How the NHS ‘culture of concealment and denial’ hurts patients

Good morning. It is no secret that NHS England has many problems: it is crumbling (literally), patient care backlogs are at record highs, there is a recruitment and retention crisis, and quality of care is declining with the results for patients sometimes life-threatening.

Over the last two decades a parallel problem has emerged. The NHS ombudsman Rob Behrens described to Guardian health editor Denis Campbell that the health service has a “cover-up culture”. Behren has identified an alarming practice where some trusts “cynically [bury] evidence about poor care” to maintain their reputation. It is not the first time that cultural problems have been identified – over the years a number of reports and inquiries have highlighted practices of silencing and punishing whistleblowers.

For today’s newsletter, I spoke with James Titcombe, a patient safety specialist, about Behrens’ findings and why it is taking so long for the culture in the NHS to change. That’s right after the headlines.

Five big stories

In depth: ‘In some cases the harm after a tragic event is equal to the harm of what happened in the first place’

The health service is a large, fragmented institution made up of many organisations, regulators and trusts that have their own cultures and processes, so it is difficult to identify just how widespread the cover-up culture is, but there are some indicators. In the annual NHS staff survey more than 30% of staff reported that they lack confidence that the NHS would take action to learn from incidents involving patients, which James Titcombe says is “deeply worrying”.

Just under 60% of staff say that the NHS treats staff who are involved in an error, near miss or incident fairly, which is a very small improvement from the previous year. “But, still, you have got more than 40% of staff who feel they wouldn’t be treated fairly and that’s obviously a big part of the problem”.

Cover-ups

Behrens told the Guardian that he had found that, too often, lessons are not learned in the health service and requisite changes to ensure mistakes aren’t repeated do not happen. Instead a “cover-up culture” has often led to the punishment of whistleblowers who raise concerns.

Titcombe mirrors this assessment in his analysis of the situation. “There is sadly still a culture of concealment and denial,” he says, which has left staff frightened. If doctors, nurses and other medical professionals are worried for their careers it discourages and disincentives openness and transparency. Titcombe adds that there is variation within the health service when it comes to the work culture because it is to a degree splintered. A well-functioning culture is one that centres “problem-sensing” at every level and supports staff to feel “psychologically safe” to talk openly about their concerns, including hazards that have not yet become a problem. This behaviour ideally would be rewarded, Titcombe says, and regarded as an example of “exemplary professionalism”. This is not possible in individual trusts where leaders prioritise “reputation management”, as opposed to patient safety and transparency.

Harm to patients

Where these cultures exist, issues remain hidden or are not escalated, to the detriment of patient safety, leading to avoidable harm or death. In 2019 there were more than 130,000 avoidable deaths in Britain, which accounts for more than 22% of all deaths. Of these, 64% were classed as preventable and 36% were classed as treatable.

In the most extreme cases, the consequences can be unimaginably horrific. Dr Stephen Brearey flagged concerns about the serial baby killer Lucy Letby (above) in 2015 but was ignored by senior staff. The inaction meant that Letby was able to kill further babies in the following summer. Following Letby’s conviction, Brearey said many other doctors had contacted him describing similar experiences of being dismissed. One survey in the wake of the trial found that 71% of doctors believed that whistleblowing damaged their careers.

Is anything changing?

This problem is not new. An inquiry in 2015 found that whistleblowers were ignored, bullied or even intimidated in the health service. And a series of scandals over the past two decades found that a central part of the problem was a climate of fear that stopped people from speaking out when they spotted issues. An investigation into the Mid Staffordshire hospital trust in 2013 found that abuse of whistleblowers was a key failing in the handling of a situation that led to hundreds of patient deaths due to poor care between 2005 and 2009. James Titcombe has been raising the alarm about the structural cultural problems in the NHS since 2008 after his nine-day-old son, Joshua, died as a result of failures in his care. Why is change so slow?

Some initiatives and measures have been put in place – like the legal duty of candour which was instituted in 2014 and is now under review – but the ombudsman found that hospitals are still not being transparent when things go wrong. There have been more recent significant steps forward like Martha’s rule which allows families to seek an urgent second opinion if a patient’s condition deteriorates, but the underlying culture remains largely unchanged.

“You’d think that a system would wrap their arms around patients and families who have lost people and do everything possible to help them heal and recover,” Titcombe says. “Sadly what often happens is instead they go through this battle, sometimes for years on end, which compounds their harm considerably. In some cases the harm caused for those families following a tragic event is equal in many ways to the harm of what happened in the first place. It has such a devastating impact on people’s lives”.

What else we’ve been reading

• If I’m still as half as sprightly as some of these nonagenarians when I get to that age then I’ll be absolutely chuffed. One woman came out at age 95, and became “a new girl”. Another gained thousands of fans as an influencer. We meet the people in their 90s turning their lives around. Nazia Parveen, acting deputy editor, newsletters

• Natasha Beddingfield’s Unwritten is (at least for me) a go-to karaoke song that brings unbridled joy to just about everyone, so reading this interview with Dave Simpson in which the singer tells us all how she came up with this certified banger was a delight. Nimo

• The snarky rivalries between the world’s tech billionaires has filled many column inches of late with the most recent war of words involving a challenge to a cage fight. For the Atlantic, Ross Anderson takes a look at the drama between the kings of tech. Nazia

• I came across the Tiny Fey girl-band sitcom Girls5eva over the weekend by accident, and I’m so glad I did. Stuart Heritage explains how Netflix saved this gem from cancellation. Nimo

• We are heading towards the world’s first trillionaires being crowned – but what does it mean when individual wealth reaches levels we’ve never seen before? Duncan Weldon finds out. Nazia

Sport

Football | Nottingham Forest have received a four-point deduction for breaching the Premier League’s profitability and sustainability rules, dropping them into the relegation zone, one point from the last safe spot. An announcement from the Premier League is expected on Monday and Forest are likely to appeal. Luton, with whom Forest drew 1-1 on Saturday, have been lifted out of the bottom three by the punishment.

Cycling | After Britain’s most successful female Olympian, cyclist Laura Kenny, announced her retirement on Monday, William Fotheringham profiles the six-time medalists rise and “golden era”. “In the years of ‘peak Laura’, she turned one discipline in particular, the elimination race, into her personal party piece,” he writes.

Cricket | Captain Heather Knight paved the way for England Women to win the opening T20 international against New Zealand by 27 runs. Knight hit 63 from 39 balls as England reached 160-4 in Dunedin before bowling two tight overs as the visiting attack put the brakes on New Zealand’s reply.

The front pages

The Guardian leads with an exclusive: “Garrick membership list reveals roll call of British establishment”. The Mirror carries an interview with Keir Starmer, under the headline “I will not let you down”, while the Telegraph headlines comments from the shadow chancellor with “Reeves: Britain faces 1979 moment”.

The Times reports “Sunak risks losing key votes on Rwanda bill”. The i says “Energy customers set for payouts worth billions in scandal that’s ‘bigger than PPI’”. The Financial Times leads with “Deloitte launches biggest shake-up in a decade as market slowdown looms”.

The Sun has a picture of the Princess of Wales on its front page, with the headline “Great to see you again, Kate!”. Finally, the Mail reports “Harry and Meghan are downgraded by Palace”.

Today in Focus

Cartoon of the day | Ben Jennings

The Upside

A bit of good news to remind you that the world’s not all bad

“Tell me, what is it you plan to do /
with your one wild and precious life?”

It is this one, simple question – posed by Mary Oliver’s poem The Summer Day with which Moya Sarner begins her new weekly series, How to build a better life. It is a subject Sarner is perfectly poised to tackle, having changed course from a career in journalism to become psychodynamic psychotherapist working for the NHS. In the first entry, the focus is on listening and how it can sustain us. “To protect our brain cells from dying, to nourish our minds and live better throughout our lives, we need to deepen and enliven our relationships by listening.”

Sign up here for a weekly roundup of The Upside, sent to you every Sunday

Bored at work?

And finally, the Guardian’s puzzles are here to keep you entertained throughout the day. Until tomorrow.

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