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Tell me what's wrong

There are some ‘seriously oppressive cultures’ in the health service, says Henrietta Hughes, a doctor and NHS national guardian. She tells Keith Cooper why staff should raise concerns

It must have been awkward when Henrietta Hughes walked in on her first day.

‘The more senior trainees, the registrar and the senior registrar were very concerned,’ she recalls.

‘I was to work for this consultant, and they said, “this person is not supposed to have female trainees”. It was a bullying and harassment situation. I thought, ho hum, just get on with it. I didn’t know I could do anything about it.’

Hearing this now, it’s a little difficult to believe, coming from this calm and confident head of the NGO (National Guardian’s Office), a relatively new arm of the NHS. Dr Hughes (pictured), a GP, is coming up to two years as the national guardian, a ‘whistleblowing tsar’ in the vernacular.

The NGO seems a modest operation, occupying a share of office space on the road to Victoria Coach Station. It’s so many goldfish bowls, gawping over a courtyard of glass and girders, where people teem beneath.

The NGO is charged with helping staff to ‘speak up’ and Dr Hughes is putting her early career experience out there as a reason why it’s needed. ‘When I’ve asked other junior doctors if anyone else has heard of anything like this before, hands go up.’

Like many in medicine, such early experiences stick, and steer careers.

'I do sometimes come across cultures which are really oppressive, really seriously oppressive'

Her own, she describes as ‘common or garden’. From a family of doctors, she wanted to be one early on.

‘When I was two, my grandfather made me a surgeon suit from surgical drapes and that was it,’ she says. After medical school at Oxford and Barts NHS Trust, came house officer and research roles, then her first choice of specialty: training, obstetrics and gynaecology. She later switched paths to become a GP.

While she casts this move in a positive light (‘it’s the best career decision, I ever made’), it aided a welcome escape from hospital life.

‘When I go back into hospitals, I do sometimes come across cultures which are really oppressive, really seriously oppressive for the staff,’ she says.

‘Not just for the doctors, but for all staff.’ Life as a GP is ‘nice’ and ‘old-fashioned’ in contrast. ‘I massively enjoy seeing patients. It’s just an amazing insight into people’s lives. You have that continuity with an individual, the whole family.’


Guide through the maze

She compares her role as the national guardian to medical practice. ‘As a GP, I help to navigate individuals through the system,’ she says.

‘As an appraiser for medical directors and GPs, it’s that same thing: listening, finding out what people’s challenges are, what their goals are and helping them to move along the path to that place. With this role, I’m doing that but for the NHS as an organisation… even if the scale is quite different,’ she adds with a laugh.

The NGO was set up on the say of Sir Robert Francis QC, whose probes found ‘appalling patient care’ at Stafford Hospital and ‘truly shocking’ treatment of staff who raised concerns, there and elsewhere. Staff who spoke up lost their jobs and suffer ‘serious psychological damage’ his report, Freedom to Speak Up, from 2015 says.

There are no similar roles to the NGO in Wales, Scotland and Northern Ireland, although the Scottish Government has plans to establish a National Whistleblowing Officer soon.

So what does the national guardian do? And how does it expect to help staff to feel able speak up?

Dr Hughes sees her role in three parts. The first is to train and support the network of ‘freedom-to-speak-up guardians’, a chief recommendation of the 2015 report.

There are now hundreds, from multiple professional backgrounds, including medicine, nursing and administration. They’re an alternative conduit for raising concerns to ‘official channels’ which have treated whistleblowers so poorly in the past.

Freedom-to-speak-up guardians aim to solve problems that get ‘stuck’ in the system, she says, interlacing her fingers into an upward arch.

‘We don’t want that pattern: when someone gets ignored, gets a lot of work-related stress, goes off sick, or leaves, or it damages their career.’

She speaks of one trust where a single trainee covered the whole site overnight.

‘There were more people in Costa than junior doctors. It had been raised through systems, such as Datix, through the educational supervisor,’ she adds, her hands chopping the table, marking each failed attempt.

‘Nothing had happened. Then the freedom-to-speak-up guardian was approached and immediately contacted the chief executive. Actions were put into place that night.’ The hands rise for a swirl: ‘Those are the things that give me the energy.’


Beyond the doctor

Now that all trusts have freedom-to-speak-up guardians, she is turning her attention to primary care: general practice surgeries, opticians, dentists and other providers in this 50,000-strong sector. Funding for recruitment has just come through and she’s working with ‘early adopters’.

‘It’s not going to be a one-size fits all model,’ Dr Hughes says.

The NGO’s second role is to carry out ‘case reviews’, a relatively new system of checks in the NHS to examine how well trusts handle concerns and treat those who raise them.

She lacks power to enforce recommendations, relying instead on other regulators in the NHS, such as the Care Quality Commission and NHS Improvement, for ‘teeth’ and ‘bite’.

These reviews launched in June 2017, some eight months after she started. But the time they took to get off the ground attracted some criticism.

When Norman Lamb was Liberal Democrat health spokesperson, he described the NGO as a ‘damp squib’ following its ‘astounding failure to investigate a single case, 18 months after the role was first announced’, in an article in The Mirror, just weeks after Dr Hughes started.

'I’ve worked in really toxic and dysfunctional organisations but I’ve also worked in really positive ones'

Bringing this up fails to faze Dr Hughes. She was ‘starting from scratch’ she says. (Her predecessor, Dame Eileen Sills, had resigned after two months in post.)

‘Our review system was a pilot,’ Dr Hughes adds. ‘So one of the things that I thought would be a really good thing to do would be to recruit some staff,’ she says before a comedy pause. ‘For a start,’ she adds,
with a laugh.

The third part of her role is the one she admits to be the most ‘nebulous’.

‘It is to challenge the system,’ she says. ‘To get our regulators and sponsors, the Care Quality Commission, NHS England and NHS Improvement to think about the cultures in their organisations.’ She wants the GMC and unions too – including the BMA – to appoint freedom-to-speak-up guardians, as hospital trusts have.

‘It’s the culture of the surrounding organisations that derive the culture inside the providers,’ she says.

Dr Hughes’s initial prescription for a healthy NHS culture is now infamous for the reception it received.

Staff need more ‘trust and joy and love’ she told The Times in an interview to mark her appointment, appearing to urge them to be like actors in the rom-com, .

‘Simply ordering people to be happy will not wash,’ replied retired consultant rheumatologist Andrew Bamji, in one letter of response. ‘Platitudes and wishful thinking will not work,’ said another.


‘Quite soppy really’

She admits her Love Actually prescription was received with ‘deep cynicism’. ‘I think I’m quite soppy really,’ she says, ‘but who wouldn’t like the film?’

If she has any regret, it’s in the headline that went with it: “‘Happiness is the best medicine,” grumpy doctors and nurses told”.’

‘I don’t think grumpy is the right word,’ she says. ‘Harassed, harassed. It’s going to happen. I will often put myself in other people’s shoes,’ she adds. ‘I’ve had my good days and bad days myself.’

But despite the cynical reception, there’s a serious point behind her love for this syrupy flick, which relates to her work here and her earlier career.

‘I’ve worked in really toxic and dysfunctional organisations but I’ve also worked in really positive ones. I know where I’d like to work better.’

With a more positive, Love Actually vibe in the NHS, she’ll no longer be needed, a laudable goal for sure.

‘My ideal scenario would be that every organisation has supportive line managers, so that we don’t need freedom-to-speak-up guardians, we don’t need a national guardian, and that we have a positive and a supportive culture in the NHS and in all organisations,’ she says with a final dramatic swirl of her hands.

‘Then I can go and do something different. And start seeing patients.’

Given the extent of bullying and harassment in the NHS, they may be kept waiting some time.

A BMA raising-concerns advice service provides support to members who have concerns about patient safety but are not sure how to raise them. Call 0300 123 1233.

Read the BMA's guide to raising concerns

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