A very disappointing and arguably flawed `Freedom to Speak Up Review Report’ by Sir Robert Francis published in February 2015. A flawed document because all the basic steps of problem solving are not evident in the report. Also, properly to analyse the problem and establish a solution requires a good understanding of industrial psychology, organisational behaviour and the power of conformity, how world class quality standards are achieved and how to create the organisation culture needed to achieve it.
Step 1. What is the problem? The Report recognises that the protection of whistleblowers is a problem but fails to recognise the important problem of sacked whistleblowers, who are now unable to obtain redress for wrongful dismissal or redeployment in the NHS – the rectification of this essential if the Report recommendations are to have any credibility? It also fails to recognise that the NHS is generally incapable of effectively rectifying failures in the quality of its services identified by whistleblowers/employees and for that matter its customers. Step 2. What is the cause of the problem? The cause of whistleblowing is not effectively identified or analysed at all. Step 3. What action should be taken to deal with the cause of the problem? The Report provides a list of 20 `Principles and Actions’ as to how providers of NHS healthcare and regulators should behave and recommends yet another policing body to try to enforce it, which cannot be effective because it does not address the cause of the problem. Step 2 ‘what is the cause of the problem’ is missing in the report i.e. what is causing people to bully others and repress free speech? As a result, Step 3 in the report does not address Step 2 and thereby resolve Step 1.
The main cause of the whistleblowing problem is reasonably clear. The NHS is managed like a totalitarian state i.e. a very hierarchical command and control (C&C) dominated dictatorship using, target setting, regulation, inspection, intimidation (naming and blaming) at every level in an effort to improve productivity and quality to meet the needs and demands of customers. It is a seriously outdated divide and rule, parent – child, them and us organisation and management system which creates fear in the workforce and is reminiscent of the UK car industry of the 1970s, which similarly failed competitively to improve its productivity and quality of products and services to meet customer need. Whistleblowing is only defined as such in centralised totalitarian/dictatorial command and control dominated management regimes. Free speech (and particularly the truth) is the biggest threat to dictatorship, which it has to suppress to survive. Anyone who does not agree with its commands and practices is considered to be against the regime. In such moribund cultures, which also breed informers, the vast majority of managers and staff do as they are told, avoid responsibility and keep their heads down for fear of losing their job or destroying their chance of promotion. Indeed, the only way for people to gain promotion is to conform to meet the demands of their paymaster whoever they may be. All such regimes over a period of time fail to adapt to rapid change and inevitably corrupt and divide themselves into a protectionist profession silo mentality resulting in a pass the parcel service.
Sir Robert recommends appointing yet another formal policing/inspection type system of an Independent National Officer and Freedom to Speak Up Guardians both of which are responsible to the totalitarian organisation and management system causing the present culture of fear and bullying. Behaviour change in the workplace cannot be achieved by regulation and inspection anymore than you can make people like each other. Also, telling people how they should behave will not result in their behaviour changing. People’s overall behaviour in an organisation is substantially determined by four things: 1) its purpose; 2) its organisational paradigm i.e. the way it is organised and managed; 3) the knowledge and skills of its employees and 4) financial resources. 2) the NHS organisational paradigm is a key factor related to the problem, although the lack of a clearly defined purpose, financial resources to meet customer demand and the serious lack of knowledge of quality management methodology throughout the organisation is also contributing to the problem.
As a democracy, founded on the principle of no taxation without representation we, as owners of the NHS, should all be deeply concerned at the way the NHS is organised and managed. Democratic, creative and progressive societies and organisations, where command and control management influence is minimal, are dependent for their existence upon everyone at every level being empowered to speak up to contribute to the process of continuous improvement of that society or organisation. A free press is essential and everyone is a whistleblower in an open democratic `stop the line’ (to use a process manufacturing analogy) continuous improvement organisational culture. High quality services in complex industries like the NHS cannot be achieved in organisations operating a closed totalitarian C&C management dominated regime, which is designed to control social behaviour by subordinating and disempowering people – the exact opposite of what is required. Thus the only protection a whistleblower in the NHS can be given is radically to dismantle and reform the present management regime of the NHS. In turn this will radically improve productivity and the quality of services. Dismantling the regime will involve breaking it up into smaller autonomous units, creating an adult to adult management culture and training and involving everyone in the business planning and quality improvement and control process. There are only two ways to break the organisation into smaller units. One is to privatise it, the other is to democratise it. One of the problems with the privatisation of front line services is that it will fragment the services and thus militate against developing integrated services which is so desperately needed in the NHS, although the private sector may more effectively provide some supplier services. Also, privatisation/marketisation and thereby competition does not ensure the development of high quality services. The car industry in the UK has always been highly competitive, but cost effective high quality car production was only achieved when total quality management methods, involving all staff, were introduced into the production process.
It should be recognised that the Department of Health/NHS is by no means the only organisation involved in providing health and wellbeing services. The vast majority of existing local government services were created to prevent ill health through poor living conditions and to encourage individuals to maintain good health and wellbeing. Public health, environmental health, refuse collection, leisure and recreation (re-creation), housing, social services and town planning services were all created for this purpose. In the case of mental health and the physical health of older people, which take up a sizeable part of the budget of the NHS, the importance of many of these services working together in harmony with health services to provide a whole person service cannot be underestimated. Thus the democratisation of the NHS has to be the way forward and in doing so change the way it is organised and managed by creating district/neighbourhood multi disciplined and skilled health and care teams to work with clusters of GPs to provide an integrated service and empower staff by training everyone in quality improvement methodology. At present, circa £100bn is being spent by NHS civil servants, managers, clinicians and other professionals (represented by institutes/unions) with no accountability for their performance or the spending of public money to the local electorate. By devolving the commissioning and management of NHS services to the city/district level based upon the model used by local authorities, top health managers and clinicians would be directly appointed by elected representatives of the whole community to whom they would also be accountable for the design and delivery of services and the spending of public money. It will also resolve the problem of whistleblowing. Whistleblowing is not a term that has been used in local government, where any attempt to suppress free speech of managers and staff (who are obliged to serve the whole council) by the political party in power would be seized upon by opposition political parties likely in the council chamber itself or through the free press.
Arguably the Government/Department of Health/NHSE should concern itself only with developing overall NHS policy with regard to national health outcome standards, financial resource allocation and managing specialist services, which are not economically viable to be provided at the local level. Otherwise, the local provision of NHS services should be delegated to the local community level, which arguably if placed under one health and care provider management umbrella would better enable the integrated management of all services related to the prevention of and recovery from ill health and the maintenance of good health and wellbeing. It would also enable the creation of a more customer focussed service that can work in partnership with families and individuals at the district/ neighbourhood level better to identify customer need and encourage them to take more responsibility for managing their own health and wellbeing along with the development of the public services they own. Increasingly the electorate are losing trust and confidence in the ability of national politicians and thereby national Government to manage public services to meet people’s needs. The time has now come to devolve much of the commissioning and management of the NHS to the local community level in the manner described above. In this process two birds will be killed by one stone – protection for whistleblowers and the creation of a high quality customer driven fully integrated health, wellbeing and social care service.
John L Green MSc, NHS trust governor Sir Brian Jarman, Emeritus Professor, Imperial College, London johnlewis,firstname.lastname@example.org. \W&Q-4 Copyright © 2015