are you free to speak up in your team?

I would like to show you “Freedom to Speak Up”, the review chaired by Sir Robert Francis QC. The purpose of the review published in 2015 was to provide independent advice and recommendations on creating a more open and honest reporting culture in the NHS.

The review followed on from the Public Inquiry, also chaired by Sir Robert, into the Mid Staffordshire NHS Foundation Trust which exposed unacceptable levels of patient care and a staff culture that deterred staff from raising concerns.

The 20 principles to create “an open and honest reporting culture in the NHS were:

1. Culture of safety: Every organisation involved in providing NHS health care, should actively foster a culture of safety and learning, in which all staff feel safe to raise concerns.
2. Culture of raising concerns: Raising concerns should be part of the normal routine business of any well-led NHS organisation.
3. Culture free from bullying: Freedom to speak up about concerns depends on staff being able to work in a culture which is free from bullying and other oppressive behaviours. 
4. Culture of visible leadership: All employers of NHS staff should demonstrate, through visible leadership at all levels in the organisation, that they welcome and encourage the raising of concerns by staff. 
5. Culture of valuing staff: Employers should show that they value staff who raise concerns, and celebrate the benefits for patients and the public from the improvements made in response to the issues identified. 
6. Culture of reflective practice: There should be opportunities for all staff to engage in regular reflection of concerns in their work. 
7. Raising and reporting concerns: All NHS organisations should have structures to facilitate both informal and formal raising and resolution of concerns. 
8. Investigations: When a formal concern has been raised, there should be prompt, swift, proportionate, fair and blame-free investigations to establish the facts. 
9. Mediation and dispute resolution: Consideration should be given at an early stage to the use of expert interventions to resolve conflicts, rebuild trust or support staff who have raised concerns. 
10. Training: Every member of staff should receive training in their organisation’s approach to raising concerns and in receiving and acting on them. 
11. Support: All NHS organisations should ensure that there is a range of persons to whom concerns can be reported easily and without formality. They should also provide staff who raise concerns with ready access to mentoring, advocacy, advice and counselling.  
12. Support to find alternative employment in the NHS: Where a NHS worker who has raised a concern cannot, as a result, continue in their current employment, the NHS should fulfil its moral obligation to offer support. 
13. Transparency: All NHS organisations should be transparent in the way they exercise their responsibilities in relation to the raising of concerns, including the use of settlement agreements. 
14. Accountability: Everyone should expect to be held accountable for adopting fair, honest and open behaviours and practices when raising or receiving and handling concerns. There should be personal and organisational accountability for:  a) poor practice in relation to encouraging the raising of concerns and responding to them; b) the victimisation of workers for making public interest disclosures; c) raising false concerns in bad faith or for personal benefit; d) acting with disrespect or other unreasonable behaviour when raising or responding to concerns; e) inappropriate use of confidentiality clauses.
15. External Review: There should be an Independent National Officer (INO) resourced jointly by national systems regulators and oversight bodies and authorised by them to carry out the functions described in this Report, namely: a) review the handling of concerns raised by NHS workers and/or the treatment of the person or people who spoke up, where there is cause for believing that this has not been in accordance with good practice; b) advise NHS organisations to take appropriate action where they have failed to follow good practice, or advise the relevant systems regulator to make a direction to that effect; c) act as a support for Freedom to Speak Up Guardians;provide national leadership on issues relating to raising concerns by NHS workers; d) offer guidance on good practice about handling concerns;publish reports on the activities of this office.
16. Coordinated Regulatory Action: There should be coordinated action by national systems and professional regulators to enhance the protection of NHS workers making protected disclosures and of the public interest in the proper handling of concerns.
17. Recognition of organisations: Care Quality Commission (CQC) should recognise NHS organisations which show they have adopted and apply good practice in the support and protection of workers who raise concerns. 
18. Students and Trainees: All principles in this report should be applied with necessary adaptations to education and training settings for students and trainees working towards a career in healthcare. 
19. Primary Care: All principles in this report should apply with necessary adaptations in primary care.
20. Legal protection should be enhanced 

Acces to the report: Freedom to Speak up
National Guardians Office: Web Access

photo: (*) Photosolde.
Lita Cabellut 
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breaking the hospital model

The hospitals have to move from the concept of “repair shop” function to a "hub" in their community: providing social services, improving education and becoming aware of their significant economic role in communities. Hospitals have the potential to affect the economic model and the social determinants of health by leveraging their hiring, purchasing, investing, and other operational assets more intentionally.

• HUB means an organization or institution that is a focal point in a community and helps blend together a range of stakeholders and services that improve the health and economic mobility of residents. It does not necessarily lead activities or function as the sole focal point—often it is a partner with other institutions. But through partnerships and its own services it enables organizations and people with particular skills, assets, and connections to work more effectively together to improve the neighborhood.

Some recomendations to promote a Hub:

Data
Improve the collection, use, and sharing of data among sectors to facilitate partnerships. Hospitals as data warehouses centers for the community, assuring interoperability and data governance including detailed demographic data, and other information to build a picture of the community.

Partnerships
Make greater use of intermediaries. Hospitals, are often seen by many community organizations as remote yet powerful institutions, and a lack of trust arising from little or no history of partnerships. Hospitals has to build trust inside their community. Intermediaries are organizations or individuals that provide specialized skills or “connecting” functions that facilitate partnerships,

Leadership
Widen the skill sets of hospital leaders and key staff. Train the leaders and the staff. The full potential of hospitals as hubs requires leaders in these institutions to have a broad vision and set of skills, to manage the delivery of less traditional services, and to work with partners and intermediaries.

Essay and error
Government has to increase the promotion of the pilot projects and programs in different communities and encourage the impact evaluation. Also, they should give more flexibility in the hospital's payment systems being less oriented to outputs and more to outcomes. Take steps to facilitate the braiding and blending of public and private resources from multiple sectors and sources.

Access to the article: Hospitals and Schools as a Hubs (2016)
Authors: Stuart Butler and Carmen Diaz

photo: Third and Colectivo Rua
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