Building a Culture of Openness from Blunt End to Sharp End

Image by gauri_lama (CC BY-SA)


Timescale: 2016-2019

Funder: Department of Health Policy Research Programme



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. Concerted efforts to learn from high-profile failings have led to clear recommendations for action, and specific policies seeking to foster openness. But cultures do not change rapidly, and healthcare cultures (in the NHS and other systems) have often struggled with openness. 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. Hierarchies, institutional structures and professional boundaries have impeded candour, while fear of repercussions of speaking up contributes to suppression of valuable intelligence.


Project aims

  • To evaluate the current state of cultures at every level of the NHS relating to openness, transparency, and learning, including change over time and variation across settings.
  • To gain an understanding of how far specific policies and initiatives developed by senior managers and policymakers and introduced since the publication of the Francis inquiry have changed norms, attitudes, practices, and behaviour and thus translated into positive action at the level of patient care.
  • To generate and disseminate findings and practical recommendations for policymakers, senior NHS managers, and clinicians that will inform policy and make a real difference to how openness is put into practice.


The research study

Though the literature highlights factors important to improvement, such as leadership approach and role-modelling and organisational safety climate, not enough is known about how far cultures are changing, ‘what good looks like’, and how positive cultures can be facilitated to secure the best possible experiences of openness for patients, families and staff. Our study will address this void.

The study will use a mixture of quantitative and qualitative methods, drawing both on existing sources of data, in particular results from the National Staff and Acute Inpatient Surveys, and new data that will be generated during the course of the study. The project will involve a survey and interviews with senior staff in a range of organisations providing NHS services and in-depth interviews with a range of staff, patients, and carers in a purposive sample of healthcare organisations. The survey is being carried out by Wilmington Healthcare Ltd. These data will allow researchers to assess attitudes to transparency and how they have changed through time, to evaluate how policy around openness is being put into practice, and to identify examples of both excellent performance and of minimalistic compliance.


Project team

Graham Martin

Mary Dixon-Woods

Jeremy Dawson

Sarah Chew

Imelda McCarthy

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