By Dr Minh Alexander retired consultant psychiatrist 2 May 2022
Summary: NHS England/ Improvement has reluctantly disclosed a copy of the secretly commissioned King’s Fund review report on poor culture at the Healthcare Safety Investigation Branch, under threat of possible certification to the High Court by the Information Commissioner. The King’s Fund report is a poor affair with little real factual content, and fails to deliver much transparency and accountability. It may be that is what was ordered. Related disclosed correspondence and terms of reference show that the review was never intended to look for hard evidence and it was expressly instructed to avoid specific issues of compliance against standards and policies, performance and culpability. The report’s authors’ identities have been withheld. But the report does nevertheless paint a picture of poor culture in broad strokes. The poor culture and the secrecy pervading the review process are particularly unacceptable given HSIB’s role as a safety agency. Importantly, the Department of Health and Social Care was involved throughout. It remains to be seen whether the DHSC’s related decision to strip HSIB of maternity investigations and set up a Special Health Authority under direct government control will serve patients well, or is just a pretext for controlling the maternity liability bill.
Background
The creation of the Healthcare Safety Investigation Branch was part of Jeremy Hunt’s patient safety theatrics, whilst defunding the NHS and refusing to implement core recommendations from the MidStaffs public inquiry such as safe staffing. He sold HSIB as a safety culture panacea that was based on aviation safety models. This rested on claims that everything was wonderful in aviation and at the Air Accident Investigation Branch from whence HSIB’s chief investigator came. The truth is things may not have been all peaches at AAIB. Indeed, the Department of Transport have fought tooth and nail to avoid releasing AAIB staff survey results that I first requested in 2018 and it is still a matter of litigation with the ICO opposing the government. Moreover, there are questions about aviation safety culture arising from matters such as the Boeing regulatory capture scandal and problems at the Civil Aviation Authority:
Aviation body accused of forcing out staff who raised safety fears
HSIB was established with heavy input from a clique of Hunt’s anointed associates. As a political instrument, it was initially protected, and was located as a sub-committee of NHS Improvement.
Shortly after the small agency was created, Hunt roped HSIB into his maternity crusader narrative. HSIB was tasked with a national maternity investigation programme which far outstripped its original capacity. Rapid expansion was required and HSIB ended up with satellite regional maternity investigation teams linked to local NHS trusts. The maternity investigation programme grew like Topsy and about a thousand cases were processed annually.
This exposed a large volume of care failings and helped victims establish liability. It had substantial financial implications nationally because liability for maternity cases is high. Injured babies and their families must be compensated for a life time of disability and care.
To complicate matters, HSIB was also supposed to be transitioning to independence, subject to the passage of the Health and Social Care Bill. The legislation passed on 28 April 2022 and HSIB is now expected to become an independent non departmental DHSC body within a year.
HSIB whistleblowers started emerging from at least June 2019:
Safety watchdog hit by poor governance and culture
Scandal
Fast forward to January 2022. The press reported a scandal about very poor leadership at HSIB and the findings of a related King’s Fund review that had been quietly commissioned by NHSE/I and which had not been published. The headlines were lurid – “Rasputin-like characters”.
The secrecy was a concern.
Also of note, shortly after the leaks to the press, the Department of Health announced that it would strip HSIB of its maternity investigation programme. In its stead, the government would create a Special Health Authority under direct DHSC control, for only up to 5 years, to take over maternity investigations.
The purported reason for the time limit being that it expected that NHS trusts would become good enough at investigations to take back control within that time. Sigh.
FOI disclosure about the King’s Fund review
I asked NHSE/I, under FOIA, about the context in which the King’s Fund review was commissioned and for a copy of the report itself.
NHSE/I mostly ignored me, requiring two formal ICO interventions and deadlines of 10 and then 35 days, with a threat of possible certification by ICO to the High Court about non-compliance and contempt of court.
This was despite Andrew Morris NHSI Chair assuring me twice that he would liaise with the NHSE/I FOI department. On the very last day of the 35 day tranche, after I wrote and tweeted to Amanda Pritchard NHSE/I CEO, the regulator finally responded.
This is NHSE/I’s formal FOI response letter, and disclosed correspondence between NHSE/I and the King’s Fund and the review terms of reference:
NHSE/I FOI response letter 27 April 2022 re King’s Fund culture and leadership review of HSIB
FOI disclosure NHSE/I Kings Fund correspondence and review terms of referemce
In the disclosure there was correspondence exchanged between NHSE/I and the King’s Fund about prices and services as early as March 2021, and a proposal for the review by the King’s Fund dated April 2021 was included.
NHSE/I indicated that the review was commissioned in May 2021. The actual correspondence commissioning the review was not supplied, but NHSE/I informed me that Aidan Fowler, National Medical Director for Patient Safety commissioned the review in response to HSIB staff whistleblowing to the NHSE/I Freedom To Speak Up Guardian. Upon checking, it became apparent that Aidan Fowler has been both a senior manager at NHS Improvement AND Deputy Chief Medical Officer at the Department of Health and Social Care since 2018.
The Kings Fund report was disclosed:
Bizarrely, the five authors’ identities were redacted. They were described as exceptionally senior for the purposes of the King’s Fund’s sales pitch to NHSE/I, but they were purportedly not considered senior enough for the purposes of overriding section 40 FOIA (personal data). Hey ho.
I do wonder which senior NHS managers or former senior managers NHSE/I was so reluctant to name. Not perchance any miscreants trailing a history of scandal or any with conflicts of interest?
Of interest, the King’s Fund report revealed that this was not the first review on HSIB. It showed that HSIB staff complained that previous reviews had been carried out but were perceived to have been spiked and swept under the carpet. I have asked NHSE/I for more information about these other reviews.
The correspondence from the King’s Fund is rather ingratiating in tone, emphasising the commercial nature of the relationship with NHSE/I.
The April 2021 King’s Fund proposal for the review includes the agreed narrow terms of reference focused on soft perceived culture, with prohibitions to stay away from hard examination of compliance with policies, performance or conduct and culpability of any individuals.
For example:
“(c) Assess whether people wanting to raise a concern were aware of or had
access to appropriate policies and support identifying any actual or perceived barriers to reporting, making complaints, FTSU or other mechanisms of raising concern – although the quality of the policies and their application is outside of the scope of this review.”
“(c) The Review will not make any findings nor make any comment on the conduct, performance or competence of any individual who has raised a concern or is the subject of a concern”
There was a keenness to shut down specific cases examples, old or new:
“(b) The Review will not reopen individual cases, concerns or investigate new reports or complaints against specific individuals. Those wishing to raise or discuss any new concerns will be advised of the pathways for the resolution of such concerns.”
Additionally, the King’s Fund team were steered by a reference group composed of NHSE/I, including Aidan Fowler, and someone else from the DHSC. Steered to what end?
A draft version of the King’s Fund report was shared with NHSE/I. An email and attached comments by Aidan Fowler on this draft report were redacted and omitted from the disclosure bundle by NHSE/I under FOIA Section 36 exemption. That is on grounds that it might prejudice the effective conduct of public affairs. Or in plain English, embarrass important people.
One can only speculate on what was said that made it necessary to withhold this information.
| Mr Aidan Fowler This is Mr Fowler’s interesting CV according to his LinkedIn entry, a UCL graduate then surgeon at a DGH for ten years, followed by a rise through the management ranks via the NHS Fast Track Executive Development Programme: Aidan Fowler LinkedIn CV |
The final King’s Fund report of the review dated January 2022 is an opaque piece of work with the flowery, imprecise language of appreciative inquiry technique.
| Appreciative inquiry is a cuddly technique of quality improvement based on inspiration, positivity, being your best you and all that. It is used by NHS organisations and a document posted by NHS England illustrates some of the nature of this technique: “The Power of the Positive Image: Dreaming o Working in groups. Remember back to the best experiences you described earlier today. o Its 2021 ask each other ’How’s it going? What are you doing these days?’ Be interested and co-create the story o Create something using the materials here that expresses your positive images of the future in some way” |
There is a veneer of superficial empathy by the King’s Fund team.
But their report actually contains very few facts and so fails to respect the subject matter and the people concerned.
As perhaps reflected in the way that aggrieved HSIB staff continued to whistleblow to the press after the review concluded, to expose specific examples of what happened to them. Secrecy is not conducive to justice and accountability, and the leaks were perhaps an inevitable consequence of NHSE/I’s handling of the matter.
Even survey results collected as part of the King’s Fund review were not factually reported. There was no excuse for this, because: the data was aggregated and anonymised. The results should have been clearly provided. But the King’s Fund only gave details in the appendix about response rate: “Concurrently, an anonymous staff survey was run. This was compiled of quantitative and free text questions. The response rate was 172 people, 68.5 per cent of the organisation population.”, but no specific survey results.
| The technique of hiding facts and data from reports, to avoid embarrassment An astonishing example of this was revealed when correspondence between senior managers at the Care Quality Commission surfaced. It showed them plotting to make a CQC inspection report on Basildon hospital services appear tough, but to strip it of any real data: “Being hard hitting without presenting critical data will I suspect be more politically acceptable than criticising with evidence” |
Several months of work by the King’s Fund team of five were summed up in these meagre core findings:
- HSIB has a very committed and skilled staff team who do great and important work.
- The organisation exists in a very uncertain current and future context, with confusing accountability and the added complexity of being subject to legislation currently going through Parliament.
- Unclear governance and accountability are compounded by confusion about organisational policies and processes not being followed, while HR support has been lacking.
- We heard mixed views about leadership and culture in different teams. Many staff report poor behaviours from the executive team, individually and collectively, and the team’s leadership is regarded by many as poor.
- This manifests itself through a perceived command-and-control approach to leadership, lack of openness to challenge, hierarchical approaches to management and behaviour that is out of step with the organisation’s values.
- Bullying, sexism, racism and other forms of discrimination and unprofessional behaviours appear to be prevalent and tolerated – this goes right to the top of the organisation.
- The national and maternity teams retain different identities and ways of working, with widespread perceptions of unfair treatment and favouritism.
- All of this is very damaging to the health and wellbeing of staff, diminishes the culture and undermines the potential of the organisation.
- There is a breakdown in trust and lack of confidence that these issues will be addressed by the executive team.
These findings were shared with HSIB staff in November 2021, after which HSIB’s Chief Investigator announced his retirement.
The King’s Fund report stated that not all staff perceived problems, and some were surprised to hear of them. Some thought the executive team had been unfairly blamed.
In maternity investigation teams, some managers were reportedly seen positively, but there was serious concern about others:
“There was a very strong voice from staff regarding senior maternity investigation team leaders not being held accountable for behaviours that had a very negative impact on staff.”
Irritatingly, there is no quantification of those who had concerns and those who did not, and so there is no solid factual basis on which to understand the scale of the reported problems.
HSIB staff asked for acknowledgment from the leadership of its failures, for better culture, for close supervision of HSIB by NHSE/I and DHSC and for a clear transition plan to HSIB independence.
The King’s Fund made recommendations in terms of external organisational development and HR support.
Of relevance in the disclosed correspondence, NHSE/I had noted eight months previously in correspondence of 25 March 2021 that HSIB wanted Mersey Care NHS Foundation Trust to fulfil this role, so it seems the King’s Fund plan for external support was in reality a foregone NHSE/I conclusion:
“Aidan has just flagging with me that HSIB may want to use MerseyCare NHS Trust to do the actual support/improvement element.”
There is a hint that whistleblowing arrangements were not fully satisfactory at NHSE/I as there is a recommendation to improve them. Could this relate to any failure to act sufficiently to earlier episodes of whistleblowing about HSIB?
NHSE/I have tried to draw a veil over the exact number of whistleblowing disclosures that were made, claiming small numbers and privacy arguments for not telling me more. I have asked them about the numerical threshold that they have applied.
The King’s Fund was emphatic on discrimination:
“This must be supported by some immediate actions on equality, diversity, and inclusion in the first six months of 2022.”
“Direct and urgent action must be taken in response to the racism, sexism and discrimination experienced by people in HSIB. This work must be a priority for the executive team and senior leadership of HSIB. NHS England and NHS Improvement as the employing organisation has a responsibility to support this, while the Department of Health and Social Care should be responsible for overseeing progress against this recommendation.”
The King’s Fund claimed that the issues of racism and sexism were particularly severe:
“We heard some acknowledgement and sadness regarding racism and sexism in people’s response to the findings. These are not issues that are unique to HSIB and are found in many organisations. However, the level to which they were prevalent in HSIB means inclusion needs to be at the centre of organisational development work going forward”
It is a great pity there was no specific evidence provided to demonstrate how the King’s Fund arrived at this conclusion, which had such toxic implications for HSIB’s leaders.
Despite the reluctance to report facts, there seemed to be some overreaching of competence and remit when the King’s Fund diagnosed that some HSIB staff had “trauma”, which would need workplace supplied counselling:
And finally, this being a King’s Fund paper, there was the typical exhortation:
“A sense of common purpose and drive to improve health care bound many in the organisation together. These are strengths to build on.”
All told, the King’s Fund report seems unsatisfactory in its vagueness and low information content, for what was doubtless a steep fee. (In the disclosed correspondence, NHSE/I asked if it would cost above or below £25K.)
On top of this is the hypocrisy of NHSE/I judging HSIB for poor culture when it harbours failed NHS managers, and the hypocrisy of NHSE/I and the King’s Fund not publishing their own staff survey results. Some of this was covered in this recent blog:
Kings Fund & NHS Improvement: Holier than thou shaming of the Healthcare Safety Investigation Branch
We know there were clearly problems at HSIB, but there are insufficient facts for real accountability and transparency. This seems unfair to both victims and accused.
And we do not know if the HSIB situation has been exploited by the DHSC.
But it is clearly unacceptable to have such poor culture at a safety agency.
We have yet to see if the DHSC’s excision of the maternity programme from HSIB will serve patients well – or if the proposed Special Health Authority will be operated as a gatekeeper to control maternity liability. The Secretary of State’s current behaviour towards bereaved families at Nottingham raises additional concerns about his intentions:
Families call for Nottingham maternity review chair rejection
In the meantime, I have sent the King’s Fund report to the Department for Transport Permanent Secretary in case the Department may wish to review its systems for detecting failures of culture, or to comment on the reference that it likely provided for the HSIB Chief Investigator. I have yet to receive any comments.
UPDATE 31 MAY 2022
I asked NHSE/I for the earlier reviews on HSIB that were cited by the King’s Fund report of culture and leadership at HSIB. NHSE/I have disclosed a single, partially redacted 2020 report about failings in maternity investigations and cultural issues of bullying, target driven/ production line approach to reports:
RELATED ITEMS
Staff Surveys and FOI adventures with AAIB and HSIB
Julie Dent is Sajid Javid’s controversial appointment for heading the Nottingham Maternity Review. This post is about various governance failures at the NHS trust where Julie Dent was previously the Chair:
This post is about the recycling of the disgrace former CQC Chair Jo Williams back into the NHS, quite possibly with the assistance of a former King’s Fund Chair who failed to answer questions about his role:
Another turn of the Magic Roundabout: Jo Williams’ referees
This about whistleblowing governance failures, made worse by collusion between the National Guardian’s Office with an NHS trust board, and failings in maternity care:
Alexander's Excavations 
Thank you, Dr A., for your perseverance and discernment.
Fact-free, evidence-free, and investigatory-free are safe and effective guidelines for those in responsible positions who wish for a long and rewarding career within our institutions. Far better to rely on the ever-present treasury of public relations reassuring and diversionary word salads. Or, minimal responses – the way to get on in certain organisations is not to make a mistake. The only way not to make a mistake is to do nothing.
The NHS seems to offer a wonderful career structure for those of a certain disposition. Pity about the suffering patients though.
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