By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist 28 May 2017
Staffordshire and Stoke on Trent Partnership NHS Trust (SSOTP) was held up as an example of good whistleblowing practice by Robert Francis in his report of the Freedom to Speak Up Review 1, but there is now evidence that the trust has withheld evidence of whistleblowing failures.
After the publication of Francis’ report of the Mid Staffs Public Inquiry in 2013, it was announced that SSOTP would employ Helene Donnelly, who was formerly a nurse at Mid Staffs, as a Cultural Ambassador to facilitate the positive resolution of staff concerns. 2
Donnelly gave evidence to Francis’ Public Inquiry about falsified A&E waiting times at Mid Staffs, and reported that she suffered reprisal as a result of raising concerns:
Donnelly gave a detailed interview to the local press about how she intended to approach the Cultural Ambassador role:
“I’m not a corporate person who’s just going to tell the Trust what they want to hear,” she says. “I’m not going to help them sweep things under the carpet. And I think, given my history, they know I’m not going to do that! I hope that message gets out to staff, that I’m not just a tick box, I’m real and I’m here and I’m trying to highlight issues and promote the importance of people speaking out.” 3
In June 2013, Donnelly wrote positively about her role in the Nursing Times, and reported:
“My chief executive has been very positive about wanting to know if things are not right for staff, especially if patients could suffer as a result.” 4
In December 2013 the local press reported that she had been awarded an OBE for her role as Cultural Ambassador. 5
Donnelly was later listed as an advisor to the Freedom To Speak Up Review 6, and accompanied Francis on the day that the Freedom to Speak Up Review was launched. She has maintained a high profile and features in a promotional video that the National Freedom to Speak Up Guardian has asked local Speak Up Guardians to promulgate. 7
Transcript of some of Donnelly’s comments from the promotional video:
“Throughout all that experience, it became very clear to me just how difficult it is for people to speak up and how unsupported they are when they do and also how intimidating it is and how vulnerable you are.
So through that I developed the ‘Ambassador for Cultural Change’ role which is essentially a Freedom to Speak Up Guardian.”
“Whilst the trust will employ the individual Freedom to Speak Up Guardian, they still do have a responsibility to act independently of the trust, and they will have an accountability to take concerns outside of the organisation if necessary.”
“…it just takes one person to be brave and step forward and others will follow.”
“…you want to know that things have been put right as a result and what the learning is.”
“Culture change does take a long time but you’ve got to start somewhere. I think these Guardian roles are a very good place to start.”
“I remember when I was giving evidence at the public inquiry, Sir Robert actually asked me why did I speak up and was it my awareness of my professional duty. And actually I said as my evidence: Of course I was aware that I had a professional duty to speak up as a registered nurse, but it was much more than that. It was a moral duty and it was my moral code that was telling me you can’t let patients suffer.”
Francis claimed in his Speak Up Review report and at the report’s launch that SSOTP’s employment of a Cultural Ambassador was a success. This was despite the fact that there had been no evaluation and there was in fact no evidence of success other than a reported rise in staff contacts.
I have previously described this lack of evidence of effectiveness:
But as we know, the NHS establishment has a fetish for hype and fads. Other trusts rushed to copy SSOTP’s model on the basis of SSOTP’s of un-evaluated claims. 8
Despite the lack of evidence, Francis relied on SSOTP’s example to propose a national network of Speak Up Guardians. 9
The National Freedom to Speak Up Guardian herself acknowledged at a meeting in February this year that there was no evidence base for the Speak Up Guardians. 10
Despite this, her office later claimed in a publication that Francis’ Speak Up Review recommendations were all evidence-based. 11
When I objected 12, the National Guardian conceded that the use of the term ‘evidence-based’ (generally accepted to mean medical practice based on good quality research and meta-analysis) had been inappropriate and agreed to withdraw the claim. 13
That is, there is effectively an official admission that Francis did not base his proposal for Speak Up Guardians on much more than anecdote and opinion.
Moreover, it is now clear that not only is there lack of evidence that Francis’ exemplar is effective but that there is evidence to suggest that SSOTP’s model is unreliable.
In 2014/2015, SSOTP staff made external whistleblowing disclosures about unsafe staffing and patient safety to the media and to the Care Quality Commission (CQC), claiming that trust managers had failed to act on warnings.
Extensive information was available from a leaked trust dossier about the strains that staff were subjected to, and the harm and risk that befell patients. For example:
“…. finished a shift with dying patients in Werrington, Endon, Biddulph, Newcastle and Woore still waiting for pain relief”
“…diabetics have been left without medication to control their illnesses”
“…patients receiving incorrect drug doses and people being woken up at midnight for their medication”
“I felt unwell most of the day because of an increased workload. I felt stressed and anxious and was worried my work would not be completed during my shift. I went to A&E and was advised to rest to decrease my stress levels and reduce anxiety and stress at work.”
The trust staff who raised concerns were vindicated when the CQC later confirmed that staffing levels were inadequate and issued the trust with a warning, which included a need to improve compliance with the Duty of Candour:
“…we issued the trust with a warning notice served under Section 29A of the Health and Social Care Act 2008. The warning notice related to consent, systems to assess, monitor and mitigate risk, systems to assess, monitor and improve the quality and safety of services and Duty of Candour.” 16
Arising from this inspection – carried out in November 2015, a mere seven months after the publication of Francis’ report of the Freedom to Speak Up Review – the CQC also rated SSOTP as ‘Inadequate’ on the well-led domain. 16
The CQC reported:
“In 2014, three whistle-blowers independently contacted the Care Quality Commission (CQC) to share concerns about the trust. Specifically, they raised concerns about a poor leadership culture; unsafe staffing levels and, resulting from this, patient safety.” 16
Far from being the listening organisation that it was painted to be, staff felt let down by the trust:
“Staff morale in community adult nursing services was low. Staff told us they felt despondent, demoralised, frustrated and let down by senior managers”. 16
Importantly, the CQC noted that there was negative feedback from some staff about the Cultural Ambassador service:
“The Staffordshire and Stoke on Trent Partnership NHS Trust created a role of ‘Ambassador for Cultural Change’. This innovative role was designed to allow the staff voice to be heard and concerns from staff to surface in a way that focused on the topic rather than the individual, protecting the identity of any staff member wanting to remain anonymous. This initiative received significant national attention. We saw that not all staff were happy with this role. They were often guarded and concerned they might not have the full protection promised. While some staff engaged with the Ambassador for Cultural Change many felt that the actions from this did not follow on as expected.” 16
When I asked SSOTP for data on staff disclosures to the trust’s Cultural Ambassador since she has been in post, the trust responded partially, arbitrarily omitting data for part of the period December 2014 to May 2015. This period for which SSOTP failed to supply the data in fact covered the months in which staff concerns about unsafe staffing escalated.
SSOTP breached its legal requirements under the FOIA by giving no valid reason for withholding this data. The trust, including the chief executive, did not reply to two reminders to provide the missing data.
I made an update request about staff disclosures to SSOTP’s Cultural Ambassador and again asked the trust to provide the data which it withheld. The trust finally disclosed the missing information.
This is correspondence with the trust CEO and disclosures by the trust:
Overall, the data shows that a total of 629 concerns have been raised with the Cultural Ambassador since she took up post in April 2013, and that 110 of these concerns related to staffing levels.
The trust disclosed data in irregular tranches but it is possible to see that there was a steady escalation in the level of staff concern about safe staffing throughout the period in which the Cultural Ambassador had been in post, until staff could stand it no longer and some of them whistleblew externally.
After the issues were exposed and regulatory action was taken, there was a reduction in the number of concerns about staffing:
Yet in June 2015, the SSTOP newsletter 17 simply reported:
Many questions arise from this matter. Why did the trust withhold data for the crucial period from December 2014 to May 2015?
How did the Cultural Ambassador deal with the 110 concerns about staffing levels that were raised with her? Were the concerns appropriately escalated? Did she escalate the concerns externally after managers failed to act on the concerns, (which she affirmed above was her duty)?
Did the staff who disclosed to the CQC and press raise their concerns with the Cultural Ambassador first? If so, how did the Cultural Ambassador deal with those disclosures?
The trust has indicated that the Cultural Ambassador keeps a database about concerns raised with her. Has this information been effectively tracked? If the rise in concerns about staffing was detected, what was done about it?
SSOTP has maintained that its Cultural Ambassador has direct access to the chief executive. Was the chief executive informed of the concerns? How did trust management respond? What was the chief executive’s role?
How did the Cultural Ambassador satisfy herself that the correct processes had been followed? What steps did she take to ensure, in her own words, that staff received feedback that “things have been put right as a result and what the learning is”?
Why did SSOTP staff need to resort to external disclosures to the media and the regulator? Given that the trust has been less than open about these disclosures, have any of the staff who raised concerns suffered reprisal? If so, how has the Cultural Ambassador responded to that? Has the Cultural Ambassador herself experienced any obstruction or reprisal that limited her effectiveness?
These matters are important because they go to the heart of the Freedom To Speak Up Review.
Francis left employers in control of the whistleblowing process and of Speak Up Guardians.
Some might view this as handing prospective burglars your house keys.
It simply does not work if employers are not minded to behave accountably.
I asked SSOTP in 2015 if it had carried out any evaluation of the Cultural Ambassador role. The trust replied that it had not but that evaluation was planned. Upon further enquiry, it admitted that it had no formulated plans to share. Two years on, SSOTP now discloses that no evaluation has been implemented.
The national staff survey results for SSOTP also remain mediocre. 18 Last year, the trust was below national average for community trusts on staff security and confidence in raising concerns.
Only 74% of SSOTP staff reported feeling secure to raise concerns about unsafe practice, and only 59% were confident that the trust would act upon the concerns raised. 19
Yet despite a complete lack of substance, Jeremy Hunt has repeatedly used the Freedom To Speak Up Review for public relations purposes, claiming it as part of the evidence that he is building the safest and most transparent health service in the world. A Department of Health statement to that effect in March was reproduced by the National Guardian:
“Since the tragic events of Mid Staffs we have made considerable progress to making the NHS the safest healthcare system in the world including appointing a National Guardian and making sure every NHS organisation has a Freedom to Speak Up Guardian.” 20
Over two years on from Francis’ Freedom to Speak Up Review, there is no shortage of new whistleblower cases, with tales of continuing suppression and reprisal by the NHS.
The latest case to come into the public domain only yesterday is that of David Phelan a governor at Kettering General Hospital NHS Foundation Trust. Squaring the circle, his case like Donnelly’s, is ironically about fiddling of waiting times. 21
So over four years after the Mid Staffs Public Inquiry where the bottom line mattered more than safe staffing and performance was fiddled to hide falling quality, it seems reasonable to conclude that the NHS has learnt nothing.
Francis’ strategy of appealing to people’s better nature – instead of rigorous enforcement of whistleblowing governance – has not succeeded.
All that has been generated is a whistleblowing industry full of hot air and manufactured figureheads, that is primarily a public relations and political tool for the Department of Health.
I have asked the National Guardian to exercise her remit for identifying obstacles to safe speaking up, and for challenging the system, by reviewing what exactly went wrong at SSOTP.
I have also asked her to stop promoting the SSOTP model as an example of good practice.
Whistleblowers need real reform and genuinely safe harbour, not sound bites and gimmicks.
1 Robert Francis’ report of the Freedom To Speak Up Review 11 February 2015, page 145
“Case study: An ambassador for cultural change
A trust has established a new role which they have called an ‘Ambassador for Cultural Change’. The post was established in response to the very low usage by staff of an external advice line for those considering raising concerns. The trust knew that it had to do something differently to encourage people to speak up. The purpose of the role is to support and help drive a programme of change in the trust so that it becomes an open and supportive place to work. The Ambassador works independently and reports directly to the Chief Executive on a very broad range of matters that staff bring to her attention, such as safety, quality, welfare and process. Importantly, if she doesn’t think that the trust is living up to its values, she is able to hold them to account. She supports staff in raising concerns, offers reassurance to those reluctant to speak up, helps develop training and works across organisational boundaries to make the trust a safer place to be treated and a more open place to work. Since taking up the post, the number of incidents that have been reported and concerns that have been raised has increased dramatically”
2 This is information about the Cultural Ambassador on the SSOTP trust website:
This was the job description for SSOTP’s Cultural Ambassador role:
3 Stafford hospital whistleblower comes out of the shadows, Charlotte Littlejones, Stoke Sentinel 29 April 2013
4 Helene Donnelly: ‘Every trust should appoint an ambassador for cultural change’
5 Dedicated nurse Helene Donnelly earns OBE for NHS support role. Stoke Sentinel, 31 December 2013
6 Page 35 of the report of the Freedom to Speak Up Review
7 The National Guardian has asked Speak Up Guardians to distribute a promotional video about the Freedom to Speak Up project, as noted in the National Guardian’s newsletter of March 2017
The video can be viewed here:
8 a) Birmingham Childrens’ Hospital NHS Foundation Trust created an ambassador role, with mentoring by Donnelly:
Second trust creates role to support staff raise concerns, Jo Stephenson, Nursing Times, 25 June 2014
b) It was reported that other trusts also followed SSOTP’s lead:
Growing interest in NHS cultural ambassadors, Sarah Calkin Nursing Times 17 September 2013
9 Page 145 report of the Freedom To Speak Up Review
“7.2.15 I am persuaded that there would be advantages to the creation of a local ‘champion’ role in every NHS organisation or group of organisations. Consistency over at least the name would mean that staff who moved between different establishments would always know where to go for support. I have considered a number of potential names for this role including Safety or Speaking Up Advisor/Champion/ Guardian/Ambassador, Openness Advocate and Whistleblower/Raising Concerns Support Officer. What name is chosen matters less than a shared understanding of what it signifies. The role I envisage bears some, although not complete comparison to the well-established function of the Caldicott Guardians. Accordingly my tentative view is that an appropriate name would be Freedom to Speak Up Guardian.”
10 Agreed records of meeting with the National Guardian on 2 February 2017
11 National Guardian case review process, CQC, May 2017
“The Francis Freedom to Speak Up (FTSU) review sets out how the freedom of NHS staff to speak up about their concerns should be supported. The review’s 20 principles set out how this support should be provided and additional examples of good practice to do this are given in Annex A of the FTSU review.
3 Those principles, actions and examples of good practice establish an authoritative and evidence-based set of standards that state how NHS trusts should support their staff to raise concerns and how they should respond to them.”
12 Letter to David Behan CQC chief executive, 5 May 2017
13 Letter from Henrietta Hughes National Guardian 17 May 2017
14 Leaked NHS dossier. Nurses log concerns over care. D Blackhurst, Stoke Sentinel, 2 April 2015
15 Leaked NHS report reveals dying patients left alone and in pain. D Blackhurst, Stoke Sentinel 2 April 2015
16 CQC inspection report May 2016 on SSOTP, from an inspection in November 2015
17 SSOTP staff newsletter June 2015
18 NHS 2016 staff survey results for SSOTP
19 NHS 2016 staff survey question level data: errors and incidents
20 Department of Health press statement of 17 March 2017
21 Kettering General Hospital ‘fiddled’ waiting time records, Matt Precey, BBC 26 May 2017