Transcript of Radio Ombudsman #8: The importance of speaking up in the NHS

In this edition of Radio Ombudsman, Rob Behrens talks to Dr Henrietta Hughes, the National Guardian for the NHS. Dr Hughes explains how her career as a GP has helped her in her national role and how NHS organisations can better support their Freedom To Speak Up Guardians.

You can also download a pdf of the transcript (43KB) or listen to the podcast on SoundCloud and iTunes.

Rob Behrens: Good morning. My guest today is Dr Henrietta Hughes, the second National Guardian for the NHS. This crucially important role was created following the Freedom to Speak Up review by CQC board member, Sir Robert Francis. 

Dr Hughes is a practising GP, with over 20 years’ experience across primary, secondary and community healthcare. She was medical director at NHS England, London region, from 2013 to 2016, where she provided system leadership across 12 clinical commissioning groups, and 12 NHS trusts.

She was the responsible officer for more than 3,000 GPs. So this provided her with extensive leadership experience and an overview of the day-to-day challenges the NHS faces. 

Dr Hughes became the National Guardian in 2016, and she advises on good practice in responding to staff concerns, and provides challenging support for the NHS system to encourage a truly safe and open culture. Well, that’s a big task.

Henrietta, thank you very much for joining us today. You’re very welcome.

Henrietta Hughes:    Thank you.

Rob Behrens:    So, the custom on Radio Ombudsman is to start by asking you a bit about your background. Where were you born and brought up?

Henrietta Hughes:    I was born in London, and I’ve lived in London all my life. So, I think that, for me, as the Medical Director in a part of London where I’d been born, went to school, got married, had my children, it meant that I had a lot of understanding about the area, and my patients as well.

Rob Behrens:    What sort of values did you gain through your upbringing?

Henrietta Hughes:    I think the overriding one was about fairness, and certainly, as a GP, my experience is that people who need more support often find it more difficult to access. So, I hope that my role as their doctor is to help them navigate through the system, to provide information and support, to really listen to what their concerns are, and then act on those so that we can find a plan to move forward. 

Rob Behrens:    So, listening to people who can’t obviously articulate their own views, that’s very important.

Henrietta Hughes:    Well, I think it’s really about exploring their ideas, their concerns and their expectations. That’s very much a GP consultation model, which I’ve adapted into the role of National Guardian, thinking very much about the views and the ideas of members of staff and the workers in the NHS, and how we can then translate those into improvements for patient care.

Rob Behrens:    When did you set out to become a GP?

Henrietta Hughes:    Well, my journey towards medicine really started when I was two.

Rob Behrens:    Two?

Henrietta Hughes:    I come from a family of doctors, and my grandfather who was a surgeon made me a surgeon’s outfit when I was two. It was made from the surgical drapes, the, sort of, paper drapes that there were in the 1970s, and that smell of the, sort of, carbolic and, you know, the design of the outfit was obviously a great inspiration to me. That really set me on the path towards medicine.

Rob Behrens:    So, do you still practice now?

Henrietta Hughes:    Yes, I do. I still practice in the borough where I was born actually, and I think there’s something about that continuity of experience. As I said, about really understanding the context of patients’ lives, but also having a really good understanding of the services that are available, and good relationships with the people that provide them as well.

Rob Behrens:    Now, the previous roles which I described have given you huge access to frontline NHS staff, and provided you with leadership experience within the NHS. But what was it that inspired you to take on the role of the National Guardian, which is a hugely difficult and challenging role?

Henrietta Hughes:    Well, I suppose I’ve always been attracted to the difficult roles, and the area of London that I was medical director for in North, Central and East London has had its issues in terms of challenged health economies in lots of different ways.

My experience as the medical director was that I was dealing with a lot of situations where things had gone wrong, and we were then picking up the pieces, where patients had already experienced harm, and we were investigating what had happened.

In those investigation reports, I often saw that there were staff who were aware of issues in advance of when things had gone wrong, but either had spoken up about them and nothing had happened, or that nobody had said anything.

Also, we had individuals who came directly to us with concerns, which we acted upon, and it struck me that if we could deal with issues before they caused harm, that would be of benefit to everybody. Obviously, to the patients and their families, but also, to relieve the burden, the psychological distress that that would cause to staff as well, who were often the second victim in this situation.

So, when I heard Sir Robert Francis on the radio talking about the National Guardian role, it really struck me that there was a great opportunity for driving improvement, by attending and listening to the concerns that staff have, and then making sure that those are acted on, in order to prevent harm to patients.

Rob Behrens:    I mean, this is a huge job, and you want to promote a big cultural change. You recognise that a big cultural change is a massive undertaking in the NHS.

Henrietta Hughes:    Absolutely, and clearly, this is not something that I’m going to be doing on my own. I have a small team in the national office, but I work with over 800 Freedom to Speak Up guardians and champions and ambassadors across England. A network of people from a wide range of professional backgrounds, including nurses and midwives, physios, doctors, but also facilities managers, chaplains, board secretaries. People from lots of different aspects of the NHS workforce, who have a common enterprise of supporting their colleagues, listening, thanking them when they speak up, and then acting on the results. More importantly, giving them feedback on the actions that have been taken.

I’ve also found that there’s been a real enthusiasm in, not only boards in NHS trusts in England, but also in the leadership organisations in the arm’s-length-bodies, many of whom have already appointed Freedom to Speak Up guardians. Rob, I was just going to ask whether the Ombudsman’s office is thinking about appointing?

Rob Behrens:    That’s a very good question, and the answer to that is yes.

Henrietta Hughes:    Oh, I’m very pleased to hear that.

Rob Behrens:    We’re in the middle of making sure that we have a Speak Up guardian by the beginning of 2019.

Henrietta Hughes:    Well, I mean, that’s wonderful news because we know that the cultures in the providers are influenced by the cultures in the bodies that lead them, commission, regulate, inspect. If we can get the cultures right in those organisations, then I think we’ve got a chance for improving the culture across the whole of the NHS.

Rob Behrens:    I was interested to see in the latest survey, that you’ve done your October 2018 survey, asking guardians about their experience, that the less effective operations are among the regulators, rather than among the trusts. Is that a fair account?

Henrietta Hughes:    I think that’s a slightly harsh way of looking at it. What I would say is that, in the organisations that aren’t inspected by the CQC, the perceptions of the guardians are on a par with the trusts who were struggling.

So, we’ve thought very hard about how we can support the arm’s-length-bodies that have appointed, to buddy up with the guardians from the trusts who are really getting this right, to share that learning and ensure that we can get the best from the NHS into the arm’s-length-bodies.

Clearly, the ones who’ve already appointed are the ones who are thinking about how they can support their staff and improve the cultures in their own organisations. It’s the arm’s-length-bodies who are yet to appoint, which are the ones that I’m interested in informing, helping and providing training for their staff as well.

Rob Behrens:    It’s a very interesting account, this report, and obviously, you’re documenting information which we haven’t had before. Many of your guardians are good people who don’t actually have access to trust boards or chief executives. Presumably, it would be better if they did have that access?

Henrietta Hughes:    Well, what we’ve found is that over 40% of guardians don’t have any ringfence time. It makes me wonder how the leaders of those organisations could imagine that their guardians could be an effective resource for staff, an investment really, to provide the proactive nature of their work, where they’re able to go out into the organisation and look for hotspots of culture. Also, reactively, to be there for staff who are often in great distress and need a lot of time to be able to describe their experience. 

What we’ve found is the guardians who don’t have any ringfence time are less likely to have access to their chief executive, present to their board in person, attend regional meetings, attend training and, most importantly, to seek feedback on their own performance. 

So, the call that I would make is to the leaders of all organisations that have appointed guardians, to say, “Think very carefully about what investment you need to make in your guardian, so that they’re able to provide an excellent service.” More importantly, I think, to boards, to say, “Are you happy with the speaking up culture in your organisation? Have you met your guardian yet? Has your guardian presented to you, and have you been able to ask them the pertinent questions?”

Rob Behrens:    Yes. What is your frank view about the challenges of opening up the culture in the NHS, and how Speak Up guardians can assist in doing this?

Henrietta Hughes:    Well, we’ve already seen the impact that this is having, whether that’s the feedback that I get from unions. For example, one staff side chair said that the number of grievances in their organisation has gone down from 16 to 2, which has had a dramatic impact in the amount of hours that she’s spending on this each week. I think it also tells a story about the culture that’s developing in that organisation, and that’s an outstanding trust.

In another organisation, I’m aware of a senior member of staff who was very distressed that the patient safety issues that they’d raised hadn’t been investigated. They were so distressed they were off work with sickness, and was thinking about going to an employment tribunal. The situation was really stuck, but by working in partnership with the Freedom to Speak Up guardian, their union rep told me that they were able to get an external independent investigation commissioned, and also, that the individual was found another role in another part of the organisation, and came back to work successfully.

So, in my view, to be able to preserve the health of a member of staff, so that they’re able then to come back to work and deliver care, and avoid the stress and the trauma of a Tribunal, really strikes me as really positive progress.

Rob Behrens:    Okay. One of the issues is about the status of the guardians themselves. So, you’re independent, but the guardians are appointed by the trusts. Do you think that hinders the credibility of the system?

Henrietta Hughes:    Well, there are quite a lot of different models actually. So, some guardians are existing members of staff. Others have been appointed as external individuals, and there’s also an independent guardian service, which is commissioned by organisations. The point that I would make is, if you have a member of staff, for example, a nurse, in the organisation, do their colleagues trust them? If they trust them as a nurse, why would they not trust them as a guardian?

Where guardians are coming up against difficulties when they’re trying to escalate issues, and they’re not getting the reaction and the response that they would expect, then they flag that to my office. That may be a situation where we would give them advice and guidance, or, potentially, we would do a case review to see if the speaking up hadn’t been handled well by the organisation.

Rob Behrens:    Okay, and I’ve seen in your survey report that one of the recommendations is to focus much more on potential conflicts of interest, to make sure that people have the moral authority to take cases forward.

Henrietta Hughes:    Well, conflicts of interest are bound across the NHS, and, in fact, we published a case review yesterday into a situation where there were conflicts across the organisation. In fact, there is a standard NHS England Conflicts of Interest policy, which trusts are expected to adopt. In that particular organisation, only one member of staff, out of a workforce of 9,000, had signed their conflicts of interest declaration, and we’re seeing this in lots of different ways. 

What we feel is that, for the guardians, they need to think about whether they have any conflicts of interest. So, for example, in they’re in a line management chain, they need to think about what the alternative route might be for somebody, if they don’t feel that the guardian is appropriate for them. We’ve seen many trusts appointing networks of champions, and also, they have non-exec directors and executive leads with responsibility for freedom to speak up. 

So, although this is new, we’re thinking very much about what the barriers might be to speaking up, and how we can mitigate some of those potential conflicts, so that every member of staff feels confident that they’ve got an appropriate route to use.

Rob Behrens:    Okay. You’re doing a lot of innovative work. You’ve just had a Freedom to Speak Up month. Would you tell us a bit about that?

Henrietta Hughes:    Well, it’s always the thing that, as much as you try to communicate, there’s always more that can be done, and certainly, over the last two years since I was appointed, I do feel that there’s an increased understanding and awareness of our role. With 1.3 million staff across the whole of the NHS, getting a message out across a very crowded landscape of initiatives can be difficult.

So, with the Freedom to Speak Up guardians, we’ve had an awareness raising month, called ‘Speak Up Month’, with the hashtag #SpeakUpToMe. I have to say, the response across England has been really tremendous. Guardians have been doing lots of innovative work, including films and press interviews. There were animations, pop-up stands and events. I spoke at quite a few of those, and also, a board game was developed at Great Ormond Street Hospital, called Goshopoly, to help their staff to understand a bit more about the speaking up process.

So, I’m really delighted, and it’s not unusual really, in the way that we’ve started something off, but the guardians have taken it on and developed it in a really magnificent way. There’s still so much more to be done, and we know that there are some particularly difficult to access groups. So, the more that we can do, and that’s where I’m really grateful to you for this interview today, to continue to increase the awareness of the role, so that everybody knows that they’ve got somebody they can turn to if they want to speak up.

Rob Behrens:    I’ve got some questions from Twitter that I want to put to you, but, before that, could you just reflect a bit about the relationship between what you do and what the ombudsman does, and how we should be working together to learn from complaints and whistle-blowing, to improve the quality and safety of care.

Henrietta Hughes:    I think there’s a huge overlap in what we do, because it’s about how organisations respond to challenge. Certainly, as a medical director, part of my role was signing off responses to complaints that came into NHS England about GPs, and you could learn so much about an organisation by the tone of the letter they wrote, and the way that they responded to complaints from patients and families. I think the same is true when it comes to the way that organisations listen, thank and respond to their workforce when they also raise concerns. 

So, in terms of developing best practice, I wouldn’t be surprised if there’s an overlap between the organisations that you’re dealing with and the ones that are of concern to my office as well.

Rob Behrens:    I think that’s right. I have had a number of GPs come to my office, who’ve said to me that they would like to make a complaint, but they can’t because they fear the victimisation that they’ll receive in the NHS if they make that complaint, but they wanted me to be aware of the situation. That’s a common issue for us. You know, there’s no clear dividing line between what you do and I do in that situation.

Henrietta Hughes:    Absolutely, and I’m really delighted that NHS England are extending the funding for my office, so that we can bring this out into primary care as well, because there are issues that lie unresolved in primary care, as much as there are in the trusts as well. So, I really want every person who works in health to be able to know that they’ve got somebody that they can turn to.

Rob Behrens:    Okay. On Twitter, we have questions from Dr Minh Alexander. First one, will the National Guardian model best practice and publish all her, so far, hidden bulletins for guardians?

Henrietta Hughes:    We have a range of different information that we publish, including a newsletter, we have social media, and we publish reports on our website. There’s some information that we share with guardians, where they may want to be able to contact us for advice and guidance. So, some of that is management information, but I think it’s really helpful feedback, and I’ll make sure that we share as much information as we can with members of the public, as well as with the workforce.

Rob Behrens:    Okay, thank you for that. She also asks if you’ll increase the productivity of the office, accept more NHS whistle-blowing cases for review, and review current exclusion criteria.

Henrietta Hughes:    Absolutely. So, we had a one year pilot of our case review process, and I think with everything that’s new, we’ve been learning by doing. The office was set up with a budget which really didn’t assess what the possible work that we would be doing would include. So, it’s actually quite interesting to see the depth and the impact of the case reviews that we’ve done, but we recognise the fact that there’s so much more to be done. 

So, we’ve had an evaluation of the first year’s pilot, which we are already reflecting on, and thinking about how we can use that to expand and improve the process. We’ve had really good advice back from the advisory working group, which includes a range of different organisations and individuals who’ve spoken up and had a bad experience. We want to take all of that feedback, and the learning from the case reviews that we’ve done already, so that we can improve and expand the process going forwards.

Rob Behrens:    Okay, thank you. Can I just ask, someone has raised the issue of the tribunal involving Dr Day, and the great difficulty that whistle-blowers have when they’re faced with the legal resources of the NHS in court. Do you think that’s something that we need to reflect on?

Henrietta Hughes:    I think that tribunals should be the exception really, rather than the rule, and, you know, certainly from the experience of people who’ve told me about going to tribunal, it sounds as if it’s an incredibly difficult situation. That’s why we’re working very much on the prevention side, so that when people speak up, they are guaranteed of their confidentiality, and to avoid victimisation as well.

When it comes to junior doctors, for example, I welcome the fact that Health Education England has extended the protection for junior doctors. We’ve had some really interesting cases, where junior doctors have spoken up to Freedom to Speak Up guardians and actions have been taken as a result, in a way that they haven’t been able to get those actions through using other speaking up routes.

Rob Behrens:    Okay, thank you. Last question from Twitter, do you believe there’s a bullying culture in your own office?

Henrietta Hughes:    So, it’s always impossible to know, unless people start telling you about things, and this is where I believe that having the right speaking up culture, but then acting appropriately if people do speak up about things, is the way forward. 

I think it’s one of those things where we really want to ensure that everybody within my office, but across all different parts of the NHS, feel safe that, if they’ve got a concern, that they can raise it, that they know they’ll be thanked. They’ll be listened to. It will be acted upon, and that they will get the feedback from that as well.

Rob Behrens:    Okay. I have three final questions. First of all, your job is an immensely difficult one. You must get quite a lot of negative comment, sometimes abuse. How do you deal with that?

Henrietta Hughes:    I always take the view that feedback is a gift, and everything that we’re doing is new, and to be able to learn and improve, I want to be able to take all the feedback. You know, positive feedback is always pleasant, but negative feedback is the thing that can often drive improvement further and faster.

Rob Behrens:    But there must be a limit to what you’re prepared to accept on the personal front

Henrietta Hughes:    So, my experience is that it’s actually comments which may be made in a well-meaning way which can sometimes be more derogatory, than comments from people who’ve potentially had bad experiences, and really want to drive the improvement in what we do. I think that my personality is probably one where that drives me on to do even more and better to support people. Maybe it’s because I’m a GP.

Rob Behrens:    Okay. Second to last question, you’re a pioneer. What you’re doing is very unusual. You don’t have a lot of resource. You don’t have a lot of powers. You’ve clearly made a difference. What would you say is the biggest difference that you and your office have made so far?

Henrietta Hughes:    In the first year, we collected the speaking up data, and over 7,000 cases were brought to Freedom to Speak Up guardians. So, I don’t think it’s the difference that I’m making. I think it’s the difference that Freedom to Speak Up guardians are making, day in, day out, supporting their colleagues. If those cases have led to improvements in patient care, then it’s the positive impact that’s having on people across the whole of England, and that’s what makes me really proud.

Rob Behrens:    Okay, last question. It’s a traditional question on this programme, what advice would you give to young graduates coming into the health service, the ombudsman world, in relation to health, on the basis of your experience?

Henrietta Hughes:    I’m always guided by what’s the best for my patients, and I think if we always focus on the patients, then the decisions that come around that will always feel the right ones to be made.

Rob Behrens:    Okay. Dr Henrietta Hughes, I’m very grateful. It’s been very interesting. Thank you very much.

Henrietta Hughes:    Thank you very much for having me.