Changes in NHS culture recommended following Holyrood Committee investigation

02.07.2018

A comprehensive investigation into the culture of the NHS and how this impacts on patients has been undertaken by MSPs on the Health and Sport Committee who today publish their findings.

These include making the culture of the NHS more open and transparent allowing staff to feel confident about speaking out about their concerns, centralised reporting of serious errors to ensure early identification of wider systemic failings, more patient and family involvement in the complaints process and a review of parts of Health Improvement Scotland, whose role it is to improve the quality of care in Scotland. The report also found that NHS Boards need to be more strategic with a more diverse membership.

Convener of the Health and Sport Committee Lewis Macdonald MSP said:

“At the heart of the NHS are the patients it serves. The whole purpose of this investigation is to ensure that the culture of the NHS allows for the delivery of the highest quality of care to patients.

“We heard directly from staff, patients, NHS Board members and senior NHS managers. We heard that patients want more and greater involvement in their care and how it is delivered. Most importantly, when things do go wrong, there should be greater transparency allowing patients and their families to feel confident lessons will be learned.

“There are also significant measures that need to be taken to ensure staff feel able to speak up about concerns. There needs to be a more open culture that values staff.

“While there are checks and procedures in place it remains inevitable that on occasion things go wrong and it is important these can be quickly identified and not repeated.”

The report makes wide ranging and significant recommendations in three key areas relating to how the NHS is run – staff governance, clinical governance and corporate governance.

Staff governance (p3)
These recommendations relate to making sure NHS staff are managed in a fair and effective way:

  • Whilst there has been an increase in NHS staff feeling confident to speak up, there is still over a third of staff who feel unwilling to do so (p14);
  • Ultimately there needs to be a culture of openness and transparency (p14);
  • The most valuable resource in the NHS is its staff. Bullying, discrimination and harassment in the workplace are unacceptable. It is concerning that only a minority feel confident to raise concerns regarding colleagues’ behaviour. Further steps need to be taken to increase confidence in the response individuals expect to receive when raising concerns (p8);
  • Further steps need to be taken on the current whistleblowing system. The Committee supports the current National Confidential Alert line but this is predominately an advice line and recommend the Scottish Government support the introduction of an external investigative line (p14);
  • The Committee recommends the Government undertakes a review of how NHS managers are currently regulated which currently differs from that for other health professionals. This creates an imbalance between clinical and managerial staff (p16).

Clinical governance (p22)
The report calls for a number of changes to ensure the processes and procedures are in place to maintain the high quality and delivery of care:

  • Clinical standards and guidelines are not being used as effectively or as consistently as they should be (p26);
  • The Committee heard examples of nurses and midwives unable to access continuing professional development (CPD) during their working day. The Scottish Government are asked to place statutory requirements on boards to ensure delivery of appropriate CPD time for all NHS staff (p27);
  • The Committee found NHS patients can face barriers to making complaints and also lack of confidence that raising a complaint would result in changes to care or treatment (p31);
  • The current complaints system is too process driven. Complaints are addressed with limited input from clinical staff directly involved in providing the care and treatment (p31);
  • There needs to be a greater consistency with how Serious Adverse Events (SAEs) are dealt with by the NHS. An SAE is an event which could have caused or did result in harm. There is a lack of consistency over what is being recorded as an SAE. The Committee is calling for centralised reporting to ensure wider systemic failings are identified and swiftly acted upon (p35);
  • The Committee recommend the Scottish Government should undertake a review of Health Improvement Scotland (HIS) functions in five areas: 
  1.  Implementing a more systemic and coherent approach to its work. Consideration should be given to giving HIS greater enforcement powers to address concerns regarding standards and guidelines.
  2. HIS should be more proactive including a greater surveillance function to help identify and preferably prevent systemic failures at an earlier stage.
  3. Its scrutiny function should include consideration of a greater role in relation to the monitoring and delivery of clinical standards and guidelines.
  4. HIS should be tasked to make further improvements to the current operation of the SAEs national framework
  5. The role of the Scottish Health Council, an organisation whose role it should be to oversee how well Boards consult with members of the public in whom the Committee has no confidence.

Corporate governance (p40)
These recommendations relate to the structures and processes for decision-making and accountability, controls and behaviour at Board level:

  • NHS Boards are responsible for providing strategic direction and we want to see them undertake a greater constructive challenge on how central direction impacts locally (p43);
  • Public and staff confidence in NHS Boards is critical. Boards must fundamentally change their relationship with stakeholders and the public and go beyond consulting and informing to focus on collaboration and co-production. Boards must also become more open and honest about pressures and challenges they face (p51);
  • Accountability and decision making between Boards, regional boards and Integrated Joint Boards require to be simplified and made clear (p55).
  • It is important diversity and gender balance in board membership is achieved. The Committee is also concerned that currently there is an underrepresentation of people with disabilities, people from minority ethnic groups and people from different social groups (p48);
  • No member of a Board should also be a member of charitable endowment boards and the dual membership of boards, joint boards and local authorities should be reviewed (p58).

Background

The full report is available here:

The Governance of the NHS in Scotland - ensuring delivery of the best healthcare for Scotland (pdf 1MB)

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