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In place of fear

thedoctor issue 4

Bullying continues to plague the NHS. Doctors remain scared of speaking out for fear of ruining their careers, and many feel the reporting process has yet to be taken seriously. However, the most passionate about the problem are starting to make inroads into a historically insurmountable issue. Keith Cooper reports

There is something stubborn about bullying and harassment in the health service.

One in four experienced it last year, says the national NHS staff survey – and the one before that and the… you get the idea.

While there have been efforts to tackle it, there is a fear it may worsen still, as the ever-growing intensity of work and the unsettling nature of organisational change tends to bring out the worst in people.

So what can be done?

Steps are being taken and some show promise. Our understanding of bullying and its ugly cousins – harassment and incivility – is getting better. There are pockets of good practice.

However, finding a comprehensive fix is some way off. It’s a big, long job and one which must reach to the top, one source of the problem. That’s why the BMA is in it for the long haul, with its bullying and harassment campaign.

‘There’s only one thing which counts from this moment on: what we do to put things right,’ BMA council chair Chaand Nagpaul (pictured above) told the association’s bullying and harassment conference last month.

‘We need a solution across the whole system, starting with the Government. It sets the tone,’ he added.

‘Then there’s the culture in NHS England and NHS Improvement. It’s also about providers and each one of us doctors. How we treat each other. Bullying and harassment is everybody’s business.’


‘You blow people up’

We are still in a world where senior staff in medical schools complain of ‘too many Asian girls interested in marriage’ and studying in their institutions, Caroline Elton, an occupational psychologist who supports doctors, told the conference.

Another sought her support after being casually informed by a black and minority ethnic colleague that ‘you blow people up, you people’, as he was examining an X-ray.

‘He didn’t know what to do, so he worked harder and harder. And so the more his colleagues saw him as different.’

It is not easy to talk about being bullied in much of the NHS.

‘I have been told that, should I report any bullying behaviour, “the doors of the hospital would be closed to me”,’ one doctor told Northumbria University senior lecturers Madeline Carter and Neill Thompson, who research bullying and harassment in the workplace.

‘It is generally not worth reporting unless your career is on the line. The process is soul destroying,’ another said.

‘We would like to have seen a difference in the levels of bullying and harassment in the NHS in the past two decades,’ Dr Thompson told the conference.

‘But we haven’t.’ Many policies, such as zero tolerance, which insist ‘it should never happen’ made every single problem ‘adversarial’, he added.

‘We see no evidence that they are an effective deterrent.’

Then there are the barriers to ending bullying and harassment.

From the toxic sub-cultures in departments and teams to the behemoths which organically grow, then ossify into the great NHS bureaucracy of trusts and Government agencies.

There is gathering evidence that many quarters of the NHS are yet to tear such barriers down, despite evidence that doing so could improve patient care.

A survey by the National Guardian’s Office, which is aiming to instil a ‘speaking up’ culture in the NHS in England, found four in 10 hospital-based ‘guardians’ are given no dedicated time to help staff.

Just under half are appointed without interview, surely a sign they’re not taken seriously.


Room to speak

The same survey finds a link between ‘speaking-up cultures’ and high-performance ratings from the CQC (Care Quality Commission), strengthening the official case for their existence. Having a speaking-up culture is much more than just posting a policy on a website, the National Guardian’s Office says. It’s about ‘walking the walk’, an attitude that treats staff who raise concern with a welcome, not a harrumph.

According to the criteria it applies the three big health agencies, NHS England, NHS Improvement and the CQC, would be in the company of trusts judged ‘requires improvement’. It’s evidence, if any were needed, that culture must change at the top.

But it’s not just bullying and harassment which are being seen as a problem. There’s growing evidence of another, perhaps less obvious, interpersonal hazard to patient care: incivility.

‘If you asked me 10 years ago what the answer is, how to avoid errors, I would have said process,’ Coventry emergency medicine consultant Chris Turner (pictured above) said.

‘If only everyone did what they were supposed to do. But I hadn’t thought about the whole picture,’ he added.

‘The process is important but is exists within an environment. I wasn’t respecting the environment in which we are delivering healthcare. The process is important, but so are the people.’

Dr Turner particularly wants to end incivility in the NHS. It’s no game or gimmick. With West Midlands junior doctors Penny Hurst and Joe Farmer he leads a campaign, Civility Saves Lives, circulating evidence that rudeness at work not only hits recipients but those around them, too. In the teamwork business of medicine, in the emergency room, theatre or clinic, civility makes a difference.

Dr Farmer signed up after seeing a colleague crumble under firm words of frustration from a consultant.

‘What had gone wrong? Though I couldn’t put my finger on it at the time, what I’d witnessed was incivility,’ he says (see 'Uncivil partnerships' below).


Bullying costs billions

If these established effects of bad behaviour on poor patient care, hospital performance or harm to your colleagues fails to force action, there’s another factor which may, as BMA representative body chair Anthea Mowat (pictured below) pointed out.

‘As well as the moral case for dealing with the issue, the financial cost to the NHS organisation is high,’ she said, flagging a recent paper by academics Roger Kline and Duncan Lewis.

‘They estimate that bullying costs the NHS nearly £2.3bn a year,’ she said, and the figure is for England alone. It’s a figure which doesn’t include the cost of incivility, a factor they recognise as potentially costly but were unable to measure.

‘NHS bullying isn’t just toxic for staff: it’s costing billions,’ goes The Guardian headline, above its comment piece.

‘Despite a 2016 ministerial call for action there has been neither an improvement in the levels of bullying in the NHS, nor an increased willingness of staff to report it,’ it says.

But doctors are calling for the NHS to take speaking up seriously.

For bystanders to step forward too. Staff must be helped to challenge bad behaviour and there must be far better complaints handling in practice.

‘Those who experience bullying or harassment must be better supported,’ Dr Mowat said. ‘Problems must be dealt with and our working environments made supportive and inclusive, so we can work better together to provide the best patient care.’

Find out how the BMA is tackling bullying


Uncivil partnerships

Treating colleagues badly can worsen teamwork, delay diagnosis and harm patients – and there’s research to prove it, says junior doctor Joe Farmer

‘No. Don’t do it like that. You’re not doing it right. Move. Let me do it.’

The words were said without threat or anger by the consultant to the senior registrar during a hysterectomy I assisted as a foundation trainee.

I’d got to know her well in the months we’d been paired on the on-call rota. She was leading the operation but struggling to insert the first port into the patient’s abdomen for the laparoscope. What happened next was difficult to watch.

The second-guessing. Each hesitation met with dismay and further frustration by the consultant. A cycle was set in motion, some sort of switch was thrown in the theatre. Staff began talking among themselves, avoiding eye contact. Little things took longer. Finding the right suture, counting swabs.

Overall, the operation was a success; no harm came to the patient. But something had turned sour. I felt frustrated for the registrar, a respected colleague. I felt frustrated for the consultant who wanted the best for her patient.

What had gone wrong?

Although I couldn’t put my finger on it at the time, what I’d witnessed was incivility. Through conversations with colleagues, Chris Turner and Penny Hurst, and the research that I’ve read, I’m now convinced of its effect. The research reflects what I witnessed that day. That incivility hits not just the recipient but those around them too. It worsens teamwork, delays diagnosis, and risks worse outcomes for patients.

This must be happening commonly in medicine.

These are the words Dr Turner, Dr Hurst and I believe. They’re why we set up Civility Saves Lives. Not to accuse.

But to raise awareness of the research which reflects what we’ve all personally witnessed on reflection.

That incivility harms healthcare.

Joe Farmer is a junior doctor in the Midlands and a co-founder of Civility Saves Lives

Find out more about Civility Saves Lives

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