Continued Petition

I will begin the answer and ask Ms Rogers to fill it out. We are happy to take your guidance on the length of answers.

I am certain that awareness of the national confidential alert line could be improved. There are no circumstances in which awareness is perfect, but it is fairly broad. The line is certainly known about by all the NHS boards and by the employee directors on the boards, who represent the interests of the trade union side of the partnership. We seek to make staff aware of the line through a number of routes.

You asked whether the line’s use can be conflated with raising a grievance. I understand that, in law, a grievance needs to be dealt with between the employee and the employer so, if someone phones the national confidential alert line and expresses a grievance, it will be referred to the employer. If there were other aspects to the person’s concerns, that would not be the only route that the national confidential alert line could take. For example, it can also refer matters to Healthcare Improvement Scotland, and it has done so.

If you would like more detail, Ms Rogers can provide that.

There are issues in which whistleblowing and grievance come together. People feeling aggrieved at work and their having concerns are, by their nature, not things that are always easy to separate out completely. There are therefore times when those matters have to be taken as a whole. Sometimes, the response to an employee raising a whistleblowing issue can lead to their having a sense of grievance or feeling that the matters were not dealt with in the manner that they would have wished in the first instance. As a general principle, when people are unhappy about something, it is possible for such issues to become conflated.

A lot of work has been done to raise awareness of the line. Public Concern at Work has attended the NHS staff conference, for example, and has issued small, pocket-sized guides to the line and various other materials. The honest answer to the convener’s question about awareness is that it has grown over time.

That would depend on the nature of the person’s concern. If the concern was about a clinical matter, it would have to go through the appropriate clinical governance—otherwise, we would be breaking the chain of accountability.

It is probably difficult to answer the question without a specific example, and I am more than happy to take any specific examples. I am not trying to dodge the question, but the answer very much depends on the facts and circumstances of the individual case. If you prompted me to think about a case in which a member of staff was concerned about their immediate line management, for example, and was therefore—to be simple about it—afraid of what might happen next, we would urge such staff to contact their trade union representative or another appropriate representative in all circumstances. Escalation is available in board governance and, ultimately, there is a whistleblowing champion on each board to whom matters can be addressed. Does that answer the question?

I think that Public Concern at Work was referring to the independent assessment of a case. In the consultation that we have done, an independent national officer was proposed. The favoured option in responses to the consultation was that such a role should rest with the Scottish Public Services Ombudsman.

It is clear that, ultimately, that would be a matter for the Scottish Parliamentary Corporate Body. However, to be straightforward about it, it is recognised that an ultimate recourse to an independent national officer is worth having.

It is recognised by me as the chief executive of all the national health service, by ministers and by the health workforce director. We agree that such a role ought to be put in place.

I am clear that it should be, and ministers are clear that it should be. As I said, it is ultimately a matter for the Parliament to agree on. Given that the role would be for the ombudsman, it would also matter whether the ombudsman was content to take it on, and we are working closely with it on that. I am confident that we should establish an independent national officer and I would be disappointed if we did not.

We are on record as committing to an on-going call line as part of the remedies that are available for whistleblowing across the NHS. At this stage, we are not committed to PCAW or any individual supplier in that process. As you have identified, the contract will end in June, and we will undertake the normal procurement processes until then to look at who else might be able to provide the facility for us.

We receive six-monthly reports from PCAW, and some of the usage numbers are of interest to us. One important message for the committee to hear is that, although the national confidential alert line is an important part of the remedies, it is only one part.

We have been working for two or three years on implementing the NHS Scotland workforce strategy, the first component part of which is about values and culture. We are seeing some indication that those values and the approach to the culture of patient safety are starting to be embedded in NHS board activity. We have some support in that space. The policies and procedures in the partnership information network guidelines, which some committee members might be familiar with and which we have established across NHS Scotland, are also starting to give a more consistent approach to how such activities are rolled out across Scotland.

Your point about whether people are actively using the alert line is well made, but that is not the only indicator of the temperature of whistleblowing culture or support. I will say honestly that we need to do much more to make the service aware of the facilities and remedies that are available and to see that those processes are brought to bear consistently well when they are required.

09:30

I will address the question about confidence in using the service and the other remedies that are available, which Shirley Rogers mentioned, and then go on to the point about having an open learning culture. Every year, boards have a review, which is sometimes a ministerial review and is sometimes led by officials. At the annual reviews that I attend, there is always an opportunity to meet the partnership forum. That is one mechanism—although not the only one—through which we hear directly from the partnership about how staff in the board are feeling and about any issues that they want to raise with me or the minister. I sense that there is a degree of confidence in those arrangements but, as I said in reply to the convener, we can of course ensure that they are more widely known about and understood.

The data is hard to interpret, but it may suggest that the spike in calls at the beginning was from people who had been bottling up issues because they had felt that there was nowhere to go with them until the national confidential alert line met that need. The reduction in calls might not indicate a loss of confidence in the system itself.

Shirley Rogers might want to add something before I go on to the point about an open and transparent culture.

It would be difficult for me to come here and say that everyone is confident about the system, because people’s confidence depends on the response that they receive and how closely they feel that that response addresses the issues that they have raised. We began the evidence session with a question about conflating issues; sometimes it is impossible to separate things out for people in a way that is as optimal as they would like. Sometimes issues are raised and dealt with appropriately and sometimes the response is not as optimal as it should be.

It is fair to say that we have put a great deal of investment into partnership working in the NHS in Scotland and in our staff governance arrangements, and some of that has been externally validated. Although that has taken the agenda forward, for some individuals those relationships have not been helpful. In addition, sometimes the relationships between individuals and their representatives are not ideal.

I will not say that I think that the system works perfectly every time. There is a huge investment in making people aware of whistleblowing. The issue was not talked about in any setting 10 or 15 years ago, but there is increasing awareness of it and of what works. There is also increasing awareness of the effectiveness of listening. Often, individuals are looking for a process in which they feel that they have been respectfully, appropriately and considerately listened to. We are building that into our leadership development capacity and our whole approach to how a modern NHS is managed and how people experience the workplace.

We have demonstrable evidence of that, some of which is externally validated. We have had a report on partnership working in the NHS by the University of Nottingham, which was complimentary about the work that had taken place. However, even that report recognises that there is still more to do. As we continue on this journey, we are continually trying to improve and learn from the situation.

Although that activity is taking place in boards, we are also addressing the issue in policy terms. It is my pleasure, although sometimes with sadness, that my role frequently involves meeting people for whom the system has not always worked as well as we might wish. It is helpful to policy making for us to learn from those experiences, too.

Openness and transparency are a fundamental building block of improvement. We do not get improvement if we do not have openness and transparency.

The issue is how openness and transparency are dealt with and treated. If something very minor happens in the care of a patient, it is first fundamental that the patient is told and, secondly, it is essential to record the incident. The incident might be as minor as the wrong drug being brought—not administered, but simply brought. That is recorded as an incident of harm, although there was in fact no actual harm to the patient—there was potential harm, which is still recorded.

The issue is partly about how that plays out in the space in which it happens—such as a ward or theatre—and partly about how it plays out in public. I encourage people to make sure that any incident at all is reported and recorded. We can understand why, if the public discourse is that the number of incidents of harm has rocketed, that is an external inhibition on people being transparent, although we are trying to record what actually happened and it is not the case that harm levels have rocketed. If recording is met defensively, people internally will be less inclined to do it; if it is met openly, with a view to learning from incidents as part of people’s professional and personal development, they will be encouraged to do it again.

There is of course the duty of candour, so people are required to report things. I am absolutely clear that, although it might mean that it looks as though incidents are increasing when they are not, proper reporting, openness, transparency and recording are essential. I have no doubt about that and, if a senior clinician were here, I am certain that they would say the same.

All that I can say is that there is not pressure from me to do that. I would not press people on what to call an event—if it is a significant adverse event, that is what it is. I would not press them to call it anything else. The only way that we will learn is by treating incidents with the appropriate level of seriousness.

I would be very happy to share with the committee the guidance that we have on those matters. It is too voluminous to go into in detail now, and some of it would require the advice of a clinician rather than my advice as a professional administrator. However, it would be of no difficulty to share with the committee the guidance on all those issues, if members would find it helpful.

First, to be simple about it, there is no such thing in my world as low-level bullying. It should not happen at all, anywhere. If there is a sense that something like that is being normalised, that is utterly and fundamentally wrong.

If the culture in a place means that certain things are tolerated, my view is that what you permit, you promote. If I, as a leader or a manager, permit something to happen, I am, in effect, promoting it. Again, I regard that as wrong.

We greatly value the partnership relationships and arrangements that we have with trade unions such as Unison. We work with them to ensure that awareness is raised and that, when people have what might seem to be low-level concerns, there is still scope to raise them. There is clear evidence that, when the workforce is engaged and feels valued, it will deliver better. There is an absolute line of sight between an engaged workforce that feels valued and the care that we provide to people. Ms Rogers can say a bit more about that.

Our intent is that the right thing happens the first time and that the quicker there is resolution of a matter, the better. If Unison is alluding to something of a relatively modest nature being raised and resolved and therefore not reported, I think that there is an issue about reporting, but we want the right thing to happen the first time. We have had conversations with the Royal College of Nursing, Unison, Unite and others about examples that they have of individuals who have raised concerns and had them immediately addressed by their line manager, so the concerns have been resolved and they have moved on. It is important that we are aware of those instances.

Going back to the point that the director general made, we need to be aware of issues when they arise and be able to fix them. In fact, we want boards to be responsive at every level of leadership within the organisation. If somebody raises something and says “I need X” and they get X, that is helpful. What we need to reinforce at every opportunity are the standards of conduct, behaviour and all the rest of it that are expected to apply in terms of our relationship with the boards and their relationships with their employees. Those are reciprocal things that are about not just what we expect from employees, but what employees can expect of the organisation that employs them.

Therefore, we want to hear about every instance. I could not agree more with the DG about there not being such a thing as low-level bullying. People are either bullied or they are not, just as a woman cannot be just a bit pregnant. If something bad is happening to someone in a place, we need to be able to respond to that quickly. The way in which boards can do that is by matters being safely and appropriately brought to people’s attention and resolved.

I have a couple of things to say on that. First, a number of reports by Healthcare Improvement Scotland have been published as a result of issues being raised by people through the kind of opportunity that you described. There is evidence that, through such means, issues are listened to and taken seriously.

Secondly, we have different arrangements for reporting instances of fraud, for example, which would not come through the helpline. I am not saying that someone who was concerned about fraud could not contact the helpline—of course they could—but there are other arrangements for reporting fraud. Some of the issues that were identified in Edinburgh might have been dealt with slightly differently. However, Ms Rogers can provide more detail on the issue.

09:45

That is a valid point. We are learning as we go with the whistleblowing helpline, and as I have said, we will review its effectiveness as we go forward to the next contracting round. It is one of a range of remedies. The NHS has a number of policies and procedures, such as the partnership information network guidelines, internal grievance procedures and NHS counter-fraud services, as the DG alluded to.

To date, Healthcare Improvement Scotland has looked at nine cases of potential concern that have arisen from the PCAW helpline. HIS has put fairly substantial weight behind some of those investigations to make sure that there are appropriate conclusions and that concerns are remedied. However, we are not finished yet, and the helpline is one of a range of remedies that we are developing. We believe that there is considerable merit in pursuing the independent national officer role and we intend to do that. Angus MacDonald asked how confident we are that we will do that. It is our intention to have a proposition for parliamentary consideration in a reasonable order of time.

We hope to be in a position to consult by the autumn. We understand the additional assurance that might be given by the independent national officer role.

I will start, then Shirley Rogers will follow on. One reason why I decided that it was appropriate to speak to the press about this—there was an article in The Herald and there were reports elsewhere in September last year—is that, as chief executive of the national health service in Scotland, I need to set the tone for our behaviour. I wanted to make it clear that, from my perspective, there is no place in which people should be inhibited, through fear, from raising concerns. I spoke to the press because I recognised that in some places there was some fear. I would not have done it if I had thought that there was nothing to fix. I accept that there can be some fear.

Sometimes the fear is well founded—in other words, people have had bad experiences and that causes them to think that they might have a bad experience again—and sometimes it is not very well founded and is just a vague fear that a person has that if they do or say something, something bad might happen. In either case, I want to continue to work with people, through the partnership arrangements that we have, to ensure that people can raise concerns without fear. That is why I said in response to Brian Whittle’s question that I am pressing so hard on the issue of transparency.

At a very basic level, if people know that there is a way to do something that is clear and understood, that is a lot easier than having to work out what to do. Ms Rogers will be able to speak eloquently about the PIN guidelines that are in place. My point is that there needs to be something that is locally visible that tells people how to raise a concern, if they have one. If someone has a concern, having to work out what to do with it can itself act as an inhibition.

I am seeking to set the standard and to be clear that bullying and harassment in any form whatsoever has no place anywhere in the NHS. Have I completely fixed the problem? No, I have not.

Let me give you an example. Obviously, I cannot talk about individual cases, but this example is sufficiently anonymous for me to believe that it is useable. An MSP approached me on behalf of a constituent and put before me some documentation about that constituent’s experience. I read that documentation and gave it to Shirley Rogers, the director of workforce, and Fiona McQueen, the chief nursing officer. They engaged with the health board in question and with the nurse director in question. As a result of that, the person’s concerns were taken up and addressed appropriately—I am saying to you very explicitly that, up until that point, they had not been. That person was not treated respectfully and their concerns were not heard properly. There were many factors—there are two sides to every story—but the bottom line was that the person’s concerns were not properly heard and, when they were, the situation was resolved satisfactorily.

No. The member of staff had been experiencing issues that affected their ability to perform their work effectively, and the result of the process was that those issues stopped being treated as trivial and secondary and were treated as issues that ought to be addressed and resolved. Appropriate professional development and training were also put in place in that area so that staff generally could understand the appropriate way to deal with those issues and the appropriate way to listen to concerns as they were raised.

I personally have been involved in a number of ways in issues where remedial action has resulted in disciplinary action, ranging from guidance to dismissal.

I want to talk a bit more broadly about the question of a culture of fear. I have been an NHS manager in NHS Scotland for well over 20 years. NHS Scotland is a big place, with 156,000 people and 22 health boards across our geography. It is difficult to make a sweeping statement when we talk about culture. After all, the culture in south Glasgow is not the same as the culture in north Glasgow, never mind the culture in Glasgow versus the culture in Orkney. Therefore, we need to be culturally intelligent and sensitive to the circumstances.

That said, we have been clear about the standards that we expect in NHS Scotland. We have an internationally regarded workforce strategy, and the first of only five elements of that strategy is about culture and values and how we behave to each other in a modern workplace in a way that is supportive of people who have a right to expect to be treated in a particular way.

We review all our employment policies in light of the everyone matters strategy and in light of those values and behaviours, and we learn from the experiences of individuals who talk to us about their experiences. Over the past year, we have been focusing particularly on leadership and management development activity. As committee members will be aware, leadership and management development has been an issue for the NHS in Scotland. We had a target to reduce managerial costs where we could and, as we have been doing that—and I should say that we have been very successful in reducing those costs—we have been working hard to improve the level of managerial and leadership behaviours and the quality of that input. We have been doing a lot in that space.

We have also listened to other voices. We have heard from trade union representatives and experts in the field, and a variety of others have shared with us their experiences of how they are managed in the NHS. We have learned from all that. I have shared a platform in a number of forums with individuals and with organisations ranging from the royal colleges to Stonewall and various others to talk about how we create or support the kind of environment that we want. At its best, the environment here is world class. However, it is not at its best everywhere, and we have been doing a lot in that space, too.

Members will have seen from our evidence that we have been investing around the board table to increase understanding at governance level of boards’ responsibilities in this regard. We have introduced the concept of board champions, which has landed extremely well in some places. In others, however, there is more work to be done to make sure that people are confident about the roles.

We also have more to do in telling the successful stories. If we are serious about shifting the culture, we need to have messages to demonstrate that people who have raised concerns have had those concerns appropriately and satisfactorily addressed. We have examples of that, but they are not as complete as we would want them to be, to allow us to talk about the process in a way that would give people confidence in it.

I do not need to tell the committee what it takes to be a learning organisation, as I am sure that you will be more than aware of that, but all the evidence on how to create, support and develop learning organisations points to the need to change fundamentally the relationship that organisations have with their staff in the area of blame. That is where our efforts are targeted. When we talk about the alert line, our champions, our PIN policies and procedures and the independent national officer, we recognise that, in order to shift the culture, it will take a number of initiatives working together to make sure that we always make the response that our workforce deserves.

An employee of NHS Scotland can—and should—use their employers’ policies. Obviously, I cannot speak for local authorities but, similarly, I would expect local authorities’ staff to do the same.

Clearly, as integration proceeds, people will be working closely together, and an incident might become known to two people, one of whom works for one employer and one of whom works for another. Both employers might need to think about such incidents arising. However, the route that any employee can take remains unchanged even if they are working in an integration partnership.

Building on Mr Gray’s response, I think that he is entirely right to say that an NHS Scotland employee continues to enjoy and be subject to NHS terms and conditions. Similarly, if we come at the issue from a local authority perspective, we will see that those staff are subject to the authorities’ terms and conditions.

In reality, most people’s experiences of what happens when things go wrong are determined by the first response that they get. Therefore, if someone raises a concern, we need people to be more confident about the process and not simply to ask what terms and conditions the person is subject to. We are working carefully with the chief officers—given Maurice Corry’s background, he will be aware that some have a local authority background, some come from the NHS and others come from elsewhere—to ensure that they all have an understanding of the terms and conditions that pertain, so that their first response is appropriate and supportive.

I do not have the evidence to suggest that that is so, but it is difficult to say that something is not so. However, in the early stages in the integration partnerships’ establishment, I was asked by the partnership forum at an annual NHS board review if I would not simply impose the partnership arrangements that apply in the NHS to the integration partnerships. I said that I would not do so, because imposing arrangements on anyone is not a good way to get them to accept them or to ensure that they benefit from them.

We are finding that, in a number of the integration partnerships, the arrangements that we have in the NHS are, as it were, being drawn forward into the integration joint boards. I genuinely welcome that, because it is of benefit if people can have access to one set of partnership arrangements when they are at work. However, my view remains that imposing arrangements on people who work for other employers is not how we gain their confidence.

10:00

No, I think that the opposite is true. There is no circumstance in which an employee, regardless of whether they are employed by a local authority, a health board or one of our third sector partners, cannot raise a concern. It is not the case that the NHS partnership arrangements not being in place mean that staff cannot raise concerns. I would be more likely to damage the prospects of people having confidence in the arrangements if I were to impose them than I would be if I were to put them in place following proper negotiation.

Ms Rogers might want to add to that.

I will say a few things about how we have been seeking to exert influence in that space. As committee members will understand, we are talking about not only employees of local authorities and the NHS; third sector and independent sector organisations and all sorts of other people get involved in that space.

There are two things that it might be useful for the committee to understand. First, the NHS has a methodology for looking at employees’ experience at work called iMatter, which was developed in concert with an academic institution—the University of Dundee. It is a piece of work that through self-diagnosis by individuals and teams, looks at how people experience their life at work. It is held in high regard and has been rolled out to good effect across the NHS in Scotland, and we have been able to share it with partners across the IJB landscape. A large number of IJBs are using the same methodology, and four local authorities are in discussion with us about how they might use what has been quite a useful tool across the whole of their workforce.

The second thing that it might be helpful for the committee to appreciate is that, before we put in place the IJB landscape, we set up the human resources working group, which is looking at the HR implications of an integrated service delivery process that uses employees from different organisations. The group, which I previously chaired, has been looking at the issues and seeking to share experience and methodologies. We would be the first to acknowledge that the NHS is not necessarily the best at everything. We have shared methodologies on job evaluation and workforce planning, and we have looked at things such as staff surveys, the “Taking the temperature” reports, whistleblowing and various other bits and pieces.