patient safety and staff events, and also advise on issues such as improving staff morale.

8. The Department of Health & Social Care should itself recognise the importance of psychological factors in the NHS by re-instating the post of Chief Psychology Advisor to advise the Secretary of State on such matters.

9. Concerns and protests over the years in relation to major flaws in NHS management systems were repeatedly ignored. If they had been heeded, major distress and suffering to NHS staff and their families, including the suicide of Amin Abdullah, could have been prevented. There should be critical reviews, with external input, of the behaviour of those bodies during those years – Dept of Health & Social Care, NHS England, CQC, NHS Improvement.

10. Positive information about Trusts is often more readily available than critical information. On Trust websites, there should be much greater transparency and ease of access to information relating to: cases referred to regulatory bodies and the expenses incurred, cases of suspension or dismissal and the expenses incurred, compromise agreements and the amounts spent, cases that have gone to employment tribunal and expenses incurred, cases that have gone to the High Court and expenses incurred, litigation/compensation cases and expenses incurred, patient complaints, adverse clinical episodes including ‘Never Events’ (serious, preventable patient safety incidents),incidence of bullying and discrimination as indicated in NHS Staff Surveys, etc.

11. Conscious or unconscious cognitive bias contribute both to failures in patient care and mistreatment of NHS staff. All healthcare professionals, from doctors and nurses to chief executives and HR directors, should have training in the psychology of human bias. The more senior the role of the healthcare professional the more intensive and the more frequent should be the training that is put in place. Appointment and disciplinary panels should have dedicated forms of this training. (See my BMJ article on unconscious bias).

12. The Fit and Proper Persons Regulation (Regulation 5) has clearly been a failure, and the current review (‘Kark Review’) of the regulation is to be welcomed. The Care Quality Commission must take some responsibility for failing to implement that regulation properly. As well as a much improved regulation, there needs to be a review of those cases submitted to the Care Quality Commission where they failed to take any action against directors about whom concerns were raised.

13. The National Guardian’s Office, set up to deal with whistleblowing in the NHS, although well-led, appears to have made uncertain impact on patient safety or staff wellbeing. Its role, funding and independence from other NHS bodies should be subject to a major review.

14. The Health and Social Care Select Committee of the House of Commons should give greater scrutiny to issues that affect staff wellbeing and issues relating to NHS management.

15. Hospitals in Britain were once inspected by teams from professional bodies such as Royal Colleges, but these inspections were replaced by those carried out by regulatory bodies. Those accreditations by professional bodies should be reinstated and appropriately coordinated with inspections carried out by the Care Quality Commission (see my BMJ Article on accreditation).

16. The Public Interest Disclosure Act (1998) is 20 years old and needs to be reviewed in the light of NHS inquiries and developments over this period, and concerns which have been raised about its effectiveness in supporting whistleblowers.

17. The Law Society and the Department of Health & Social Care should jointly review the role of the legal profession in issues relating to the NHS. This should examine not only the vast amounts paid to lawyers, but issues such as  training of lawyers in NHS matters, their training on the role of unconscious bias and motivational reasoning in health-related legal settings, showing compassion when NHS employees are cross-examined by lawyers in court, etc.

18. There should be a fund to support NHS staff in distress who are in financial need or have suffered major financial loss, for whatever reason – illness, bereavement, loss of income in the context of whistleblowing, legal costs in employment tribunals, etc.

19. There should be an award scheme for NHS whistleblowers who have shown the courage and self-sacrifice to stand up and speak out.

20. BME staff and former whistleblowers should have greater representation in senior positions in the Department of Health and Social Care.