Cultural issues related to allegations of bullying and harassment in NHS Highland: independent review report

13. Experiences of Inappropriate Behaviour

A Matter of Concern

13.1. A significant majority of those with whom the review engaged have, over a number of years suffered, or are currently suffering, fear, intimidation and inappropriate behaviour at work. In this chapter, I set out what I have been learned from many sources.

13.2. The number of individual cases in which people have experienced inappropriate behaviour which falls within the broad definitions of bullying and harassment described earlier is a matter of the utmost concern. Many appear to have suffered significant and serious harm and trauma, feel angry and a sense of injustice and want to have their story heard. There are, it appears, serious concerns about the mental and physical wellbeing of a significant number of members of staff. There are, I am told, links to anxiety, depression, withdrawal, alcoholism, drug abuse, suicidal thoughts and other serious consequences.

13.3. A number of those against whom bullying allegations have been made are also, or have been, the subject of inappropriate behaviour themselves. Bullying can be both upwards and downwards – or both. Many people have been afraid to take steps to address issues internally or to speak out, currently and over a period of many years. Many feel that no really effective, safe, mechanism to do so has existed.

13.4. One comment offered was that:

"Many individuals have come to serious harm over these years in addition to the destruction of a highly motivated staff base at what used to be a fantastic hospital."

13.5. A clinician told me:

"I've seen scores of people who have worked for the organisation who have said their distress is such that they have enacted or considered self harm to deal with the pressure. These are people who work for the organisation who have cut themselves or seriously attempted to take their own life by overdosing. Over the years this has not been an uncommon occurrence. Bullying has a really corrosive effect on a person's life, not just at work, but on how they feel about themselves, and on how they interact with their families. Feeling oppressed, under the scrutiny of a manager, this really affects people. Perfectly able, intelligent people can become unable to cope. Over the years I have met many people who describe experiencing those sorts of emotions. It's not just within NHSH, although I think NHSH is the largest employer in the area, so it's not surprising I see this as often as I do."

13.6. A significant number of employees, at all levels of seniority, have resigned, moved to other jobs or retired as a direct result of their experiences in NHSH and inability to achieve satisfactory resolution, some to their financial detriment. Many of these situations and their direct relationship to the work situation at NHSH are, I am told, vouched by independent medical reports and other evidence. The following remarks sum up the situation experienced by many:

"My decision was not taken lightly. Although I loved my job I felt it was impossible to return to this unhealthy, toxic environment and with an extremely heavy heart (I cry now as I type this), I asked if I could take early retirement from service."

13.7. One member of staff who felt compelled to depart described how she had felt and the indignity which she experienced:

"Yesterday was a dreadful day in the office and I feel that managers were avoiding any contact with me whatsoever! I was dreadfully upset and I decided at that point that I could not continue to work under this veil of indifference. I had hoped to leave the organisation with some degree of dignity and recognition of my dedication to NHS Highland."

13.8. Another member of staff in a rural location described the impact on herself and colleagues:

"The main issue was the process in which it was managed and how [a number] of us ended up being left with no outcome, no apology. We felt completely overwhelmed by it all and definitely under appreciated by an organisation to which we have given a collective work life of [over 60] years ([and many more] years to the NHS)."

Range and Scale

13.9. After the whistleblowing occurred in September 2018, there were apparently 90 calls to a trade union support line in two weeks. That union advised me early in my review that it had nearly 150 cases, many of which were unresolved. One union official told me: "Over 20 years of working for a trade union, I have never seen the reaction we got when this went public."

13.10. I cannot reflect the full range and scale of concerns expressed but I do wish to acknowledge the candour and clarity with which people wrote and spoke to me. The volume and specificity could leave no one in any doubt about the seriousness of the problems, many of which remain outstanding. As mentioned earlier, a significant number of these cases arise in rural areas and local departments as well as in the major centres.

13.11. Themes emerged for staff who feel they are not valued, not respected, not supported in carrying out very stressful work and not listened to regarding patient safety concerns, with decisions made behind closed doors. They feel sidelined, criticised, victimised, undermined and ostracised for raising matters of concern. Other respondents cited a clique or pack mentality, being kept out of the loop, abuse by email, leaking of sensitive information and being briefed against. Many described a culture of fear and of protecting the organisation when issues are raised.

Views Expressed

13.12. In this section of the report, the words of a few individuals, suitably anonymised, speak for themselves. These are not random remarks. I have selected them because they express views I heard repeatedly. I have formed the view that it is important for these voices to be heard (a) to make clear how serious the problem has been and continues for many to be and (b) in the hope that by bringing this out now NHSH can begin the journey to a better place. Further views are expressed in other sections of the report. As I have said repeatedly, they are not offered for their wholesale factual accuracy but to enable the reader to build a picture of the depth and extent of how people have felt. I have not attempted to investigate responses to all of these views.

13.13. I am aware that, for many, this degree of specificity is painful and frightening. It creates a situation where individuals are fearful that what is recorded is directed at them, rightly or wrongly. Responses to bullying can themselves seem or feel intimidating and inappropriate. I am also aware that for some of those who feel they have suffered inappropriately, reading all of this may also be traumatic. Therefore, in recording these views, I ask readers to be sensitive to the impact of what follows on individuals. And to remember, throughout this report, that there will often be several sides to a story.

A Rural Practice

13.14. For me, much of what I heard was encapsulated in a meeting I held with fifteen members of staff in a rural medical practice. My anonymised record of the comments made at the time summarises what I have heard about how many people feel at work generally in NHSH.

"We've put up with it for so long"

"Our manager has made our life hell for years"

"He shows no respect, it's his way or no way"

"He intimidates us, speaks to us like children"

"It's one rule for us, and one for him"

"He owns us like slaves"

"Higher up management backs him up – it goes all the way up"

"His line manager knows – he is scared of him"

"They all know, they've heard it all before"

"It's an abuse of power, it's all about control"

"He gets away with it"

"What's the point in taking it up?"

"HR held a meeting with us but there was no proper follow up"

"HR cc'd the person I was complaining about!"

"I wrote to his line manager confidentially but my letter was passed on to him and I had to meet with him; Datix is the same"

"I got no response to my letter"

"iMatter is a paper exercise, a tick box; he takes the meeting and decides what we discuss"

"We don't take it up because we fear recrimination"

"There are inconsistencies in how they apply the policies"

"They are manipulating the outcomes of application of policies"

"Policies are not followed; instead they apply local interpretations in an arbitrary and discriminatory way – it's unfair"

"If we stand up, we get shot down"

"There's nothing we can do"

"This is management style of 30 years ago – bossing us around"

"We have lost many staff over the years as a result"

"Senior management needs to support the staff not the line managers when legitimate complaints are made"

"They keep cancelling meetings they promised us"

"They don't seem to care about us"

"Senior managers need to understand their role – many are in the wrong job; they need training or to change job"

"Those appointed to management need to have the necessary skills as facilitators"

"We would like adult conversations and to be treated with respect"

This last remark perfectly captures what many respondents feel has been missing in NHSH.

An Individual View

13.15. Another individual described experiences over many years:

• "Throughout my career (spanning over 20 years) I have been subjected to bullying and harassment by a colleague
• I have on several occasions addressed and escalated this with senior management, this did resolve issues temporarily
• Formal mediation was agreed and sought, no follow through on this, colleague avoided and not followed up by HR.
• Felt excluded, disrespected and inadequate, and in some cases still do.
• Professional lead role not respected or at times included within decision making processes.
• Have had to work hard to remain at work, high stress levels but have utilised coaching (external) to support.
• Experienced humiliation at times from senior management when presenting or contributing to meetings."

Historic Concerns

13.16. That this situation has prevailed for a number of years seems fairly clear. The following was brought to my attention as examples taken from a survey carried out in 2014:

• "Although concerns are expressed they are dismissed, staff feel unsupported.
• Unsupportive management focus only on negatives and problems, there is no recognition of good work. There is a total lack of inclusion or consultation in any proposed changes.
• Anyone who attempts to raise legitimate concerns is victimised and targeted
• I was shouted at by the trainer, witnesses were shocked by this and managers heard about it and did nothing (3 other people made similar comments)
• Anyone who tries to raise concerns regarding management is subjected to unfair treatment and things are made difficult
• Please, please listen and act on our concerns
• Team spirit and cohesiveness has been destroyed by negative management. Morale is very low and no-one is sure who they can trust
• There is a bullying culture here that has never been eradicated. Genuine concerns should be addressed rather than swept aside
• Unrealistic expectations from senior management and treatment by managers with an autocratic style is really stressful.
• Staff are too scared to raise a grievance, a concern or even report something that is clearly wrong. We've seen what happens to those that do
• I don't know why I'm bothering to fill this in, other than I was told to! But nothing ever happens anyway, it all gets covered up."

A Former Employee

13.17. A former employee who had felt unable to continue with NHSH summarised what she told me in a meeting in these words:

"Previous history of allegations made by the two individual nurses in the team, which had led to the suspension of the previous Senior Nurse, who later retired as she was unable to continue working in the service due to her traumatic experiences.

Perpetual bullying by the Nurse who was redeployed stating that he would 'have my job', directing the nurses to follow a particular practice pathway in the absence of professional/team discussion, taking on tasks that were not appropriate and undermining my professional status and role.

Professional disrespect and lack of understanding of roles and responsibilities. This created significant barriers between, for example, Nurses and [clinicians] in the service. There was an attitude that prevailed of superiority and inferiority and working together across disciplines was particularly difficult for some.

Oppressing certain professionals, the Service Manager undermining and making derogatory or negative remarks in front of other team members without justification, about certain colleagues, who were competent in their work, usually those who challenged others (seen as a threat). An experienced [clinician] was transferred out of the service, following her allegations about 'bullying' as she was seen as 'problematic and divisive'.

A culture based on fear and intimidation, blame, mistrust, covert practice, 'cliques', defensiveness and indiscreet recrimination, without an actual evidence base."

Other Experiences

13.18. Another nurse put it this way in our meeting:

"A wee group including charge nurses, other nurses, auxiliaries etc. treated [me] badly, talking behind [my] back, being unkind, using harsh tone, questioning [me] in front of patients, not made to feel part of the group etc. Felt intimidated, undermined, disregarded, ill informed and that [I] was a scapegoat for all the ward's ills."

13.19. One of my colleagues reported to me the experience of a bank auxiliary nurse who described consistently being treated in a derogatory manner by ward nurses:

"They speak to him in a brusque and patronising manner and do not value his expertise and experience. He estimates this happens more than 50% of the time. He thinks the belittling is driven by stress due to time pressure and the failure to make full use of him is driven by a hierarchical mindset that devalues auxiliary nurses. He recognises the nurses in turn are probably experiencing this treatment from doctors and managers. When he raises the derogatory behaviour with more senior nurses they tend to excuse it as being down to stress and do not tackle it robustly. He thinks that a team culture is needed."

13.20. A hospital worker told me:

"The degree of low-level and at times almost direct intimidation and bullying was very marked, with a pervasive feeling of fear and being unsettled in the job. What we as practitioners did each day was brought into question, with more and more constraints, and if we tried to explain how impracticable a new dictate was we were met with disregard, and an increase in feeling of being singled out, with her raising increasing "concerns" against individuals. Grievances were taken out against the manager, and although no evidence was found to back up the manager's "concerns" regarding practice, these were still upheld and our grievances against her given little credence, but the line taken was not to worry about it. My concern is that even when going through the official routes, if it is a manager a concern is raised against, it feels almost as if there is a closing of ranks, and even the unions did little to fight against this."

13.21. A junior member of staff described in detail her concerns in one unit:

"This has created a very fragmented and divisive culture across the unit. Junior [staff] are being blamed/scapegoated for mistakes they were not involved with and errors being made by senior [staff] are being covered up and collusion is occurring to blame junior [staff] for these errors."

13.22. A former employee had this to say:

"… in the NHS Highlands they burdened me with an excessive workload, made unilateral decisions without discussion, treated me like a robot rather than a human being, isolated staff (divide and conquer), emotionally blackmailed staff, put targets over patient care and safety, did not treat me with respect or appreciate me and severely affected my health and well being and ultimately made me seek employment elsewhere."

13.23. A laboratory assistant told me:

"I have never seen any workplace managed in the manner that this laboratory is now, it thrives on bullying at all levels as well as favouritism and gossip. There is no adequate staff training at all and I have been set up to fail on so many occasions."

13.24. A little vignette sums up the feelings of many who experienced a kind of cognitive dissonance:

"NHSH invested in promoting dignity at work policies. They organised this dignity at work workshop/meeting. I went to it, they paid all of this money out on mugs etc. then there was a presentation from two people at HR. At one point, one of the speakers was not confident – what are we doing next? And the other snapped saying "well I don't know, it's your bit!" It was right before my eyes."

13.25. An administrator described her experience in one department as being "kept out of decisions made by senior managers and then expected to communicate and defend unpopular decisions to staff", who would see her as the problem. She experienced bullying both from managers and from staff she was trying to manage. "I kept being handed a loaded gun". If she tried to tackle underperformance she was not backed up by management and then was criticised by staff for letting underperformers get away with it. She expressed concern that HR offered little support when she asked for help with bullying – options were either to live with it or raise a grievance, which would take a long time. In any formal meeting "HR only support the manager, so the staff member gets no support. Also, HR isn't confidential".

13.26. The damaging impact was described by another administrator who told me:

"I now find myself in complete limbo with no specific job role,... I am excluded from all staff meetings and have no contact with the actual local dept …The support staff still will not speak with me or acknowledge me in any way. I am struggling with immense feelings of rejection and isolation."

13.27. A former senior manager vividly described a series of experiences of what is known as "gaslighting" perpetrated by an even more senior manager. I am told that gaslighting is a form of "psychological manipulation that seeks to sow seeds of doubt in a targeted individual or in members of a targeted group, making them question their own memory, perception, and sanity. Using persistent denial, misdirection, contradiction, and lying, it attempts to destabilise the victim and delegitimize the victim's belief." Gaslighting was a word I became more familiar with during my review as respondents described their experiences.

13.28. This sort of unpleasant experience was corroborated by a former support manager:

"A number of staff complained about [a particular event], including myself, and this is when I started to be managed out of the business. Within a relatively short period of time my self-belief had been undermined so comprehensively that I would never have employed myself and was eventually signed off with stress (this is common in this department). When I was under treatment by my GP (none of those who signed the letter in the press) they were entirely unsurprised by my experience and said that stories like my own were common from NHS workers."

13.29. The experiences seem to be widespread across NHSH; this example comes from a rural community:

"It is widely felt by staff that there is an institutionalised culture of bullying management on [this island] but nothing can be done about it."

An Experience of the Board

13.30. I conclude this section with a completely different situation to those described above, in which a senior clinician describes an experience with "the Board" (which is used as a collective term here and may not refer to all members or an actual Board meeting). I do not offer this for its factual accuracy (as ever, perceptions will vary in a very pressurised situation) but record it as an indication of how dysfunctional things appear to have been and the resulting impact:

"What we experienced on that afternoon was both eye-opening and frightening. We were looking into the dark soul of the NHS organisation. Our team was shocked by this. Senior clinicians – three of them – moved to tears during the meeting. A lot of anger expressed about the way we were treated. The body language of board members was very unpleasant. There was an attempt to undermine us, make us look foolish. The behaviour was threatening. They left, we agreed to nothing. We agreed to meet the next day to discuss further. All shell-shocked. One colleague left during the meeting. Another tried to leave but was told to sit down. What took place was well beyond our collective scope of experience, and as such it was powerfully disorientating. I had never witnessed anything like it. In this way the Board broke the collegiate will of our clinical team. They left behind a fragmented, confused and angry remnant. In ways we found difficult to discuss I think we all felt ashamed of ourselves. Many of us were traumatised and remain so. Most of us felt that we had failed to defend the interests of our service and our patients. The methods of ambush, intimidation, isolation and undermining reflect the themes raised by those who requested an investigation into "bullying" at NHS Highland. It demonstrated a Board that is not listening to the concerns of its staff, driven by its own agenda and believing itself to be above the law. At a subsequent meeting arranged at my request, the Board Chairman asked me a very direct question: "did you feel bullied?", to which I answered "yes". That meeting …was never acknowledged, and to my knowledge no steps were taken to investigate the issue of high level bullying that the Chairman and chief executive had identified. What I perceived as formulated organisational subjugation allowed inconvenient truths to be concealed. As seen in other instances within the NHS, this kind of behaviour presents a risk to patient safety and to the long term reputation of the service. My concern is that that behaviour, which they probably don't recognise as being bullying, has a very significant influence on the safety of our service. Has allowed us to brush under the carpet the opinions of senior clinicians and very significant risks across NHSH."

Managers' Concerns

13.31. The allegations of bullying go both ways. Managers are also said to be the recipients of inappropriate behaviour from members of staff. This from an island community:

"My experiences are actually of NHS Highland Managers being bullied not the other way around. I have seen a very concerning increase in 'bad behaviour' from my colleagues over the past 3 years. I have been shouted at, screamed at, sworn at, lied about, accused of being unprofessional and uncaring too many times to keep track off. I feel as an organisation NHS Highland have lost their way a bit by not being assertive enough when managing services, the public and staff."

13.32. Similarly:

"I have had instances of managers being bullied by their nurses. This manager was accommodating the nurse's availability only and then scheduling everyone else around that one nurse. When I asked her if she felt bullied, she burst into tears and left."

13.33. This from a manager in a middle management situation expresses clearly the difficulty for someone in that position:

"During my employment as a Manager I found myself managing an unprecedented situation involving a member of staff I line managed. I found HR to be completely ineffective, my senior managers showed little interest. The end result of this ghastly situation was finding myself at the centre of grievance by the member of staff – unfounded accusations were made against me. I was made aware of this way of a phone call on a Friday evening from a very senior manager. Although I continued to work, I was under investigation which took many months to resolve. The outcome was 'no case to answer'; the situation was not dealt with appropriately. My experiences are not in isolation within NHSH….

I have also found myself being accused of bullying & harassment by a member of staff I lined managed. I took my role as a manager extremely serious and ensured I followed due process …I have evidence of this. The staff member involved did not want to be managed, had been used to 'doing her own thing' due to lack of structure within the area of responsibility. I viewed her as a risk, had significant concerns re her capability including clinical competence. She chose to accuse me of bullying her – again lack of support from HR was evident and the outcome was unsatisfactory. Again this not unusual in NHSH – people do not want to be managed, nobody takes responsibility contributing to compromising patient safety."

13.34. This comes from a long-serving senior manager who feels vulnerable at work:

"This has been a distressing time for me and I don't feel that there has been support for me as a (wrongly accused) manager within the organisation. I know the truth will out so to speak though so I just have to hang in there until it does. Fortunately my immediate line management know that the accusations are untrue and there is evidence to substantiate this however it concerns me that people can just make up stories on the bullying bandwagonand because NHS Highland is currently in the position it is in, the stance feels along the lines that managers must be at fault and need to improve as opposed to supporting managers who find themselves wrongly accused. I feel that I am a very vulnerable position and this unresolved situation has the risks of impact on my ability to continue to manage effectively without fear of accusations."

13.35. One manager described the impact on him of the recent accusations as a form of bullying itself:

"There has been an overwhelming feeling by myself and managerial colleagues that we have been labelled as bullies. Various individuals have had open access to mainstream media, social media and other avenues to express their allegations of bullying and labelling all levels of NHS Highland structure as bullies, including [one MSP] in open questioning at the Scottish Government. To me this could be considered as indirect intimidation and bullying without the right to reply. I have had to personally defend myself against various comments and assumptions outwith work as a result of the allegations made which includes my ex line manager. This may seem "par for the course" considering the serious nature of the allegations but unacceptable as an individual where I have no control of how the allegations were made to the press."

13.36. These views are clearly of great importance and reflect both the multifaceted nature of the situation and concerns about the way matters have been handled, together with the implications, on which I comment elsewhere.