Why candour makes all the difference to culture

It’s the most common cry of businesses that have been in trouble. ‘We’re going to be much more transparent now,’ they announce proudly. ‘It’s all about openness.’

Well, saying the right thing is easy. It’s actions that matter. So how can organisations turn their open-handed promise into reality?

In its response to the Francis Report into the failings of North Staffordshire Hospital, the Government uses a good deal of language that sounds reassuring – accountability, openness, compassion – and then there’s a clause with a ‘duty of candour’. This is the responsibility to be open and honest, which surely must be a good thing?

But hold on: this ‘duty of candour’ refers specifically to ‘providers’, NHS terminology referring to private organisations providing services. That’s all fine, but shouldn’t it also apply to managers and employees?

The big question is just how open is the NHS as a working environment, which is important if we are to avoid the catalogue of horrors reported by the inquiry. After all, North Staffordshire Hospital might be a one-off within the health service.

Sadly, the most recent employment survey from the Royal College of Nursing suggests not. It expressed concern about the ‘culture of fear and intimidation’ in some workplaces. More than a quarter of respondents felt they would not be treated fairly if they reported being harassed at work by a colleague. A recent survey of 2,000 GPs also revealed that two of every five South West England GPs are planning to quit because of the hostile work environment experienced.

Changes in policy and systems will go some way to improvement, but the key issue to fix is culture.

How was it possible that all those complaints from patients’ families went unheard? How was it possible for senior staff to ignore concerns from colleagues? Why was it considered alright to disregard acute issues raised about patient safety?

This all occurred because there was not a culture of candour. Far from being open, people were afraid to speak out, and those who did were ignored or even bullied.

If this behaviour is normal for its 1.3 million staff, which makes the NHS the biggest employer in Europe, it will be tough to shift. As it opens up to private organisations, it is even more vital that the NHS operates in a culture of openness.

Culture is defined partly by what is tolerated. Integrity must be visible in the way leaders conduct themselves and hold people accountable.

But culture doesn’t happen by chance; it takes willing commitment.

First, you need a strong code of ethics – short and accessible – and to help people understand how to put this into action. Then it’s necessary to reinforce accountability for upholding standards and make sure leaders live up to this, visibly. Train managers in how to encourage open conversation. And support it all with daily interactions that require open exchange. This will make candour normal and blame not tolerated.

Please, NHS, make a ‘duty of candour’ part of your code of ethics for all employees. And, from the very top, make openness a shared responsibility for everybody. So that as patients, families, employees or providers, we can all restore our trust.


Note: Since the writing of this article the NHS policy has changed and instituted a Duty of Candour; however, this continues to be a huge cultural challenge for NHS Trust, hospitals and institutions.

[First published in CorpComms magazine in 2013.]