Are ambulance trusts making same mistakes that led to Mid Staffs scandal?

A national guardian has warned of negative cultures in ambulance trusts preventing workers from raising concerns as she called for a “cultural review” of ambulance organisations.

Mid Staffordshire NHS Foundation Trust was lambasted for having a target-driven culture that led to poor care, which could have contributed to the deaths of hundreds of patients.

Stafford Hospital was described as the scene of unprecedented abuse and neglect. More than 200 deaths were investigated by Staffordshire Police in an inquiry over “high mortality rates” between 2005 and 2009, although no charges were brought.

An official inquiry described the hospital’s A&E department as being “immune to the sound of pain” while the trust’s surgery department was labelled “inadequate, unsafe and at times frankly dangerous”.

The scandal was only exposed thanks to a small band of campaigning families in Staffordshire who formed a group, called Cure the NHS, to demand improvements in patient safety. They were praised by the head of the inquiry, Robert Francis QC, for exposing a culture in which targets outweighed patient care.

He outlined a series of failings, of poor management, bullying of staff, cuts to nursing staff levels to save money and a near obsessive focus by senior managers on meeting government targets. His £13m inquiry saw a total of 290 recommended reforms for the NHS, of which 281 were accepted by the government.

Today the National Guardian for the NHS, Dr Jayne Chidgey-Clark warned that pressures on ambulance trusts in England are threatening to once again put targets above patient welfare.

She said there was currently a “considerable focus” on targets – such as call answering, handover delays and ambulance response times.

“A focus solely on targets can – especially under pressure – make us blind to how those measures are achieved and at what cost,” she said in a new report.

“I fear that a focus on targets may inadvertently be having a negative effect on the culture of ambulance trusts – just as it did at Mid Staffs.”

One senior ambulance leader told the review team: “When I first started, everyone I spoke to said we have a culture problem. Sexism, racism, homophobic, cliquey. We are going to fix it but not yet. We need to sort out other things like wait times.”

Dr Chidgey-Clark also raised concerns about staff not feeling they could speak up about concerns and described a “culture of silence” where “workers could often not speak up, and concerns were often unheard”.

Some people who had raised concerns “suffered detriment” as a result, she added.

“We heard about experiences of bullying, harassment and discrimination, she wrote.

“Workers spoke about cliques between directors, managers and workers which was stopping people from raising issues because they feared the consequences.”

The report called for an “independent cultural review” of ambulance trusts to help transform poor culture in the trusts.

The National Guardian’s Office and the role of the Freedom to Speak Up Guardian were created in response to recommendations made by Sir Robert in his report on the Mid Staffs scandal. He wanted to encourage NHS staff to speak openly when they had concerns.

Some of the findings in the latest report include:

• l The culture in ambulance trusts was having a “negative impact” on workers’ ability to speak up.

• l Some ambulance staff described bullying, harassment and discrimination.

• l Workers spoke about “cliques” between directors, managers and workers which was stopping people feel able to speak up.

• l Some staff felt raising concerns would not accomplish anything.

The report adds: “Broader cultural issues such as favouritism and cliques, ‘command-and-control’ decision making, and bullying and harassment were affecting workers’ ability to speak up and the confidence they would be listened to.”

Not supporting workers to speak up is having an impact on staff wellbeing and “ultimately patient safety”, the National Guardian’s Office said. As well as calling for a cultural review into trusts, the report also recommends that trusts adopt speaking up as a “business as usual”.

It also called for better regulation of trusts to ensure staff could speak up when they felt they wanted to.

Dr Chidgey-Clark said: “Leadership throughout healthcare – including ambulance trust leaders and regulators – must do their part by listening to workers and treating their voices with the same respect as patients’.”

The latest warning of a damaging results-led culture in the NHS also comes less than a year after a report revealed shocking failings in maternity care at Shrewsbury & Telford Hospital NHS Trust, where a staff culture and dogmatic principles helped create an environment that resulted in countless tragedies.

The report, from maternity expert Donna Ockenden, concluded that 201 babies could have – or would have – survived with better care at the trust.

Amongst the issues uncovered were staff frightened to speak out about failings amid “a culture of undermining and bullying”. Leaders and midwives were also found to have pursued a strategy of keeping caesarean section rates low, despite the fact it repeatedly had severe consequences.

In an interim report published in December 2020, Ms Ockenden noted that for around 20 years the caesarean section rate at the trust was consistently eight to 12 per cent below the England average, with this being held up locally and nationally as a good thing. Her review team formed the clear impression there was a ‘culture’ within the trust to keep caesarean section rates low.

On the latest report, Daren Mochrie, chairman of the Association of Ambulance Chief Executives (AACE), welcomed the findings, welcoming “the greater insights it provides into the current workings of the Freedom to Speak Up culture, including the role of the guardians within NHS ambulance services, and the further opportunity it presents for comprehensive and consolidated improvement in this area for the benefit of staff and patients alike”.

“Alongside and on behalf of our members, AACE will support and work with the National Guardian’s Office, NHS England and the Department of Health and Social Care to implement the recommendations and ensure that they have a meaningful and sustainable impact within the ambulance sector.”

A West Midlands Ambulance Service spokesman said: “Ensuring staff feel empowered to raise concerns is a cornerstone of this organisation. It is one of the reasons why we have so many ways for staff to raise issues that they are worried about.

“This ensures the individual has a method that is appropriate for their individual wishes, be that through a peer, manager, union or confidential method. Because of this, we know that staff are empowered to, and do raise concerns, when they see the need. The Trust has a network of over 50 Freedom to Speak Up Ambassadors based at all of our sites so that staff can raise issues locally. This is backed up by our Freedom to Speak Up (FTSU) Guardian with executive and non-executive leads. In addition, FTSU is regularly discussed at our board meetings.

“We are looking forward to rolling out the new training to all staff, volunteers and governors to further embed the scheme so that it is at the forefront of each individual’s mind, should they have a concern.

“This report provides us with another opportunity to review our ‘speaking up’ culture so that we can look to see what more we can do to give staff the confidence to speak up.”