The data on physician associates in the UK, and speaking up in the NHS
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Welcome to the Medicine and Science podcast from the BMJ. I'm Cameron Abassi, Editor-in-Chief. In this episode, new research into physician associates. It's not quite an evidence-free zone, but it's certainly an evidence-light zone. We continue our coverage of racism in medicine with the NHS Race and Health Observatory.

Which I take as a badge of honour, in fact, because it means that we're having some level of impact and we're probably doing something right. And what stops NHS staff from speaking up? The evidence around this, which is around kind of hierarchy, the fear of speaking up and the retaliation that might follow, but also the futility that so many people feel that even when they do speak up, that doesn't necessarily result in change.

We start with Physician Associates and I'm delighted to be joined by Trish Greenhouse who has just conducted and published a rapid systematic review. Trish is a long-standing friend of the BMJ and one of the world's leading experts in evidence-based medicine. Trish, just introduce yourself please.

Yeah, so my name is Trish Greenhush. I trained as a general practitioner and I am now Professor of Primary Care Health Sciences at the University of Oxford. And one of the things I look at is the workforce that's delivering healthcare. And you've just completed a rapid review into physician associates and aesthetic associates and

Safety. Could you just tell us a bit about what that work is and what is a rapid review? A rapid systematic review is a review that is done within a very tight timeframe. And so you have to trade the thoroughness of a systematic review with its timeliness. So you have to make trade-offs. Okay.

I think in this particular review, we had enough time to look at the quite small collection of papers that we identified. And we did have a thorough look at every single paper that met the inclusion criteria. So tell us something about the research question then. What precisely was it?

Well, the research question was oriented to a very important and topical policy question, which is what is the efficacy and safety of physician associates and anaesthetic associates in the UK context? And I was contacted by Gillian Leng, who's been commissioned by West Streeting, who's the Secretary of State for Health and Social Care in the UK. And

She contacted me in the same way she was contacting a lot of people, academics and policy people and frontline clinicians, because she's trying to kind of get lots of views. And I thought, well, since I'm an academic, I'd better bone up on the academic research here. And so the whole thing slightly grew like Topsy. Yeah.

But we did end up, as you know, sending a fast-track review in the hope of meeting the deadline for the submissions to the Lange Review. So we'd actually have a peer-reviewed paper to send her rather than just the things that I dug out a month ago. Yeah, which we now do have published in the BMJ. Tell us what you found.

Well, the first thing we found was that most of the papers in the academic literature on this topic are not research. They were editorials, they were opinions, they were stories. And that's in the academic literature, never mind what you find on the internet. Of that research,

about four-fifths of it done outside the UK. There's certainly quite a bit of research in the States that seems to suggest that this role could be successful, but that's the American literature and we didn't cover that. What we looked at was the UK literature, and that was a completely different kettle of fish. Most of the research was asking

slightly tangential questions like what other staff thought of them, for example, or what PAs thought of their own role. But there were only about eight or nine studies where these professionals had actually been observed doing the job that they'd been hired to do and where someone had made some kind of measurement of their performance.

And there weren't any studies at all that looked at safety incidents. And nobody in UK has looked at deaths, serious harms linked to physician associates. And I was really surprised at that because I thought someone should have done that. This is a new role that was introduced only a few years ago in UK.

People are not as highly trained as doctors, but they are taking on some of the roles of doctors. And you would have thought there would be some research into safety incidents. And there hasn't been. Yeah, which is really surprising. The other thing I want to talk about is there's been very, very few studies in very few settings. You know, you read in the paper, Spoon.

physician associates are working on cardiology wards, for example, and doing certain procedures, or they're working on liver wards and they're doing procedures on liver wards. There was one example of a PA that had put in an acidic drain, for example. There isn't any research on that. There's no research whatsoever on...

the kinds of things they are doing and whether or not they're good at it and whether or not they're safe at it. It's not quite an evidence-free zone, but it's certainly an evidence-light zone. Yeah, when you looked at, I mean, there's very small numbers of papers in different settings, primary care, secondary care, emergency care. Were there any differences?

Yeah. So the primary care literature, the biggest study, which actually looked at quite a lot of consultations, only looked at seven physician associates. Now, were those seven representative of the wider population of physician associates? We have no idea. But what those researchers showed was that

The PAs needed quite a lot of supervision. They were seeing a case mix that was less sick and less complex than the caseload that was seen by doctors. And you can see why. And

What was shown in primary care was that the PAs took longer to see patients, but they were cheaper. And so then the question is, well, were they cost effective? And the answer is, well, if you don't take account of the GP supervising them, they were, they were actually cheaper. But if you do take account of the fact that the GP has to keep copying in, signing prescriptions, overseeing their work, checking their work, then they don't work out cheaper.

And one of the things we did in our systematic review was what we call a sensitivity analysis, that if you spend more than about two minutes supervising a PA per consultation, then the PA becomes more expensive than the general practitioner. The other thing in primary care was that the physician associates really didn't feel very confident about

you know, the classic sort of hospital consultant saying, and GPs just see all the easy cases, they're all sore throats. Actually, what you see in general practice is this massively undifferentiated population. They can come in with anything wrong with them. Almost every surgery, you've got someone who is a lot sicker than you thought they were going to be, if you like. And you've got to be able to pick that up. And the problem is if you haven't had

a lot of training it's actually quite difficult yeah so i think we concluded that seeing undifferentiated patients in primary care was not really a very good use of the pa role yeah the

The paper I really liked was a study of PAs on medical and surgical wards because one of the things people were questioning was do PAs have an area of knowledge that's different from any other health professional? The

The argument was, well, PAs just know a little bit of medicine, but they don't know as much as doctors. Actually, this study by Varee Drennan and her team showed that the PAs do have a particular area of knowledge. And it's what we call in the paper, knowing the ropes, right?

So whereas the junior doctor might only be there for three months or six months, the PA might be there for several years, which means they know how that particular ward operates. They know the people. And so they're actually quite good at holding the show together, if you like. So it's not that they have advanced clinical knowledge. What they have is quite advanced local knowledge. And that's very useful. If you get admitted to hospital for your hernia or whatever it might be,

The PA can come along and say, right, this is the way things work here. And Dr. So-and-so will be around tomorrow morning. And this is when you have your blood test. All very useful. And so I think it's sort of important to recognize that there is an area of knowledge that PAs have, but it is not clinical knowledge. It's something a little bit more subtle than that. There's another couple of studies where PAs were compared with junior doctors in the emergency department area.

There didn't seem to be a great deal of difference between the PAs and the junior doctors, partly because the PAs had usually been there for longer. Again, they knew the ropes. But one of the big differences that one study found was that the PAs were ordering a lot more x-rays. Hmm.

We all know that it's not a very good idea to have too many x-rays if you don't need them. And so it would be really good to repeat, to replicate that study to see if what's happening is that the PA with less medical training is actually ordering x-rays on people who don't really need them. Yeah, but you did, I mean, at least there were some lessons there from the papers you did look at, but it seems to me what you've described doesn't really match what

physician associates are doing in the NHS today. That's right. So the primary care studies were mostly done many years ago, more than 10 years ago. And even the hospital studies were done several years ago. So there are one or two more recent studies, but there aren't many. Now, what that means is that the evidence base is

on these roles is not directly relevant to what is happening in the NHS today. And that is really troubling. Trish, thank you very much for doing this important work and sharing those insights with us today. Thanks very much, Cameron. And Trish's new review of the data on physician associates and anaesthetic associates in the UK is now available on bmj.com.

I'm now joined by Habib Nukwi from the Race and Health Observatory in the UK. Welcome Habib. Thank you for having me. And the interesting story about the Race and Health Observatory is that it was founded five years ago after our theme issue on racism in medicine and it was proposed in that theme issue and

than it came to be so we're connected with it absolutely yes which feels good so first of all tell us a little bit about who you are and what you do sure my name's habib nakvi i'm the chief executive of the nhs race and health observatory the observatory was established to hold up a mirror to the rest of the health care system

to explain the scale of the challenges we have around race and ethnic inequalities in health and healthcare. But not just to highlight the scale of the challenge, but to also provide solutions to some of those deep-seated challenges that we have. And then in that time, and this is what your piece is looking at, that you've written for us, a piece called Together We Can Challenge the Racism That Persists in Healthcare.

How much progress do you think we've made? I think what we have in this country now, particularly over the last few years, is a social movement around acknowledging that racism actually has a role to play, not just in determining people's health outcomes, whether that's physical or mental health, directly, but also indirectly through the social determinants of health.

what we call the causes of the causes of the inequalities that we see. So how does racism, for example, have a role in determining people's life chances in education, in relation to the criminal justice system, in relation to workforce and workplace experiences, in relation to healthcare access? So we are now beginning to see more of a discourse in society as a whole around the role of racism

and particularly so within our healthcare system. But just to be clear, what you're saying is that education, housing, transport, employment, etc., clearly they impact upon health and wellbeing outcomes. But you're taking one step further back than that and arguing that racism...

can influence those elements, those determinants of health, which of course then lead to inequalities in health. Absolutely, yes. And how clear is the evidence on that, Habib? Well, the Institute for Health Equity carried out research, which was published last October, October 2024, which shows that

very clearly that relationship but also looks at how structural racism, particularly in London, has a direct impact on people's access to healthcare, their experiences and their outcomes but also has an indirect impact

impact upon life chances and how structural racism, interpersonal racism can come together to play a role in the institutional racism that we see in policies, processes and behaviours on a day-to-day basis within our working practices. Okay, and my understanding also is that if you address racism, it doesn't only improve

and well-being outcomes for minorities, for ethnic minorities. It also improves outcomes for the whole population. Is that correct? Well, it's like any intervention. If you get it right for the most vulnerable, you're likely to get it right for everyone. So it's looking at...

It's looking at co-design and co-production of interventions that will actually meet the diverse needs of our diverse communities, but doesn't leave anybody behind. And that's a way to really kind of focus on inclusion, on equity, on diversity in a way that is inclusive. Yeah. So actually you're making...

the whole system fairer for everybody, not just for ethnic minorities. Absolutely. This isn't just, you know, the work we do isn't just about making things better for black, Asian and ethnic minority people. We're here to make things better for everyone. Yeah. And the evidence shows that. Because some white communities have, and particular age groups and socio-economic groups, have particularly poor outcomes.

Yes, they do. And we know that. And we know that there are coastal areas. And we know that there are, you know, the intersection between social class and race. And so to focus on interventions that actually don't leave anybody behind, are inclusive in their very design, is really essential. Yeah. The reason I'm laboring this point is that often people don't see it as their problem.

You know, you think, well, OK, it doesn't really affect me. It might help somebody else. You might not really be that enthusiastic about it. But actually, if you think about it in the way you've described it, it's going to help you as well. Absolutely. And also in relation to the workforce, we know a diverse and fully engaged workforce at all levels is essential for better patient outcomes, patient safety outcomes.

and patient experience for all patients yeah and and so it's important that we get that right because this is you know there's a moral case and there's a legal case but there's also a product productivity case here yeah as well and and it is about making sure that we get this right for everyone just to ask you with everything that's happening in the us and the particular agenda which isn't

i mean it's sort of an anti-woke agenda uh which i'm not saying racism is being woke i think tackling racism is tackling a genuine issue which is about fairness and justice uh in society um do you think the way the political uh winds are shifting might have an effect on you well because i mean we had reform saying in their manifesto for last year's election that

you know, one of their pledges was to finish off the race and health observatory. Which I take as a badge of honour, in fact, because it means that we're having some level of impact and we're probably doing something right.

There's nothing wrong with being awake to injustice and social inequality. What we do within the observatory is to focus on the evidence and the data. We're evidence-driven. We're data-driven. We highlight where the inequalities exist and the scale of that challenge.

And then we put forward very clear solutions to those challenges, working with our partners, of course, including the NHS, including the government, including communities, including people on the ground so that we can resolve those deep-seated challenges. So, you know, we don't get involved in culture wars. We don't get caught up.

in the wokeism rhetoric. We just focus on what the data and what the evidence tell us. Yeah, I mean, there are other forms of discrimination. Should we have observatories in other areas or is...

that would seem perhaps like overkill. Well, the evidence was very clear five years ago and to some extent still remains the same that the inequalities in health and healthcare that we see with regards to race are some of the most stark inequalities that we see. And of course, there is intersectionality here as well, Cameron. So every one of us

has a minimum of five protected characteristics. So when we look at maternal and neonatal outcomes, we're also looking at women. We're also looking at the younger generation there as well. So it's about taking a common sense approach. And in fact, our definition of race is pretty broad within the observatory. Very recently, just two months ago, we launched a series of videos looking at

the mental health impact on Gypsy Roman Traveller communities.

We looked at, again, just very recently, looked at the communication needs of the Jewish community. And so we are taking a very broad look at some of the deep-seated challenges that we have. And, of course, we are driven by what the data, what the evidence tells us. And that's where we focus our attention. Okay, very good. So, final question. You're five years in.

I mean, assuming you're convinced, West Streeting, that you deserve ongoing funding and support, which I hope that is the case, where would you like to be in five years' time? Well, I think the first point to make is that no healthcare plan for the future would be successful without looking at some of the deep-seated inequalities that have persisted within our healthcare system for decades. So,

Our work within the observatory, the work we do day in, day out to tackle injustice, to increase, to tackle injustice and to really focus on better outcomes for all patients will be critical to the success of the 10-year plan. And we will continue to focus on

some of those very kind of deep-seated issues around maternal health, neonatal health, around supporting the implementation of what will be the new Mental Health Act. We will focus on issues around genomics, precision medicine, on sickle cell disease, and of course the workforce. Because we know that there are still

inequalities within the nhs workforce around lack of representation at senior levels and the poorer experiences that staff uh have to endure uh endure uh day in day out habib thank you for joining us thank you for having me for our final segment the bmj headed to the nuffield summit where we've been asking what stops nhs staff from speaking up

NHS staff do not feel safe speaking up about their concerns at work and they also feel they are not being given the resources to provide the care that patients need. As the BMJ Commission on the Future of the NHS reported, less than two-thirds of staff, 62.3%, feel safe to speak up about anything that concerns them. And that's according to a 2024 NHS staff survey.

and only half, 50%, feel confident that their organisation would deal with their concern. Our commission also reported that staff increasingly experience moral injury linked to the inability to provide the care they think they should be able to give.

And this week, we've seen that the chair of Moorfields Eye Hospital has resigned after more than 80 senior clinicians described a culture of fear at the trust and said that they had lost confidence in the trust's policy on freedom to speak up.

To discuss what is preventing NHS staff from speaking up, I'm joined by Katie Bramall-Stainer, Jagdeep Desi, Henrietta Hughes and Thea Stein. Could I ask each of you to introduce yourselves? We'll start with Katie. Thank you so much. I'm Katie Bramall-Stainer. I'm a GP in Hertfordshire and I'm chair of GPC UK and GPC England, the GP committees at the British Medical Association.

Jagdeep. I'm Jagdeep Desi. I'm a geriatrician at Guy's and St Thomas', president of the British Geriatric Society and deputy director at the Centre for Perioperative Care. Henrietta. Hello, I'm Henrietta Hughes. I'm the patient safety commissioner for England. I'm a practising GP and a visiting professor at the Institute of Medicine, University of Greater Manchester. And my former role was national guardian for the NHS. Thea. Hello, I'm Thea Stein. I'm the chief executive of the Nuffield Trust.

Great, what a fabulous panel we've got with us today. Right, Jugdeep and Katie, can I come to you first? I just quoted findings about staff not feeling safe to speak up, not having confidence that employers will deal with concerns and experiencing moral injury. How do those figures match up to your own experiences of working in the NHS? Katie?

I think that's a really interesting and depressing statistic. And I had a fascinating encounter earlier this week where a GP colleague of mine and a consultant colleague of mine were both comparing each other's breakdowns in their professional careers. And the GP's breakdown, he put down to having 100% responsibility and feeling completely overwhelmed because it didn't feel safe. And the consultant had a breakdown because she felt she had zero agency.

and zero ability to be able to effect change. And so both of them did not feel heard. Both of them felt they could not escalate for very different reasons. Both were immensely damaged and required time away and then rehabilitation to return. But I think it's very interesting how the juxtaposition of how things are across the primary and the secondary care domains. So I think it's going to be a tale of two settings, potentially. OK, you're from the other setting, Jagdee.

I am from the other sector, but actually I think it's not so much necessarily to do with sectors. What I tend to see in my day-to-day practice is similar conversations, but actually according to grade of seniority. So I think, you know, of course that plays into that, the evidence around this, which is around kind of hierarchy, the fear of speaking up and the retaliation that might follow, etc.

but also the futility that so many people feel that even when they do speak up, that doesn't necessarily result in change. Katie, would you agree with that? When you're in an NHS that's been starved of resources, the decade we've been through, the austerity measures and so on, we know we're not able to provide what potentially the public has been promised. And I think that can lead to quite a febrile professional atmosphere where frustrations can emerge. And of course, we have longitudinal relationships with our patients.

And I think there's a real keenness to avoid escalating complaints because GPs face double jeopardy. We don't merely have the MPTS through the GMC. We've also got local performance processes. Yeah, I mean, you talked about double jeopardy, but you also described moral injury. Yes. And that's something...

doctors are feeling in hospital and other staff are feeling? Yeah, I think moral injury is a commonly used term now, whereas prior to Covid we didn't really hear so much about it. Well when I was practicing no one spoke about it. No, that's right. Moral injury. And I think moral injury comes from the burnout that we've just been hearing about. It's the day-to-day kind of pressures that are there on all of our staff working with limited resources.

So I think that burnout is partly that day-to-day kind of impact.

But of course, it's also because of that feeling of futility that when you do try to raise a concern that maybe it isn't heard in the way that it should be. That's also a form of moral injury that you can't speak up when you want to or you need to. Yeah, no, exactly. And I think that absolutely has an impact on the way that people feel about raising these issues. OK, let's look at the impact that not being able to speak up is having on patients and

health systems. I'm going to turn to Henrietta first. Henrietta, as the patient safety commissioner, what has the effect on patients of staff not being able to speak up about their concerns, about the care that they're receiving from the NHS? What's that impact been? I would look at this in terms of how important it is that we listen to the voices of everybody. And that not only includes the workforce, but also patients and families. And I think there are some real parallels here.

And when it comes to what staff are speaking up about, over 100,000 cases have been brought to Freedom to Speak Up Guardians. There's now a network of over 1,000 guardians. All of the tools are there. There's something for me about what is it that's stopping those leaders from listening. And it's the leadership and listening and acting on what people are saying that is the real gap. I mean, presumably, if staff felt more able to raise concerns, we'd have...

we'd be more likely to prevent some of these patient safety scandals that we've had. Well, I mean, we can see this in the evidence from Martha's Rule, where it's not only about giving patients and families the opportunity to get a rapid review, it's also about giving staff the opportunity to, you know, follow up on their gut instinct. If they've got a concern about the patient's condition, even if the new score is normal, they can also pick up

the phone. And that's not just in terms of the clinicians on the ward, but porters, housekeepers, people who see the patients every day. And what we've seen is that of the calls that are coming from staff, the sensitivity is very high in terms of recognising deterioration in patients. But if they'd had to rely on the new scores and weren't given that freedom, that freedom to speak up about the patient's condition, then, you know, that's, you know,

I can't give you the exact numbers because they're not published yet, but it's dozens and dozens of patients whose care wouldn't have been escalated, even though the staff member knew or had a suspect that the patient was very unwell. Okay, well, thank you. You mentioned community trusts. Thea, you were previously Chief Executive at Leeds Community Healthcare NHS Trust. And you wrote an opinion piece for us in the BMJ, published just this week, arguing that how we behave in the NHS is a problem

but it's also part of the solution. - Well, it's got to be, hasn't it? I mean, you know, it's all about how we behave with each other. I think Henrietta put it very well in terms of the themes that we see coming through again and again and again that help create the conditions that allow people to feel safe. And I've written and spoken about before, psychological safety is at the root of good cultures, which allow people to speak up.

I think the mistake we sometimes make, I'm sure I've made it many times in my career as well, is believing as a chief exec that you are setting the culture and not recognising, of course, that your organisation

It is very important that you are setting a culture, but your organisation is full of micro-cultures and the most important thing for every member of staff is that line management they have day to day and how they feel safe with them and how they feel supported by them and how they feel able to challenge.

I mean, the issue of psychological safety seems quite a big one at the moment in the NHS. Yes, it's huge. And psychological safety is something that ideally you feel at every single level, which says that everybody... We shouldn't need Martha's Law.

We shouldn't really need freedom to speak up guardians. We do need them. And that's an indictment of where we are and how we are. I used to want my freedom to speak up guardian to be bored in my organisation. It was the greatest indication of success for me. Although, of course, it wasn't because you wanted them to speak up. But on one level, I wanted him to say to me...

just everybody's so happy. Life's so wonderful. I've got nothing to tell you, Thea. I assure you it never happened. But I learned to know that was a good sign. That's what we're aiming for. I mean, Henrietta mentioned leadership. Can you also say why you think leaders in the health service haven't been able to create the kind of environment and culture that you've been describing? Well, first of all, we should say what Henrietta said, lots of leaders do. There has been, however, a certain model of leadership

that has been supported and exalted, I would say, within the NHS over a period of time. And it was a culture that was one where you showed grip, you showed determination.

You pushed back against resistance. You were, you know, able to cope with meeting KPIs and hitting targets. And somehow that became on some level juxtaposed with the fact that you cared. You were compassionate. You listened. You were open. And a certain model of leadership, I think over time, competitiveness rather than collaboration, subtly, that model of leadership became something that if you excelled in that, you tended to do well. And we...

We are now in a position where we are really trying to say we want our leaders to be people who are not competitive We want our leaders to people who who integrate who who listen to others who are humble who etc, etc Yeah, yeah quite hard. I'm gonna open it up to the floor any minute now, but one final question for Henrietta We've got very senior people who find it hard to speak up. So What's happening there?

So, when I had our first survey of Freedom to Speak Up Guardians perceptions, I took this to the sponsors at the time, which was NHS England, NHS Improvement and the Care Quality Commission. And I spoke to their chief execs and I said, if I asked your staff, would you be rated B?

equivalent to the outstanding, good, requires improvement, inadequate, or somewhere off to the right. They all appointed freedom to speak up guardians, as did many other arm's-length bodies, professional regulators, etc.,

And what we saw was that the cultures in the arm's length bodies and the professional regulators, the national bodies, was on a par with trust rated requires improvement or inadequate. So I think we can say that this is a full system issue. This is not about problems in providers and poor leadership. It's a totally integrated system issue.

I do think the role of boards is really important because chairs, non-exec directors and particularly getting the voice of patients into boards through patient safety partners, patient stories and a real focus on quality because the more we're able to listen to the views and voices of staff, patients and families and use those to make improvement then that is where we're going to see the gains that we need.

But until boards are really focusing on this, and I agree with Thea that freedom to speak up guardians should be linked directly to the chief exec, but they also need to have a route to the non-exec directors as well to be able to have that level of freedom and support. What about the NHS board?

Well, NHS England have their own freedom to speak up guardians and I've encouraged them and they have followed my advice to focus on safety and they've had a day around patient safety. But I do also think that this goes beyond that. It goes beyond that into government departments and the role of the press, the role of the media as well. So in terms of where do we start, sometimes I remember Thea last year was saying, start somewhere, go everywhere.

So I don't really say, well, you must start here. But I think by taking the staff survey results, everyone should be reading the staff survey results in their organisations. That's what I used to do before visiting a trust. And I would turn up and say, so what's happening with your physios? And they'd go, oh, well, this, that and the other. And it's all there. It's all there in the staff survey. The more we can take on board the views of the staff and use those for making improvements, that's where we'll see the gains. Right. Thank you. OK, so let's open it up for questions.

discussion, comments and questions. We have a microphone. So do come to the microphone, introduce yourself, make your comment, ask your question. Mary. I'm Mary Dixon-Woods. I direct the Healthcare Improvement Studies Institute at the University of Cambridge. And with Graham Martin, who's Director of Research at this institute, we've been doing a programme of work on voice over many years. One thing is that it is absolutely true that NHS staff report difficulties in speaking up.

Also true is that there are about 20,000 issues raised with Freedom to Speak up, Guardians Year, and 80 to 90% of those concerns are to do with HR.

That is where we have major issues. There's a much bigger complex set of challenges to do with HR, the institutional structures, the legal framework in which trusts have to operate, the quality of the HR support that they have. And I was very glad you brought up line management because that's a major challenge. So that feels like a major area where we need to be kind of understanding the problem we're trying to tackle.

Again, several things can be true at once. People experience bullying, but also true is that people use HR processes strategically to advance their own interests. That is extremely destructive and it is extremely impactful on cultures and behaviours. If you've got somebody who you've tried to take through a performance process and then they retaliate,

by taking out a grievance. And again, I think that's not been part of the story we've told here. And the final thing that's true at once is that people feel they aren't heard. Many of these HR processes are confidential and they're never going to hear the outcome because by law they can't be told about it. So we need to find some way of sorting that. But also,

there are limitations in the improvement capacity of organisations. So there is no simple relationship between somebody raising a concern and the ability of the organisation to deal with it.

and I think that's not been kind of part of what we're dealing with. It's not the case necessarily that trusts aren't listening, it's that they have 600 page documents, packages of board papers coming through, multiple priorities, and their ability to actually deal with any of these concerns may be, well Ron will tell us, but it's hard enough to improve many issues in healthcare where we've got excellent evidence, there's

Joke deep, we'll tell you. We know what the methods are. And some of these issues are really, really messy and just very, very hard to deal with. So sorry to make it more complicated. Mary, thank you. Kevin. I'm Kevin Fong. I'm Professor of Public Engagement and Innovation at University College in the Department of Science, Technology, Engineering and Public Policy. There's a few points.

Let's start with sensors. We're talking here about voices here, but really we're talking about sensors. And it's absolutely right that we should try and amplify the patient voice as we have made efforts to do so. But in this system, we talk about complexity in a system that is on the edge of tumbling into chaos with the risk of patient harm. And in that system, the most sensitive and useful sensor actually is our staff.

We should amplify the patient voice, but they should be your censor of last resort. Your frontline teams are there and trained. And if we don't listen to them, we can't get to the right answer. Right now, I think our failure to listen to the staff leads us into something that looks akin to organisational leprosy. By the time that we're resorting to, and we have to necessarily listen to our patients as well, we're into deep tissue injury by that time.

That's the first thing. Second, you can't do this just by creating culture. This is not what you learn when you study engagement models is that you need deliberate processes to do this. It doesn't just happen because we create the right cultures. We make it easy for people to speak. You need deliberate mechanisms that can get signal through and to short circuit it from the frontline signal where it's purest and most sensitive to the point where you can do something about it. Third point, we are talking only here about sensors.

What we know of complex systems that teeter on the edge of chaos is you need feedback loops that function well to stabilize them. So you need the sensors, everything we've spoken about this morning. You absolutely need to be able to get the signal up, but you need to be able to do more than just listen to your patients and your staff. You need also to be able to process that signal in a sensible way and have the means to have an effector mechanism. The reason that people aren't heard

and the reason that people aren't speaking up is because they behave the same way as all senses in all feedback loops where nothing changes. They re-habituate and they slide into a new set point. We should know this. We were trained in this at medical school. So it's not just about our ability to speak up. It's not just about

amplifying the voice of our patients and our staffs. It's about having a good processing tool and the means to effect. And I'm sorry, but that does mean deliberate mechanisms. It means resource. It's more than culture. And this is what we get wrong. Okay. Thank you.

Hi, Adrian Boyle, President of the Royal College of Emergency Medicine and the not-proud leader of the most burnt-out specialty on the annual GMC survey. And the points about the moral injury are felt very keenly by my members. On the way over here, I took a call from a clinical lead who has a chronically crowded emergency department, very high rates of sickness, and he was talking – he was asking me for advice about how he can escalate

because he had done everything. He had created fire safety, he got the fire safety officer to say, "Is this department safe?" They'd said no. He'd invited his chair, he'd invited his Neds, he'd had multiple escalations. And the comments that we heard at the beginning about people not feeling they've got agency were really reflected because he said, "I've done all of this." And everyone said they've listened, but no one has explained the trade-offs. No one has explained, "Yes, we know you've got a problem,

we have to deal with all these other priorities. So while there's... And he was saying, should I bother? Because if nothing's going to happen, why do people do it? I'm harming my career by doing this for an uncertain return.

I just want to pick up your first point, which is I think there have been at least two or three very clear public examples where staff have elevated an issue, very serious issues, to the chair of the trust or the chair of the hospital, and they haven't got anywhere. I mean, what do you do in that situation? I think this then makes it very difficult for people to speak up. Thea? Yeah, I think it's...

I mean, it makes me very sad, obviously, because I would like to think, and I could see other people's faces looking sad as you spoke about your colleague who spoke to you on the way here, because I would like to feel at the very least, and I would call emotionally intelligent leadership would sit down with that leader and the staff team and say, we also don't know. We also don't know. And I think that leaders find that encouraging.

very, very difficult to do. Chairs often have got to their position through authority, through the ability to say they know what to do. And actually some of the situations we face at the moment require of us the ability to sit with teams and go, I don't know either, but I'm alongside you, I'm with you, what will make it just a little bit better today? And probably your colleagues simply need some of that to say, I don't know.

I don't know what. Do you have an idea? And they may have, well, if we did this, let's try everything. But actually, I don't know. And I think it's what I came back to. We have not trained and supported our most senior leaders, except those who find it, to be able to say, I don't know.

Katie, do you want to make a final comment? We've covered a lot today and there are so many solutions facing us. And I think Thea's points around that honesty and going, actually, yeah, I don't know either. This is awful. It's that acknowledgement. And that's what comes back to that integrity and authenticity behind it, which is what we need so, so, so fiercely. So I think kind of the main themes that I've kind of really picked up from today relate to

us not being in a situation where we are able to give honest and accurate kind of feedback for a variety of different reasons.

And certainly at the moment for certainly the consultant body, having supporting professional activity time constantly withdrawn is actually kind of reducing their ability to be able to listen effectively, deliver feedback with honesty and then follow up and process the signal that's coming into them. So they're so kind of busy firefighting things that you're not actually able to deliver change on the shop floor.

So I think there are lots of things that organisations can do at every level to support that. And some of it will reflect back into things like bringing back firm structures that allow people to build effective teams, support each other, maintain staff well-being, but listen to the patient voice throughout that as well. OK, well, cue Henrietta for the last word.

We need more productivity in the NHS. We need to unlock the potential that is there by creating the conditions for the workforce to flourish. And the best way to do that is to think about what the patients are saying, what the families are saying, what the staff are saying. And

for leaders to prioritise using that information to learn from it and make improvements. And if we could do that across the whole NHS in the way that the best organisations are doing it, then I think we would see tremendous change in morale, in the well-being of staff, in patient safety and outcomes, and certainly to deliver on the 10-year plan.

Right. I want to thank you all for joining us and participating in this roundtable panel. And in particular, thank you to our panelists. Thank you very much. The full discussion and write up of that summit are now available on BMJ.com. That's it for this episode. We'll be back in a fortnight talking about the prognostic element of the assisted dying bill and about a new collection on nourishing South Asia. Until then, I'm Cameron Abassi. Thanks for listening.