Appendix 3. The Picker report

1. In order to collect views on the culture of neonatal units across England, the Inquiry drafted a survey. The survey was then administered by Picker, an international health and social care charity, and sent to 32,121 staff from 118 Trusts^* with neonatal units.¹
2. The survey was sent by email to nurses, midwives, doctors, consultants, managers or senior managers working in, or connected to, neonatal units on 1 February 2024. The survey was open to responses from 4 March 2024 to 8 April 2024.²
3. Staff were asked about the overall culture of the neonatal units in which they work, and about their working relationships both with those in the same occupation and with others. They were asked to rate their level of agreement on a five-point scale (strongly disagree; disagree; neither agree nor disagree; agree; strongly agree) with a number of propositions. Responses that agreed or strongly agreed were rated as positive; any other response was rated as negative.³
4. The final number of eligible responses was 7,497, representing a response rate of 24.2% – sufficient to yield statistically meaningful results. The response levels largely reflected the proportions of the entire population in each eligible occupation, and there was a regional spread of responses across England’s commissioning regions.⁴
5. The respondents were predominantly more experienced staff members: 42.6% had worked at their Trust for less than 5 years, compared with 57.4% who had worked there for longer than 5 years; 25.9% of respondents had been employed by their Trust for more than 15 years.⁵
6. The majority of respondents (67.8%) had worked more than ten shifts on the neonatal unit in the preceding six months. Approximately a quarter of respondents (24%) had not worked on the neonatal unit in that time.⁶
7. The survey found that 77.6% of respondents believed that the culture of their neonatal unit was good (i.e. they agreed or strongly agreed with the statement). Interestingly, only 20.6% of people stated that improvement in their unit’s culture was unnecessary, which suggests there is no complacency and an openness to improvement.⁷
8. Doctors and consultants were more likely than the other clinical occupations to report both that the unit’s culture was good and that there was an open and frank culture on the unit. Nurses were the most likely to say that there was a need for improvement in the culture. Managers’ and senior managers’ views did not diverge from clinical staff members to any notable extent.⁸
9. Each group was generally positive about working relationships within their occupation. Doctors were the most likely to be positive about their internal relationships (95%), along with consultants and senior managers (also over 90%). Midwives were the least likely to give a positive response (78.4%).⁹
10. The evidence about cross-occupation working relationships shows a number of interesting results. Whilst it may be said that relationships between different groups of professionals were broadly positive, it was apparent that senior managers routinely overestimate the quality of their relationships with other occupations and with more junior managers:
    1. 61.2% of midwives reported a good relationship with senior managers, compared with 83.5% of senior managers reporting a good relationship with midwives.
    2. Even fewer nurses reported a good relationship with senior managers (49.7%), compared with 87.5% of senior managers reporting a good relationship with nurses.
    3. 56.7% of doctors reported good relationships with senior managers, whereas 82.0% of senior managers said they had good relationships with doctors.
    4. For consultants, the relevant figures were 66.3%, compared with 82.1% of senior managers reporting good relationships with consultants.
    5. 76.2% of managers reported good relationships with senior managers, compared with 91.9% of senior managers saying they had good relationships with managers.¹⁰
11. Of the groups who treat and look after patients, midwives were the least likely to report having a good working relationship with other clinical staff.¹¹ This echoes the observations of nurses at the Countess in 2015 and 2016, but it may also be a reflection of the fact that the midwives answering the survey were far more likely not to have worked on the neonatal unit in the six months preceding the survey. This may also suggest that infrequent contact is more likely to lead to poorer-quality relationships.
12. The fact that senior managers’ views of their relationships differ so markedly from those on the other side of the relationship may be explained by a number of factors, including bias against senior managers, and the survey did not test for that. Another possibility – at least as likely – may be a lack of insight on the part of senior managers about how they are seen. Whatever the cause, and there may be more than one, this finding ought to be factored into the appraisal and development of managers throughout their careers.

Footnotes

1. * 121 Trusts with neonatal units were approached to participate in the survey; 118 responded. The 121 trusts do not include the Countess.

Endnotes

1. 1 INQ0098717/5

2. 2 INQ0098717/6-7

3. 3 INQ0098714

4. 4 INQ0098717/8-11

5. 5 INQ0098717/11

6. 6 INQ0098717/11

7. 7 INQ0098717/12

8. 8 INQ0098717/12

9. 9 INQ0098717/13

10. 10 INQ0098717/13

11. 11 INQ0098717/14