I submit this evidence in a personal capacity but have current and past roles that inform my submission. As a junior doctor and trainee orthopaedic surgeon, I have been involved in the British Orthopaedic Trainees Association (BOTA) since 2014, first as its Education representative, then as its Vice President and its President; I am now its Immediate Past President. During my tenure as President, I launched and promoted the #HammerItOut campaign, which focuses on negative workplace behaviours such as bullying, undermining and harassment within both Trauma and Orthopaedics, surgery and the wider NHS. This work has sparked a movement which has been picked up by other Royal Colleges, specialist societies and trainee organisations. It was the focus of a TEDxNHS talk and the National Academy of Sciences (Washington DC) invited it be presented there, as an example of how to bring about change in healthcare. In my capacity as Vice Chair of the Academy Trainee Doctors Group (ATDG), and with the success of the #HammerItOut campaign, has lead to my recent role, as lead for launching further work via the Academy of Medical Royal Colleges. Our work has seen these issues rise to the top of agendas, as well as beginning to create a culture where people feel they can and must speak up and a drive for creating a safer NHS. I am submitting evidence as I believe that for the goals of the HSSIB to be achieved in full a meaningful culture change needs to be brought about, with both cultural and legislative change, empowering a safer and kinder NHS for staff and patients alike.
The HSSIB will struggle to command the confidence of patients and their families, as well as the staff unless it can be shown to not only have teeth, but to be a transparent process, based in truly improving both patient safety and the NHS as an institution. While there is any feeling that it will be used for blame or more “targets”, it will find it difficult to get buy in from the stakeholders it so desperately needs to engage. The HSSIB will need to be seen by patients, their families and staff alike, to be part of a "just culture" whereby those in the NHS are not punished for actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated. The issue here being that the in the 2016 NHS staff survey, for example, the percentage of staff experiencing harassment, bullying or abuse from fellow staff was approximately 25% and 11% of staff said they had experienced discrimination at work in the past 12 months. This will make a belief that a new bill will make any real “shop floor” difference, challenging at best.
I believe the HSSIB must include private healthcare as well. As the line between private and NHS blurs, with NHS patients being treated in the private sector, we must see patient care and healthcare culture as a homogenous thing. The ability to afford (or not) private care should not impact on whether one experiences, or works in a safer, or less safe environment.
In terms of whether patients and the public might be confident in regards ‘safe space’ investigations will remedy issues in the current complaints mechanism, the HSSIB will need to demonstrate, and deliver some real change. This again, is primarily cultural in nature – both patients and staff alike need to be shown that the goal is improving care, creating a safe and positive NHS, not blaming or punishing. It should also be clear that making a complaint is a good thing, if the aim is one of growth and learning, not, for example, seeing heads roll or “jumping the queue”.
The issues around whether a legally protected ‘safe space’ is necessary to successfully undertake NHS investigations is inextricably linked to whether creating a ‘safe space’ for safety investigations will “encourage patients, families, NHS staff and other participants to speak freely. A legally protected safe space is not synonymous with a culturally psychological safe space, where people, either staff or patients feel they can be open and honest.
A psychological safe space, as well as one created by the HSSIB is needed if the outcome is both learning and patient safety; this kind of space is challenging to create in the current climate within the NHS. In 2015, the General Medical Council (GMC) National Training Survey (NTS) found that 7% of doctors in training reported having experienced undermining or bullying behaviours themselves; 13% said that they had witnessed such behaviours and 17% felt they had been undermined by senior colleagues. In the 2016 survey, the numbers were similar and 1 in 20 doctors in training said they had a bullying or undermining concern but did not wish to report it within the NTS. The GMC acknowledges that they believe that even underreporting is, itself, underreported.
In the 2016, the British Orthopaedic Trainees Association (BOTA) undertook our own Census; 43% of trainees stated that they had witnessed a colleague being bullied in their Trauma and Orthopaedic (T&O) post; 7% reported that they themselves had been the victim of bullying. 70% of trainees had witnessed a colleague being undermined with 25% reported having felt undermined themselves in the last 4 weeks. The work by BOTA led to a much larger piece, run by the Joint Committee on Surgical Training (JCST), BOTA and the Association of Surgeons in Training (ASiT). This found that, across the surgical specialities, 25% of trainees feel negative or very negative about their future, 60% had witnessed or experienced these negative workplace behaviours, with sexism, racism and homophobia featuring heavily. 69% did not report experiencing and 75% did not report witnessing bullying, undermining or harassment.
International data, looking at Brazil, Canada, Germany, Spain, France, Italy, the USA and the UK showed an average rate of 65% experiencing bullying, harassment or undermining in healthcare, with the UK scoring higher than many.
Reflecting on this, when asking if the HSSIB will be able to create these spaces, to effect change, as well as whether or not there are safeguards in place for those referred to in said investigations, I feel it is vital to work towards much wider culture change. To effect change and ensure recommendations are enacted, the NHS (and wider healthcare) needs to be a culture whether the power gradient and hierarchy is flatter. Where there is a power gradient, a blame culture and a culture of silence, as well as a belief that making a fuss will have negative career impacts while not making a real difference, it will be challenging to focus on learning and patient safety. A focus on wellbeing, of both patient and staff, including support for those referred to in the investigations, will be vital, so that an investigation is seen as a good thing, rather than a witch hunt, associated with feelings of blame or isolation.
The NHS has a problem with a negative workplace culture, and bullying, harassment and undermining all have the potential to impact upon doctors and allied healthcare professionals of all levels as well as the care that patients receive.
The problem is large and likely underreported; Healthcare needs culture change and systems change and the HSSIB is in a position to help facilitate bringing this about.
Mr Simon Fleming MBBS., MRCS. M.Sc, FRSA, MAcadMEd, MASE(RACS), MFSTEd, AFHEA
Immediate Past President, British Orthopaedic Trainees' Association
Specialist Registrar Trauma & Orthopaedics, Percivall Pott
Vice Chair, Academy Trainee Doctors' Group (ATDG),
Chief Resident, International Conference on Residency Education (ICRE)
Ph.D Candidate, Medical Education, Barts and The London, Institute of Health Sciences Education
8 June 2018