Following Francis: from targets to teams

This week saw the third Francis report about how to build a safe NHS and end the workplace culture of bullyingElizabeth Cotton reviews the report and writes that we must move away system based on top down political targets towards one that actually delivers personalised care. Published on LSE British Politics & Policy Blog

The latest Francis report, released 10 February, says nothing new to those working in the NHS. It finds that bullying is endemic in the health service, and that most people survive working by keeping their mouths shut. Focusing on the problem of  how staff can raise their concerns about patient care without fear of victimisation, the report has been called the whistleblowers’ report. But it also tries to tackle a deeper question: how has our system of health become so sick that it is rife with bullying? The report offers stark confirmation that a system set up to deliver personalised care is based on top down political targets which can only be managed through command and control management and systemic bullying.

The massive NHS reforms undertaken since 2008 have been described as setting out the deck chairs on the Titanic by the Kings Fund’s recent report wasting billions of pounds and grinding the NHS into further decline. The Health and Social Care Act (2012) introduced a further intensive period of change within a context of austerity and cuts.

In an attempt to save costs, the way people work in the NHS has changed too. A radical increase in temporary and agency work, outsourcing, zero hours contracts, work intensification and a decline in real wages. These changes in the employment relationship have triggered changes in the duty of care towards patients, including projecting risks and duties away from the principal employer onto service providers and labour agencies. Working in health and social care has become precarious, a defining theme in both clinical and employment relations research.

The two previous Francis inquiries, looking at what happened at Mid Staffordshire NHS Foundation Trust, identified a link between excessive use of financial targets and the rise in bullying in NHS management. It described the NHS as running on a ‘pervasive culture of fear’, with the majority of staff unwilling to raise concerns about patient care for fear of victimisation or job loss. This culture is reflected in the rise in racism within the NHS, exposed through the influential work of Roger Kline, and the reluctance within the NHS to face up to this systemic problem. The failures have has serious implications for NHS workers, leading to high levels of burnout, stress and in a growing number of suicides.

As someone who works in mental health, I was torn by the report’s recommendation that any staff involved in raising concerns and whistleblowing will need therapeutic support to survive the brutal process ahead. The paradox is that mental health services continue to experience higher cuts than any other part of the NHS, leaving mental health workers themselves highly vulnerable and hardly in a position to contain the mental health of a very sick workforce.

So how can we get NHS workers to talk to each other again? Getting rid of a culture of bullying is going to take individual and organisational change – moving away from a black and white culture of rights and wrongs towards a relational model of care. A relational model is one where the primary value is our duty of care – but in this case not just towards patients but also our duty of care to each other as workers and managers in the NHS.

Bullying is about safety – not just patient safety but also workplace safety where I can say to my colleagues what is really on my mind and they stand a chance of listening to me, however uncomfortable that might be for all of us. In management speak this is about building teams where people feel safe to come forward rather than locking themselves in the staff toilets every time there is a staff meeting. It also means creating inclusive teams – involving everyone delivering care from the contract and agency workers, the part timers, the people that raise concerns every single week and the people that you just don’t really like. Everyone, across disciplines and employers needs to be involved.

The current economic measurement of the NHS has failed in its duty to both patients and staff. What’s new about this report is that front line staff started talking. The trick now is to keep them talking about what’s really going on, rather than continuing to focus on politically set targets that won’t survive past May 2015. The capacity of NHS leadership to deliver these conversations should be the primary measurement of whether they are delivering quality care.


Elizabeth Cotton is an academic at Middlesex University Business School and blogs as @survivingwk. The full article by Elizabeth Cotton, Roger Kline and Clive Morton, Reversing Performance in the UK NHS: From Targets to Teams.


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