It’s fair to say the now 70-year-old NHS has not had the smoothest ride of late. A perfect storm of ever-increasing demand for services, spending cuts and an ageing population – not to mention Brexit – means more pressure on staffing levels, longer waiting times and a real potential for something to go wrong.
It’s often too easy to point the finger of blame when something does go wrong; a situation all-too familiar for mental and community healthcare provider Mersey Care NHS Foundation Trust, which serves nearly 11 million people in more than 80 locations across north west England, including a high-secure hospital.
Beset by a spate of unexpected patient suicides in 2015, and a formal, procedure-heavy culture that resulted in almost 22 live disciplinary cases and eight suspensions in an average month in just one division during 2016, the trust faced a distrustful relationship with its workforce, who felt unable to deliver the level of care they wanted for fear of having errors pinned on them.
“In the NHS we talk a lot about when things go wrong, but without meaning to, we slip into who did something wrong,” says executive director of workforce Amanda Oates. “We had a consistently high number of disciplinaries, with people sometimes suspended for six months, yet more than half ended with no case to answer. Putting those employees through unnecessary investigations did nothing to build trust. For a mental healthcare provider, we weren’t looking after the mental health of our staff.”
The turning point came when Oates discovered Just Culture by renowned safety expert Professor Sidney Dekker. “It really resonated with me. I thought ‘this could be about us’,” she says. Dekker’s work introduces the concept of the ‘second victim’: when something goes wrong, the first victim is the patient who’s harmed, but the caregiver is harmed too. “We had never considered that,” says Oates. “In HR, we can get too caught up in the processes, and we were focusing too much on who did something wrong, rather than who needed help.”
Dekker himself subsequently agreed to help Mersey Care design what was to become a ‘Just and Learning Culture’ – a combination of a change in organisational mindset and improved education, through which staff would feel supported and be empowered to learn when things didn’t go to plan, rather than feel victimised. “At our initial engagement events, staff overwhelmingly told us the fear of blame was the biggest barrier to them delivering care,” says Oates. “So our aim was to achieve the right balance of justice and learning, while still maintaining accountability.”
As well as helping to conduct staff engagement activities and setting up a dedicated microsite for them to access resources and share their experiences, Oates and her 150-strong workforce team also needed to alter the semantics used in employee relations to escape the mindset of finger-pointing. “The language we use in HR can be quite legalistic and retributive,” says Oates. “We wanted to be more positive so, rather than saying ‘managing your attendance’, we’d say ‘supporting your attendance’. It’s a minor switch, but it takes away that ‘big brother’ attitude.”
Careful to gauge opinion before sharing the project more widely, Oates and her team worked “under the radar”, as she describes it, to pilot the scheme in one division and gain the support of clinical employees and unions before taking it further. “We didn’t feel brave enough to implement it across the trust,” she says. “To begin with, there was a lot of suspicion – staff didn’t believe we were doing away with formal investigations.”
But they soon saw the value and, after a year-long pilot yielded positive results, Mersey Care made a public commitment and rolled the scheme out trust-wide to all 8,000 employees. “We unveiled the project to the rest of the trust in January 2017, and included the plans in our trust quality accounts for the year,” says Oates. “These are usually reserved for patient-focused objectives, so including staff objectives said a lot about our dedication to making positive changes.”
Word spread with the help of more than 40 Just and Learning ambassadors recruited from staff at all levels – a number of whom had been subject to disciplinary proceedings themselves – and the lack of faith in the system began to dissipate. Oates soon found employees were voluntarily contributing to the culture change. “My team gets emails all the time, querying aspects of staff experience and patient care under the Just and Learning Culture. People feel more able to raise concerns and ask questions if they think something isn’t right.”
The culture shift has also resulted in a more collaborative relationship between HR, unions and clinical staff. “We’re developing policies in partnership with patient-facing teams, building trust and giving people the confidence to raise issues before they become major problems,” says Oates. “One nurse recently told me she had a tough weekend because of staffing, but feels safe in her role because she’s got the organisation’s support if something goes wrong. That’s exactly what we want.”
Transforming the trust’s culture has also been cathartic for Oates herself – she describes watching videos of staff members telling their stories of being under investigation, filmed as part of the project, as “horrendous”.
“I cried – it’s one of the most powerful learnings I’ve had in my 20 years in the NHS,” she says. “When I looked back, I felt I’d let people down. As an HR director, I think we do everything by best practice and tick all the boxes, but then your data becomes a real person in a real situation. Sometimes we at the top become too divorced from what our teams are doing on the ground – it wasn’t intentional, but we were hurting people.”
More than 18 months since the Just and Learning Culture was rolled out, its progress is showing no sign of abating. The overwhelmingly positive impact on the trust – a 59 per cent reduction in disciplinary investigations between January 2016 and December 2017, despite the trust’s workforce doubling during this time – has garnered attention from a General Medical Council research study, and Oates has been asked to present at a national NHS forum later this year.
The project’s success has also earned Oates the HR director of the year accolade at this year’s HPMA Excellence Awards, as well as the team winning the Social Partnership Forum award for partnership working between employers and trade unions.
Looking ahead, Oates hopes to be able to attach fiscal value to the project. “This is the NHS – we need to be able to demonstrate value in monetary terms too,” she says. “But in 2016 the trust spent £1.1m suspending staff. The same projected bill for this year is under £100,000. That saving goes straight back into improving patient care – nobody can say this isn’t adding value.”
Her ultimate aim for the project isn’t financial: “My union colleagues have challenged me to eventually do away with my disciplinary policy. It sounds ludicrous, but in the long term people who don’t fit with our culture will naturally move on and be replaced with people who do. So one day, I hope it will happen.”
She also agrees that there’s sufficient scope for other trusts to adopt the culture. “Any organisation can do this if they’re prepared to really look at themselves – there’s always something to find, even in the best-performing organisations,” she says. “Everyone should be doing it. It’s not rocket science, and ultimately it saves lives.”
Watch the film about Mersey Care's Just and Learning Culture at bit.ly/JustCultureTheMovie