Improving the openness of the NHS in England: have government policies made a difference?
The study was funded by the National Institute for Health Research (NIHR) Policy Research Programme (project reference PR-R15-0116-23001). The views expressed in the report and on this website are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. This webpage has been prepared by the study lead Graham Martin with help from the study’s patient and public advisory group.
In the mid 2000s, staff, patients and carers at Stafford Hospital in the West Midlands raised concerns about the quality of care in the emergency department and other parts of the hospital. Yet for several years, complaints and concerns went unheeded, and poor-quality care continued.
Eventually, investigations by the Healthcare Commission, and then an independent inquiry and a public inquiry led by Sir Robert Francis QC, brought the problems faced at Stafford to public attention. They found not only that the quality of care had been poor for many years, but also that the healthcare system ignored or even silenced people who spoke up about the situation. Francis also suggested that many of the problems that affected Stafford could also affect other parts of the NHS elsewhere – and indeed, since then, there have been other events in other parts of the healthcare system, such as problems in the quality of maternity care at Morecambe Bay.In response to the findings of the Francis inquiries and other reports, the government introduced several new policies designed to promote openness in the NHS – for example, by requiring doctors and nurses to let patients and families know if things go wrong, by supporting people who want to speak up about concerns, and by changing the way that patient safety incidents are investigated by healthcare organisations and learned from.
But how well have these policies achieved their aims of increasing openness?
The policy changes, the study, and its findings and recommendations
In the sections that follow, you can find out more about the policy changes, the study, and its findings and recommendations.
The policies introduced by the government following the Francis inquiries
Robert Francis found in the public inquiry into the events at Stafford Hospital that the NHS should be more open about the problems it faced, listening to staff, patients and families about concerns, and using this information to improve the quality and safety of care.After publication of the inquiry, as well as reports about problems in other NHS organisations, the government introduced a series of policies that were in part designed to increase the openness of NHS organisations.Among others, the policies included:
The Statutory Duty of Candour: if something goes wrong in the course of treating a patient, the NHS organisation involve should promptly inform and apologise to the patient or their family
Changes to the way that the Care Quality Commission inspects and rates NHS organisations
Regional patient safety collaboratives that aim to bring people together to improve the quality of care in defined areas, and a community of staff, patients and others with an interest in patient safety, called the Q Community
The Freedom to Speak Up programme: changes in NHS organisations to make it easier for staff to speak up if they have concerns about quality of care, including the introduction of Freedom to Speak Up Guardians and Champions – named individuals responsible for helping them out – in all NHS organisations
Changes to the way serious incidents (that have caused harm to patients, or could have done) are investigated by NHS organisations.
We wanted to investigate the impact of these policies on the NHS.
The methods we used to look at the impact of the policies
In 2016, the team received funding from the Department of Health Policy Research Programme to look at how policies aimed at improving openness in the NHS were being implemented in NHS organisations, and whether they were having an impact on the experiences of staff and patients.
"we wanted to look at how the policies are working in practice"
Our study began in early 2017, and was completed in late 2019. We wanted to look at how the policies are working in practice: whether they are affecting attitudes and behaviours of members of staff; whether and how managers are using them to encourage positive changes; and the extent to which the experiences of patients and staff of certain aspects of openness are changing, for better or worse.The study included four main components:
interviews with senior managers, doctors, nurses and other clinicians in NHS organisations in England, and with people outside the NHS with insights into work to promote openness inside the NHS;
a survey of senior managers in NHS organisations about the changes in policy and how they were being put into practice;
analysis of data from annual surveys of NHS staff and patients (including patients in acute hospitals, and patients receiving mental health care in the community), to examine how experiences of different aspects of openness were changing, for better or worse, through time;
more detailed qualitative research in six NHS organisations using interviews to explore with staff, patients and families how policies relating to openness were being put into practice. These included three acute hospitals, two mental health and community healthcare organisations, and one ambulance service.
We were guided by advisory groups that included patients, carers, academics, NHS staff, and others with experience of this area.
"we were interested in how well all the policies worked together as a package"
The first and second parts of the study looked in particular at the views of senior staff in NHS organisations on the policies, and how easy or difficult they were to put into practice in their own organisations. We were interested, for example, in how well all the policies worked together as a ‘package’, and whether they conflicted with other policies or expectations in their organisations.The third part of the study used information from surveys that the NHS carries out each year with staff and patients to look at how people’s responses to questions that relate to openness have changed – and in particular, whether trends in people’s experiences seemed to change after the publication of the public inquiry led by Robert Francis.The fourth part of the study focused in particular on three of the key policies introduced after the public inquiry: the Statutory Duty of Candour; the Freedom to Speak Up programme; and the changes to the way serious incidents are investigated in the NHS. It looked at the experiences of patients, carers and staff of these policy changes, and at whether, together, the policies seem to be having an impact on the culture of NHS organisations.
We wanted to hear the views of senior staff about the impact of openness policies.
Our findings on the views of senior staff about the impact of policies
For the first and second parts of our study, we carried out interviews with senior NHS staff and other people involved in openness policies, and undertook a survey of board members of NHS organisations. We completed 51 interviews, and 112 people responded to our survey.People were generally positive about the new policies. Many interviewees felt that the problems at Stafford Hospital that had prompted them could also affect other NHS organisations, including their own.Participants in the interviews and the survey also found that implementing the policies was challenging. They required a great deal of work to put into practice, and generally this was not supported by extra funding from central government. Organisations were required to provide extensive information to demonstrate that the policies were being implemented, and sometimes people felt that strict expectations about things like timelines stopped them from implementing the policies in a sensible and sensitive way. For example, there was concern that requirements about when and how information about harm should be given to a patient under the Duty of Candour could prevent organisations from communicating with the patient in a sensitive, personalised way.
"staff still feared that being honest and open about mistakes could have bad consequences"
In terms of the impact of policies on the views and actions of staff, many participants felt that there was still a long way to go for some parts of their organisations in achieving openness on a day-to-day basis. Many staff, they told us, still feared that being honest and open about mistakes, or raising concerns about the quality of care, could have bad consequences for them. Memories of how organisations had, in the past, punished people for speaking up continued to affect people’s attitudes. More recent episodes, where doctors and nurses had been open about mistakes and this seemed to be used against them, continued to affect people’s views about openness.Participants in some organisations also found that their organisations were spread out, with many subcultures that were difficult to influence. In community-based organisations in particular, where work was spread out across a lot of sites, or done by small teams working in the community, it was difficult to implement policies in a way that reached all parts of the organisation. Some participants were able to identify parts of their organisations that caused concern, for example because of gaps in their knowledge about the quality of care that were difficult to fill.Senior NHS staff offered various ideas about to increase the likelihood that policies would result in change in their organisations. In particular, they pointed to the importance of ensuring that the benefits of being open were visible to people in more junior roles, working hard ensure that when concerns were raised, they resulted in action, and taking responsibility for issues identified, rather than expecting staff delivering care to address them on their own.You can read more about our findings on these issues in this peer-reviewed journal article, which is available for free.
We then sought to analyse how experiences of openness had changed for staff and patients.
Our findings on how experiences of staff and patients around openness have changed over the last decade
The first and second parts of our study looked at the views of senior managers, doctors and nurses on the policies. For the third part of our study, we focused on the question of how changes after the publication of the public inquiry led by Robert Francis seemed to have impacted experiences of openness of staff and patients.We looked at patterns of responses to three surveys that have been undertaken each year since the mid-2000s: the NHS Staff Survey; the NHS Acute Inpatient Survey; and the Community Mental Health Survey User Survey. We looked at the overall trends in responses to these surveys, and also at whether there had been a change in these trends following the publication of the Francis Report. For example, if responses to a question were already improving year on year before publication of the report, was there a change in direction, or in pace of change, after 2013?
"patients with experience of community mental health services suggested some things have got worse"
Responses to the survey from NHS staff suggested that they feel that the health service has become more open. Since the publication of the Francis Report, for example, more staff feel that the NHS responds well to patient safety incidents.Responses from people who have received inpatient care also suggested an improvement, for example in relation to information provided and involvement in decision-making.
However, survey responses from patients with experience of community mental health services suggested that some things have got worse, including their involvement in discussions about their care, and how far they are treated with dignity and respect.The divergent trends in physical and mental health seem quite striking, and may suggest that some of the efforts to promote openness have been concentrated in acute hospitals – the part of the NHS that deals with acute physical health problems. They may also suggest that the policies are more easily implemented in that sector than in mental health, in line with what we found in other parts of the study.Despite the long-term interest in trying to achieve ‘parity of esteem’ between mental and physical health in the NHS, our findings suggest that there is still a long way to ensure that community mental health service users’ experiences are in line with those of patients in acute hospitals. You can read more about our findings on these issues in this peer-reviewed journal article, which is available for free.
We continued in-depth research on experiences of openness in six NHS organisations.
Our findings on how policies have been implemented in six NHS organisations
Building on the first and second parts of our study, which looked at the views of senior staff, and on the third part, which used annual surveys to track staff and patients’ experiences of openness through time, the fourth part of our study looked in more detail at how policies relating to openness were being implemented in six organisations in the NHS. These included three acute hospital trusts, two community and mental health care organisations, and one ambulance trust. We focused in particular on the implementation of three policies: the Statutory Duty of Candour, the Freedom to Speak Up programme, and changes to the way serious incidents are investigated in the NHS.In total we conducted 88 interviews: 70 with members of staff, and 18 with patients and family members affected by the policies.
"some organisations had much better systems for ensuring the policies were being done right than others"
We found much variation between organisations in their approaches to implementing the policies. Some had much better systems for ensuring the policies were being done right than others. Similarly, some had much more sophisticated ways of learning from the implementation of the policies – for example, by bringing together different sources of knowledge about different parts of the organisation, and using them to identify and prevent potential problems.Many participants identified improvements in openness in their organisations. For example, they discussed how the Duty of Candour had helped to improve communication with patients when things went wrong, or could point to situations where the Freedom to Speak Up Guardian had helped someone to ensure that a concern about patient safety was addressed. Across all organisations, however there were areas that continued to cause concern, or even where staff seemed resistant towards efforts to improve openness. Some parts of some organisations resembled ‘fiefdoms’: areas where dominant individuals or groups were able to silence concerns, for example because of their seniority, or because of the connections they had or appeared to have with other influential people. Fiefdoms of this kind could have a chilling effect on openness.Freedom to Speak Up Guardians received a wide range of inquiries from their colleagues. The issues raised with them were often not about clear-cut problems in the quality or safety of healthcare. Rather, they often related to behaviour, or a nagging sense that things were ‘not quite right’. Guardians served an important role in helping their colleagues to think these concerns through, and make decisions about whether and how to take them further. Concerns of this kind could sometimes be important indications of problems that were developing, even if they had not yet resulted in clear issues that needed to be addressed by organisations.You can read more about our research on the Freedom to Speak Up Guardian role in this peer-reviewed journal article, which is available for free.
"it could be very difficult for patients, carers and staff alike to ensure that their concerns were taken seriously"
Staff, patients and family members who had raised concerns or made complaints about the quality of care reported mixed experiences. A notable feature of many of these experiences was that it could be very difficult for patients, carers and staff alike to ensure that their concerns were taken seriously, particularly when they did not represent simple or clear problems that could be acted upon. Patients, carers and staff described taxing struggles to ensure that their concerns were acknowledged and addressed, often coming at significant personal cost. Organisations’ systems for responding to concerns and complaints could be cumbersome, slow and unresponsive.Overall, our research in the six organisations shows the importance of coherence across the policies, and the importance of ensuring that policies are lined up with other priorities in organisations. This requires a lot of work, and a long-term commitment to making openness a routine, everyday part of the organisation’s work at every level. Organisations that had been working on this for longer, and which had focused on aligning openness with other policies and priorities, seemed to have achieved greater success in influencing the attitudes and behaviours of their staff.
So how can we ensure that changes in policy translate into real changes in practice?
Our key messages about how openness can be improved
Taken together, our findings from the first, second, third and fourth parts of our study suggest that there is still much to do to improve the openness of the NHS.Change is hard and slow. People’s memories of how the NHS has responded to openness in the past – sometimes in unpleasant or punitive ways – affect their willingness to be open in the present. For users of community mental health services in particular, experiences of openness fall far short of what might be hoped, and in some ways appear to be getting worse, not better.However, we saw good examples of openness in action in our research, and findings from across the four components of the study suggest some common activities that can help to turn openness policies into changes in the attitudes, behaviours and experiences of staff, patients and families.
Good-quality administrative systems are really important to organisations’ ability to implement policies, and monitor them to see the impact they are having. They also help to coordinate sources of information about problems in an organisation and how to respond to them. Without high-quality administration, organisations struggled to respond effectively to concerns, and to interact with staff, patients and families in sensitive and timely ways.
On its own, though, good-quality administration is not enough. Sometimes, from the point of view of people who had experienced harm or raised concerns, it could look like the organisation’s response was concerned only with ticking boxes, rather than really listening to them and addressing their needs. Sensitivity and flexibility were crucial, alongside high-quality administration.
Working to integrate policies around openness with their wider priorities and policies was important, to ensure that these pressures did not conflict with each other, and to make it clear that openness was a priority that was here to stay. Where openness policies had been ‘bolted on’ to existing work rather than embedded in it, or were not backed up by investment and commitment, this was very clear to staff and patients – and could give the impression that openness was a fad that would pass.
Achieving all this takes time, and requires long-term commitment. Openness is not something that can be achieved through a small number of time-limited projects. Rather, it needs to be an ongoing focus of an organisation’s work at every level.
We also highlighted some significant challenges that were apparent across the components of our study.
In many organisations, there is a heavy dependence on the good will of staff, for example taking on extra responsibilities on top of their ‘day jobs’, and with no extra recognition or reward. In part this reflects the fact that these policies were introduced with little extra support from central government. However, as NHS staff continue to report stress, and staff shortages continue in many organisations, this reliance on good will and ‘discretionary effort’ may not be sustainable.
A lot of the work undertaken by organisations to try to achieve openness starts from the assumption that staff themselves want to do the best they can for their patients. Undoubtedly, the vast majority of the time, this assumption is valid. However, participants spoke about parts of organisations where this approach had failed, for example where domineering personalities could silence concerns and frighten people who wished to speak up. In these situations, developmental approaches to improving openness are likely to fail, and approaches based more on performance management and even disciplinary measures may be necessary to address concerns properly.
Finally, the policies introduced since the publication of the Francis report have focused much more on the role of staff in improving openness than that of patients and families – despite the notable role of patients and families in uncovering poor quality at Stafford and elsewhere. Some organisations have taken the initiative in seeking to elicit concerns from patients and families, but there is a risk that this important source of knowledge continues to be overlooked.
You can read more about our research and findings in the full report:
Thank you
We would like to thank members of our patient and public advisory group for the study, particularly Geoffrey Smith, for their assistance in preparing this summary of our research. This study was funded by the National Institute for Health Research (NIHR) Policy Research Programme (project reference PR-R15-0116-23001). The views expressed in the report and on this website are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.