Title: Building a Culture of Openness Across the Healthcare System: From Transparency Through Learning to Improvement?
Funder: Department of Health and Social Care

Abstract: Background The need for a shift in NHS culture around openness, candour and learning is widely acknowledged following recent high-profile failings, and clear recommendations for action and specific policies to foster openness have been introduced. Yet the success of these interventions rests on how they are received and actioned at every level within the NHS. This in turn depends on willingness and ability to overcome ingrained cultural and structural barriers to transparency, and to resolve tensions within the policy framework and with competing pressures. Our study examines policy and organisational efforts to improve openness, and the degree to which these are resulting in change in attitude and behaviour at the ‘sharp end’ of care. Aims We aim to undertake a comprehensive policy evaluation, understanding the realisation and impact of work around openness at all levels in organisations providing NHS services. We ask: How do senior managers and clinicians in organisations providing NHS services understand policies and translate these into specific norms, expectations and practices in their organisations? Are staff and patients’ views on openness, knowledge of performance, and experiences of giving voice to concerns changing through time, for better or worse? Are provider organisations’ efforts to increase openness resulting in real changes in staff’s values, attitudes and actions at the sharp end of care, and in patients’ opportunities and experiences around openness—and what features contribute to success? Research plan Our study encompasses two workstreams to provide both longitudinal and current understanding of how policy is enacted by organisations and experienced by patients and staff (WS1), and to examine in detail whether and how efforts to improve culture are translating into changes in attitudes, behaviours and opportunities at the sharp end (WS2). WS1 includes interviews with a stratified sample of providers and a survey of provider organisations (addressing Q1 above), along with analysis of the National Staff, Inpatient and Community Mental Health Surveys to examine change through time (Q2). WS2 focuses on 4-6 provider organisations, sampled theoretically using findings from WS1, using a carefully designed confidential interview approach to examine consequences (intended/unintended) of initiatives for staff and patients (Q1&3). Research team Our proposal combines methodological and subject expertise from three universities in a team with long experience, a proven track record of working together, a wide network of national and international collaborators, and a history of impact. The three investigators have published widely in this field, with highly-cited papers on initiatives such as using leadership walkrounds to create forums for openness and learning, making use of ‘soft intelligence’ to detect problems of quality and safety, and the organisational, regulatory, financial and professional barriers to learning and improvement. Research staff will undertake data collection and analysis under their supervision. The team will be supported by PPI and professional collaborators with highly relevant expertise and experience and an active role in guiding fieldwork, interpretation, and publicising findings. Potential impact In addition to interim and final reports to PRP and peer-reviewed academic papers, the team will develop practice-oriented and academic outputs arising from the study. Guided by the principle that policies are only as good as their translation into action, and with active input from our advisory groups, we will use participatory learning, synthesis and dissemination events to develop outputs aimed at policymakers, managers, clinicians, patients and families. These will attend to the necessary and sufficient conditions for fostering a culture of openness, focusing on ‘what good looks like’ and how to achieve it in practice. The team has superb relationships with organisations across the NHS and an exceptional record of delivering theoretically informed but practically useful outputs with impact in policy and practice.

Lay abstract: There have been calls for a shift to a culture of openness in the NHS, to help identify problems in care, involve and listen to patients, and learn from failings to improve care quality. Efforts to learn from recent high-profile failings in Stafford and elsewhere have led to recommendations for action, new government policies around transparency and candour, and initiatives aimed at changing attitudes and actions across the NHS. But ingrained cultural and organisational barriers to transparency endure, and potential tensions exist between these policies and other pressures on the NHS, amid budgetary constraints and workforce pressures. This study provides: a detailed examination of attitudes and behaviour in relation to openness at every level in organisations providing NHS services; an understanding of whether, why and how initiatives developed by senior managers and policymakers translate into positive action at the level of patient care; practical recommendations for policymakers, senior NHS managers and clinicians that will make a real difference to how openness is put into practice. Using a mixture of quantitative and qualitative methods, the study draws both on existing sources of data on attitudes to transparency and how they have changed through time, and new data that we will generate using a survey and interviews about how policy around openness is being put into practice. It involves: comparing results from the National Staff, Acute Inpatient and Community Mental Health Surveys to examine change in attitudes around openness and learning through time and variability across organisations; a survey and interviews with senior staff in a range of organisations providing NHS services on how they are putting policy into practice; in-depth interviews with all kinds of staff, patients and carers about the consequences of policies and initiatives for culture, attitudes and behaviour in a sample of 4-6 organisations. The research team, spanning three universities, has expertise in the methods and subject area, is supported by patient, public and professional advisory groups, and has significant experience of policy impact. The study will result in high-quality, action-oriented outputs to inform policy and help organisations improve their approaches to achieving candour, openness and learning.

Research activity codes: 8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE