Being fair 2 aims to promote the value of a person-centred workplace that is compassionate, safe and fair.
A just and learning culture is the balance of fairness, justice, learning – and taking responsibility for actions. It is not about seeking to blame the individuals involved when care in the NHS goes wrong, nor the absence of responsibility and accountability.
Since the publication of Being fair in July 2019, and with ongoing work across the NHS, it is apparent that organisations still require support to improve the culture for those working within the health system to tackle issues of incivility, bullying and harassment.
Our second Being fair report sets out the benefits to an organisation of adopting a more reflective approach to learning from incidents and supporting staff.
Download the Being fair 2 report here
The key messages from the report are:
- There is a clear link between culture, workforce and patient safety.
- A poor culture is costly: The cost of non-clinical, work-related stress claims closed over a ten-year period (2010-2020) was in excess of £14 million.
- Minority groups are disproportionately impacted by formal disciplinary processes: Our Practitioner Performance Advice service found that ethnic minority groups had 1.7 times the rate of cases per 1000 and were significantly more likely to have a case with the service compared with white practitioners. Redressing disproportionate rates of disciplinary action between ethnic minority and white staff across the healthcare system is essential to foster a just system that supports staff to learn from incidents. This is in line with other recent findings.
- A diverse and inclusive working environment is beneficial for productivity and staff retention: When staff feel valued, able to speak up and psychologically safe this can have a positive impact on teamwork, staff wellbeing, efficiency and lead to higher standards of patient care.
There is already a wealth of resources and guidance available across the system to support organisations to drive improvements in culture. This report makes reference to key guidance and best practice throughout. It also provides a ‘Just and learning culture charter’ that we invite organisations to consider adopting.
Organisational culture is everyone’s business. Everyone within healthcare has an important role to play, across all professional groups and at all levels. We hope this report acts as a toolkit for organisations looking to adopt a just culture when managing incidents and supporting staff.
We are grateful to a wide range of organisations who have contributed to this report including the Care Quality Commission, British Medical Association, Royal College of Nursing, Health and Care Professions Council, The National Guardian’s Office, NHS England, the General Medical Council and others.
At NHS Resolution, we provide expertise to the NHS to resolve concerns and disputes fairly, share learning for improvement and to help preserve resources for patient care. Our work and the work of others across the system has identified that issues of incivility, bullying and harassment are prevalent across the NHS. This has a negative impact on staff recruitment, retention and overall wellbeing. We hope this document highlights not only the importance of this issue but encourages organisations to take an evidence-based approach to improving organisational culture. We will continue to work with key partners to ensure the best practice referenced throughout the report is implemented.
Dr Denise Chaffer, Director of Safety and Learning, NHS Resolution
Being Fair 2 uses Practitioner Performance Advice’s experience and expertise to strengthen its recommendations. Our findings show that practitioners from ethnic minority groups and those who qualify outside the UK are statistically more likely to have a case with us compared to white practitioners who qualify in the UK. This is an important contribution to the discussion and highlights the need to redress disproportionate rates of disciplinary action through agreed frameworks that support a consistent approach for everyone.
The report also highlights the significant link between organisational culture and individual behaviours, emphasising how fairness and open cultures of continuous quality improvement can improve staff wellbeing and patient safety. This link is explored as part of the advice that we provide and is also a key driver for our Compassionate Conversations programme, which aims to support honest conversations on practitioner performance.
Vicky Voller, Director of Advice and Appeals, NHS Resolution
Recent years have seen a growing evidence base linking organisational culture, and the behaviours it enables or incentivises, and patient care. One aspect of this is whether organisations and individual managers respond when things don’t go as planned. Initiatives such as the ‘Just culture’ movement seek to emphasise learning not blame when things go wrong. The use of accountability nudges at the point of incident have helped to reduce biased decisions to disproportionately investigate ethnic minority groups when incidents occur.
This revised version of the original Being fair report will build on that work which has already helped to significantly reduce the numbers of disciplinary cases in the NHS and reduce the relative likelihood of ethnic minority staff entering the disciplinary process. The resultant emphasis on learning not blame inevitably benefits patient care.
Roger Kline OBE, Research Fellow at Middlesex University Business School and one of the report authors
I welcome NHS Resolution’s Being fair 2 report, promoting a person-centred workplace that is compassionate, safe and fair. This is important given the recent news of the decrease in workers’ confidence to speak up in this year’s NHS Staff Survey results. No one should feel they cannot speak up to protect their patients or their colleagues.
As highlighted in the report, ensuring effective speaking up arrangements are truly embedded and at the heart of any healthcare organisation is key to improving workplace culture. While Freedom to Speak Up guardians are an additional route for workers to speak up, they cannot improve the speaking up culture on their own and organisations must take a proactive approach to foster a culture where all workers feel safe to speak up and feel heard.
Dr Jayne Chidgey-Clark, National Guardian for the NHS
In line with Being fair 2, we’re clear that a just culture – that balances fairness, learning and accountability – is key to ensuring safe, effective and kind care for people who use services.
Everyone working in healthcare has a responsibility to foster these positive working cultures. That includes being open and candid with the people in your care about all aspects of care and treatment, including when any mistakes or harm have taken place. This means lessons can be learnt quickly to protect people from harm in the future.
Our Code also encourages each nurse, midwife, and nursing associate to speak up if they see something they feel isn’t right – all professionals should be able to without fear of being discriminated, excluded, victimised, bullied or undermined.
Anne Trotter, Assistant Director of Professional Practice, Nursing and Midwifery Council
We know that the right organisational culture is crucial to safety and, as demonstrated in recent reports such the Ockenden review, the impact workforce wellbeing has on patient safety is also becoming increasingly evident. How an organisation responds to bullying and harassment can have a massive impact on individuals and the quality of care provided, as well as other important factors like staff recruitment and retention.
CQC’s strategy is clear that learning and improvement must be the primary response to all safety concerns and in order to achieve this, staff should be able to report concerns openly and honestly, confident that they won’t be blamed and that their voices will be listened to and acted on.
Being fair 2, and the just and learning culture charter that accompanies it, will help organisations promote a workplace that is compassionate, safe and fair – benefitting both their staff and the patients they care for.
Dr Sean O’Kelly, Chief Inspector of Healthcare, Care Quality Commission
We welcome NHS Resolution’s Being fair 2 report which highlights the need to focus on the wellbeing and retention of healthcare staff; reduce stress and incidents of bullying, harassment or assaults; and to work together to instil fair, learning cultures in the workplace.
The data is clear, we must do more to turn the tide of talented registrants leaving the NHS. Creating compassionate leadership and safe, supportive working environments are absolutely vital, not only to the welfare of doctors, but also to the future of the NHS and to the safety of patients.
We’re taking firm steps to achieve long-lasting change and support the wider health system to overcome barriers to change. We have accelerated our commitment to eliminate disproportionate complaints from employers about ethnic minority doctors by 2026, and to eradicate disadvantage and discrimination in medical education and training by 2031. Additionally, we continue to deliver our Welcome to UK practice workshops. And we’ve developed the Professional Behaviours and Patient Safety training programme which discusses ways of responding to unprofessional behaviours, because everyone is entitled to be treated with courtesy and dignity in the workplace.
Taking practical steps to improve doctors’ working environments will not only improve their wellbeing, but will help retain their skills and experience. If doctors are happier in their working environments, and they are allowed to thrive, they will achieve better results, which will support patient safety.
Anna Rowland, Assistant Director of Policy and Business Transformation, General Medical Council
