12. A Culture of Bullying and Harassment?
12.1. In this chapter, I provide an overview of what I heard about allegations of bullying in NHSH, describing both the minority and majority views expressed, the range of views, and commenting on whether a "culture of bullying" existed.
12.2. The majority (66%) of those responding to this review wished to report experiences of what they described as bullying, in many instances significant, harmful and multi-layered, and in various parts, at all staffing levels, and in many geographic areas, disciplines and departments of NHSH. There are issues common to the whole of NHSH, some which are particular to the Inverness area and Raigmore, and some which are particular to more rural areas and to Argyll and Bute. These affect wider communities too.
12.3. As illustrated below (in a pie chart which should be taken as illustrative only and not definitive), these are a combination of very recent experiences, experiences over years and experiences from the past. Some people sense recent improvement compared to the past, while others believe that matters remain unsatisfactory.
Respondents' Descriptions of a Bullying Culture
12.4. Many experiences have not been adequately addressed at the time and the lack of closure continues to dominate some people's lives. I am satisfied that the number of examples given to me is sufficient to warrant real concern. The issues raised are also wider and more complex than "bullying", however that is defined. There are many issues to be addressed, understood and avoided in the future. I explore these further later.
The Minority View
12.5. However, it is very important to record that a significant minority of respondents expressed views with varying degrees of firmness to the effect that there is not a problem, or at least that there is no bullying culture as such, and that any conduct of concern is nothing other than what might be expected in any similar organisation with day to day pressures.
12.6. Many people, from many different and diverse vantage points within NHSH, report that they are not affected by any such concerns and feel fully supported by the organisation. Indeed, they have been more affected by the allegations made by the whistleblowers that they do not understand and have not themselves experienced. They have been hurt and angered by the adverse impact of the allegations which have been made, on patients, staff and local communities. For many of these people, reading this report may be shocking.
12.7. In order that these views are well represented, what follows is illustrative of some of what I have been told:
"I am disappointed and upset at the way NHS Highland has been portrayed in the media over recent months. I feel that the actions taken by a small number of individuals will have damaged the reputation of and public confidence in the organisation."
"These individuals are not speaking for me."
"I do not recognise that there is a culture of bullying in Highland."
"I was absolutely shocked by the press statement about a bullying culture in NHSH. I experienced years of bullying myself by a GP colleague so I am fully aware of the effect bullying can have on health and morale but, when things came to a head in my own situation, senior management in NHSH were exceptionally supportive and helpful and I don't feel I would have got through it without them. I haven't always agreed with decisions and plans over the years but have, equally, always felt able to express my views and have felt that my voice has been heard. I have never witnessed bullying in any of the clinical situations I have worked in, which was why I was so surprised and shocked by the allegations made about NHSH."
"We have never at any time experienced anything other than courtesy and professionalism from the myriad managers we have worked closely with, over the years."
"Yes, we are working in pressured and busy environments but I have not, in all my time, been part of a bullying culture. In fact, I would say the quite opposite, I have worked and continue to work with dedicated and supportive health professionals, managers and directors whose ultimate goal is that we deliver quality patient care to the population of Highland, as they deserve nothing less. I am realistic that in an organisation of this size there will be bullies and I have come across one or two but these are rare and isolated cases. Of course, it is completely unacceptable that anyone is bullied but it really concerns me is that NHS Highland has been portrayed as having a bullying culture. In my view, NHS Highland is one of the best Boards in Scotland to work in (and I have worked in and link closely with a number of Boards in my current role) and it concerns me that potentially will be forever associated and tarnished with this bullying story."
"…nothing worse than I would expect from an intensely pressured healthcare environment operated by imperfect human beings."
"… just because a person describes this process (of being questioned about their performance or working pattern), as victimisation or bullying, does not necessarily mean it is."
"I do not perceive the culture here to be one of sustained and systemic bullying, however there may be one of benign/not so benign neglect, lack focus on core service delivery and lack of values and reflective based practice."
"The main point I wanted to make is that while I know that bullying goes on in NHS Highland, I don't believe that there is an orchestrated culture of bullying as was suggested by the clinicians who initially contacted the press."
"I'm in no doubt that in an organisation of 10 000 individuals there will be instances of individual bullying and harassment. There may also be small pockets in some services or localities. I have not seen anything that suggests it is endemic across NHS Highland."
"I have also managed staff in NHS Highland, and am managed by more senior managers and what is being described is not something I have seen any evidence of. On the contrary, where there are staff who can be more difficult to manage, or who are not particularly good at undertaking their job, the ultimate full support is given to them, I would say to the detriment of NHS Highland. I have been involved in managing some staff who in all honesty I felt were trying to play a game and trying to avoid having to do a day's work, but we as managers are bound by our policies to support these staff who are usually the ones to involve their Unions. All the evidence I see in my role is NHS Highland support their staff to high levels which would not, I believe, happen in the private sector. I have huge concerns these allegations have empowered some staff inappropriately who see this as an opportunity to blemish our organisation."
Other Similar Views
12.8. A group of consultants from one specialty wrote to me as follows confirming what they had told me in a meeting, namely that they were surprised to hear of the allegations:
"Cumulatively, we have over 70 years of experience in NHS Highland, through various service changes and management arrangements. We have experienced disagreements and conflicts, but our overwhelming experience is of dedicated staff working together to deliver care to the best of their abilities. We accept that some staff have had different experiences, but we have not personally experienced or witnessed bullying. We have found NHS Highland a friendly and supportive environment in which to work."
12.9. The diversity of experience and viewpoints is marked with these comments from the South and Mid Division Senior Leadership team. They told me that "in the senior management team, we have spoken about the allegations that were made. The feel from this team was complete shock and disbelief. What we have struggled with is the whole view of a culture of bullying and harassment that we just do not recognise."
12.10. Similarly, a group of senior nurses at Raigmore Hospital expressed the collective view that, "while there may be isolated incidents and communication issues, there is not a culture of bullying."
12.11. Frustrations allied to general contentment was summed up by one clinician in this way:
"I have been very happy working in Raigmore and have lots of positives to say about Raigmore which include team working, good colleagues, good relationships with other teams in the hospital, opportunities in developing personal interests. There are frustrations about working in NHS Highland but I imagine this is not unique to Highland given the financial constraints. I feel management do not always listen to concerns raised… and that there is a lack of information coming down from senior management. There are many decisions I do not agree with; however I do not see this as a bullying culture."
12.12. The state of general confusion and impotence in which a number of employees found themselves is reflected in this:
"I am unaware of the detail of the concerns that have been raised, I have not been party to any NHS Highland Board or senior executive level discussions. I have been in an uncomfortable position with a complete lack of information available to me. I have as a result been unable to fully understand what the issues are other than hearing snippets from medical staff who have clearly been having much discussion through WhatsApp. One Consultant advised me that there was talk of a need for organisational cleansing – quite what that involves I am not clear but it felt threatening! For myself as an individual I feel I have been severely undermined and disrespected, and I have been completely unable to support the staff that report to me effectively with regards to the current situation."
12.13. In reality, given the range of responses and experiences, there is probably for many people a continuum or spectrum. For them, the existence (or not) of bullying cannot be assessed in a binary way. As noted earlier, it is likely that pockets exist. Other observations support this:
"I've observed people with supreme experience handling very difficult situations in an exemplary way. I've seen the complete opposite as well."
"My experience working within NHS Highland is that there is not a bullying culture. There are bullies and there are incidents of bullying. There are also those who seem susceptible to bullying. I personally do not see it on an everyday basis which means I don't think it is endemic.
It may be that the specific instances where I think conflict has become bullying will be repeated to you time and again and this may represent focal pockets attributable within certain departments, certain individuals or when certain stresses hit the system. There are also people throughout the clinical, support services and management of the organisation who are excellent people with great skills and attitudes who do a fantastic job day in day out."
12.14. Interestingly, in our meeting, the clinician who expressed the latter views spoke of a number of instances of behaviour that were not acceptable and we agreed that there may be two ways of seeing the same thing and that, in fact, when one thought about it and pieced together different events, a broader picture of unsatisfactory behaviour emerged. This was not necessarily systematic or deliberately commissioned but the result of a culture which was replicated and adopted because (a) it achieved certain financial and other targets and (b) it was the way others behaved and was a safe way to protect oneself.
12.15. Other respondents also modified their views upon reflection and in discussion, especially as they reflected on their own experiences. This represents an often-expressed emerging acceptance:
"At the time that the press release went out about a bullying culture I felt that this was wrong without consultation and that it might do more harm than good. I am glad though that this is being investigated in this way and will be interested in the outcome of the report."
12.16. Another, who had challenged the allegations about bullying because of their source and at whom they were apparently directed, came to the view that he himself had actually experienced what would be described as bullying but from a different angle.
"I feel very bruised by the four. But something has been released in the organisation, so it served its purpose."
12.17. A nursing member of staff acknowledged that many people had not spoken up:
"I feel let down by a system that didn't care until it felt the pressure to atone after being publicly shamed in the press. My experience is that there are a wealth of good people in the organisation who have stood by and done nothing, because that's easier than speaking out."
The Majority View
12.18. Further along the continuum, this summary of the behaviours which have caused so much concern comes from a senior member in an important supporting role:
"Over the past ten years, I have supported [a number of] Senior Managers in NHS Highland, who reported being bullied and intimidated in their work, some to the point of tears and sickness through stress and most of them having now left the organisation. I have also supported many more in middle management who reported the same kind of bullying happening to them. It became apparent to me that models of bullying behaviour at the highest levels of the organisation, were being copied throughout. These included ignoring people, belittling them, treating their ideas with contempt and talking about them negatively to other members of staff. Often when staff have spoken out against this, or against what they perceive to be poor decisions, they are taken aside and interviewed by two or more Senior Managers and cautioned or threatened with disciplinary action. I have seen the abuse of 'suspension processes' and trite or trumped up charges being levelled at staff in order to take them through protracted disciplinary processes, during which time they are off work and instructed not to speak to their colleagues. In my mind, there is no doubt whatsoever that there is a culture of bullying in the organisation, and not just isolated incidents."
12.19. This, which bears a striking similarity to definitions provided in chapter 10, is a perspective shared by many of those who responded and who welcome the review, as the following comment from another senior and recently retired member of staff reveals:
"… I am in no doubt that NHSH has operated under a veil of fear and intimidation for many, many years. Anecdotal evidence indicates behaviours in keeping with this to be at the highest level of the organisation. Sadly, I have had confidential discussions with many colleagues who have had similar experiences to my own and have been left with no adequate resolution to their concerns and in some instances have chosen to leave the organisation. Early retirement sadly, is a very popular option…
There are many, many dedicated, highly professional and committed people working for NHSH. This review does offer a real and important opportunity to get to the bottom of why things have gone so badly wrong, make recommendations to ensure that the organisation can move forward positively and effectively enabling a happy, confident and stable workforce. This is the essence of ensuring patients receive excellent clinical, holistic, person-centred and compassionate care."
12.20. The final paragraph above summarises the value many NHSH employees place on the decision to carry out this review.
A Bullying Culture?
12.21. While, as I noted at the start of this section, the view that there is no bullying culture is represented by a minority of respondents to this review, it may be possible to conclude that the majority of employees of NHSH have not experienced bullying as such. Having said that, extrapolating from the evidence available to this review, it seems equally possible that many hundreds have experienced behaviour which is inappropriate. That seems far too many. I explore examples of this more fully in the following sections.
12.22. If it was within my remit to do so, it would not be possible to conclude conclusively that there is or is not a bullying culture in NHSH. Everything depends on context and circumstances. It depends on where and who you are. As Sir Robert Francis and others have pointed out (and as noted in the remarks on culture in an earlier section of this report), there may be pockets, sub-cultures and hotspots; one department could be perfectly satisfactory while, next door, the situation could be unbearable.
12.23. However, as noted earlier, in terms of my remit, I need to explore what, if any cultural issues have led to any bullying, or harassment, and a culture where such allegations apparently cannot be raised and responded to locally, and identify proposals and recommendations for ways forward which help to ensure the culture within NHS Highland in the future is open and transparent and perceived by all concerned in this way. I do so later in this Report.
The Gallanders Report
12.24. In passing, it is fair to note that, in November 2018, an Independent HR Consultant, Sandy Gallanders, reported to the Board.
12.25. The Draft Report stated that:
60. "The prevalence of bullying and harassment in NHS Highland is not significantly different to that in other NHS organisations or elsewhere in the economy. The problem is growing across organisations and it is something that all employers will have to address."
12.26. The report concluded that:
19. "Whilst 28 respondents expressed concerns regarding having witnessed or experienced bullying, the overall number of respondents was small and the evidence, whilst a useful indicator of further analysis being required, is insufficient in itself to warrant a conclusion that there is systemic bullying/harassment within the organisation."
12.27. The Report noted:
23. "A review undertaken by the Clinical Governance Team found that in the great majority of cases there was a proactive approach from the handler/manager to address the incident and concluded that there was no indication of specific trends for concern. This conclusion is considered reasonable on the basis of the evidence available. It is also consistent with the relatively low number of cases which are in process under the "Preventing Bullying and Harassment" policy."
12.28. In reviewing an "iMatter" Survey (an online process), the report observed that:
37. "The high level iMatter responses are encouraging. There are no "red flags" which would suggest the presence of systemic bullying and/or harassment. However, only lower level team based data would show if potential problems exist at a more localised level. This would require a higher survey completion and measures to encourage this for future surveys should be considered."
12.29. In connection with a Dignity at Work Survey, it was said:
43. "On the balance of the information available, the reported overall prevalence of bullying and harassment in NHSH reported in the DAW Survey, whilst obviously of concern and warranting more detailed examination and intervention, does not appear out of the ordinary.
The Gallanders Report in Context
12.30. There are a number of criticisms of the report. The GMB union expressed the view that the surveys cited fail to give an accurate picture of experiences on the ground, with most of the statistics coming from iMatters "which has a notoriously low staff response rate, so their numbers are skewed from the start".
12.31. The GMB also commented: "The survey is done electronically and the questions do not allow you to report, for example, incidents of bullying by saying there is a management issue, so it is skewed in that way too." It was not a proper reflection, was limited in its scope, "not representative, too quick, too easy." According to another respondent, it did not reach "an operational level where the bullying and harassment has impacted". I am told that it did not involve any discussions with individuals or seek to look at any underlying relationship or cultural issues.
12.32. I mention all of this not to criticise Mr Gallanders or his report but to help gain an understanding of why that piece of work did not uncover the issues which this review has uncovered. More generally, it is helpful to note that the gathering of information about allegations of bullying needs careful thought and insight. Mr Gallanders recognised this himself quite explicitly:
65. "The desktop analysis of survey and other data considered earlier in this report does not provide the qualitative information which lays behind some of the headline figures for NHSH. It is important that this information is mined. This will inevitably mean engaging directly with people rather than sending them another survey form. It is important to do this for two main reasons – firstly to get a better understanding of what the issues are where they are occurring and what the common themes are. This will provide a much richer source of diagnostic information to inform future planning and targeting. Secondly, engaging people is the right thing to do – a direct face to face interaction with an employee or group of employees will both provide information to the organisation to help improve things and help that employee or group feel that they are valued and cared about by the organisation."
Use of the Gallanders' Report
12.33. For completeness and because Mr Gallanders' report is full of useful suggestions which could easily be lost in the headlines about it, I have included, in Appendix 2, some more of his findings which seem to me to be helpful. I also commend the Report's list of short, medium and longer term tasks and priorities. They contain much which is of importance and utility. I pick this up in my own proposals later in this report.