Whistleblowing can be more than “an isolating and depressing experience”
Steve Bolsin considered that blowing the whistle “was an isolating
and depressing experience”.[1] From a personal point of view, many other
words could also be used to describe the experiences associated with
whistleblowing and raising concerns including “exasperating”, “irritating”
and “disappointing”, the last being applied particularly to the way some
individuals and groups respond to issues that are raised with them.
I contacted the office of the Committee of Public Accounts in
February 2006 about stroke economic research modelling work after the
National Audit Office (NAO) and its assisting research team failed to
provide details of the assumptions and calculations underpinning the
dubious thrombolysis and stroke unit outcome and savings figures in the
November 2005 NAO stroke report. On 23 May 2005 I had forwarded a BMJ
rapid response [2] to the NAO that contained numbers needed to treat
(NNTs) for thrombolysis and stroke units with the cautionary comment, “The
acute strokologists want to spend lots of money employing more doctors to
deliver a safe / unsafe treatment (patient choice and perspective) whereas
some may consider this is not a priority until rehab services are
appropriately funded and delivered.” I had been told in December 2005
that I would be contacted with assumptions and calculations for the
economic model but nothing materialised before the Committee’s 8 February
evidence hearing despite a number of follow-up e-mails. The lack of
response from health economists caused me to be suspicious about the
accuracy of the modelling and the validity of assumptions, hence the
reason to blow the whistle to the Committee.
Prospects of successful rehabilitation and return to independence for
many stroke patients will be harmed by a lack of access to appropriate
post hyperacute and acute care. This rehabilitation care can be delivered
either in hospital or the community. Sudlow and Warlow’s recent BMJ
article [3] substantiated and vindicated my 2006 warnings to MPs as it
highlighted the problems with the research and the lack of transparency
around the NAO’s arithmetic and underpinning modelling work that had been
carried out by King’s College London and London School of Economics (LSE)
staff. The assertions of the two eminent stroke experts have not been
challenged by the NAO or the health economists who constructed the model.
Sudlow and Warlow also warned about the emphasis on developing hyperacute
care distracting attention and resources from other stroke
interventions.[3] That in fact has happened as shown by the 2008 Royal
College of Physicians phase 1 organisational audit findings that noted
little development of early supported discharge and community services as
opposed to the fast progress in expanding thrombolysis services.[4]
MPs chose not to heed my 2006 warnings about the NAO stroke report’s
figures and associated economic modelling work and the potential harmful
impact on stroke service developments. Following the NAO’s 2005 report,
and the Committee’s own report in July 2006 that reproduced the NAO’s
figures, the past few years have seen stroke service commissioners -
including those in London - concentrate time, effort and resources on the
hyperacute hospital end of stroke services and thrombolysis delivery.
Sudlow and Warlow were right to single out the London stroke strategy for
comment. The London stroke model that determines patient flows, HASU and
ASU bed number requirements, and anticipated thrombolysis use also lacks
transparency around assumptions and references just as the NAO model did
back in 2005. [5]
The London model was commissioned from King’s College and LSE staff.
The model has overly optimistic if not unrealistic assumptions that do not
sit well with published evidence: a 13.4% thrombolysis rate for all
strokes in London’s model looks uncomfortably large against the Glasgow 4%
figure [3] and also the recent review findings of Professor Ford (one of
the “independent clinical review” team commissioned by London for its
work) and colleagues that noted a rate of just 3.8% for emergency service
redirection of all strokes as will happen in the London HASU / ASU
model.[5] Similarly, a 90% admissions rate to hospital does not reflect
either Oxford’s work (a 56% admission rate) [3] or even the hospital
episode statistics derived rate of 66% (73,000 stroke admissions from a
total of 110,000 strokes). Is £21 million really going to be needed for
HASU and ASU services in London as derived from the detail of the
modelling? Only £1 million has so far been committed to rehabilitation.[3]
If the Committee of Public Accounts MPs had listened and acted on
concerns back in 2006 perhaps the NAO’s 2005 stroke report and its
underpinning economic research modelling may have been more effectively
and closely scrutinised at that stage. Similarly, more timely stroke
expert challenge and comment in 2005 and 2006 of the sort in the BMJ in
2009 [3] may have given less prominence and influence to the NAO’s stroke
report and its economic modelling than it has enjoyed over the recent
years. A more balanced development and investment approach to stroke
services for Londoners may even have resulted with a fully funded and
comprehensive stroke service being commissioned by the JCPCT at its 20
July 2009 meeting [7] covering all aspects of care from prevention through
to long term community support. Instead, there is no guarantee from the
JCPCT at this time that rehabilitation will be developed and funded in
London to the same standards and with the same levels of co-operation and
co-ordination as the hyperacute and acute hospital services.
Blowing the whistle can be a very disappointing experience. A culture
of candour and transparency needs to be positively developed and
encouraged by the Department of Health and its ministers; turning a blind
eye and not breaking ranks needs to be seen as a bad choice to be actively
discouraged especially when patients may be harmed by individuals or by
systems’ deficiencies and failures.
Rapid Response:
Whistleblowing can be more than “an isolating and depressing experience”
Steve Bolsin considered that blowing the whistle “was an isolating
and depressing experience”.[1] From a personal point of view, many other
words could also be used to describe the experiences associated with
whistleblowing and raising concerns including “exasperating”, “irritating”
and “disappointing”, the last being applied particularly to the way some
individuals and groups respond to issues that are raised with them.
I contacted the office of the Committee of Public Accounts in
February 2006 about stroke economic research modelling work after the
National Audit Office (NAO) and its assisting research team failed to
provide details of the assumptions and calculations underpinning the
dubious thrombolysis and stroke unit outcome and savings figures in the
November 2005 NAO stroke report. On 23 May 2005 I had forwarded a BMJ
rapid response [2] to the NAO that contained numbers needed to treat
(NNTs) for thrombolysis and stroke units with the cautionary comment, “The
acute strokologists want to spend lots of money employing more doctors to
deliver a safe / unsafe treatment (patient choice and perspective) whereas
some may consider this is not a priority until rehab services are
appropriately funded and delivered.” I had been told in December 2005
that I would be contacted with assumptions and calculations for the
economic model but nothing materialised before the Committee’s 8 February
evidence hearing despite a number of follow-up e-mails. The lack of
response from health economists caused me to be suspicious about the
accuracy of the modelling and the validity of assumptions, hence the
reason to blow the whistle to the Committee.
Prospects of successful rehabilitation and return to independence for
many stroke patients will be harmed by a lack of access to appropriate
post hyperacute and acute care. This rehabilitation care can be delivered
either in hospital or the community. Sudlow and Warlow’s recent BMJ
article [3] substantiated and vindicated my 2006 warnings to MPs as it
highlighted the problems with the research and the lack of transparency
around the NAO’s arithmetic and underpinning modelling work that had been
carried out by King’s College London and London School of Economics (LSE)
staff. The assertions of the two eminent stroke experts have not been
challenged by the NAO or the health economists who constructed the model.
Sudlow and Warlow also warned about the emphasis on developing hyperacute
care distracting attention and resources from other stroke
interventions.[3] That in fact has happened as shown by the 2008 Royal
College of Physicians phase 1 organisational audit findings that noted
little development of early supported discharge and community services as
opposed to the fast progress in expanding thrombolysis services.[4]
MPs chose not to heed my 2006 warnings about the NAO stroke report’s
figures and associated economic modelling work and the potential harmful
impact on stroke service developments. Following the NAO’s 2005 report,
and the Committee’s own report in July 2006 that reproduced the NAO’s
figures, the past few years have seen stroke service commissioners -
including those in London - concentrate time, effort and resources on the
hyperacute hospital end of stroke services and thrombolysis delivery.
Sudlow and Warlow were right to single out the London stroke strategy for
comment. The London stroke model that determines patient flows, HASU and
ASU bed number requirements, and anticipated thrombolysis use also lacks
transparency around assumptions and references just as the NAO model did
back in 2005. [5]
The London model was commissioned from King’s College and LSE staff.
The model has overly optimistic if not unrealistic assumptions that do not
sit well with published evidence: a 13.4% thrombolysis rate for all
strokes in London’s model looks uncomfortably large against the Glasgow 4%
figure [3] and also the recent review findings of Professor Ford (one of
the “independent clinical review” team commissioned by London for its
work) and colleagues that noted a rate of just 3.8% for emergency service
redirection of all strokes as will happen in the London HASU / ASU
model.[5] Similarly, a 90% admissions rate to hospital does not reflect
either Oxford’s work (a 56% admission rate) [3] or even the hospital
episode statistics derived rate of 66% (73,000 stroke admissions from a
total of 110,000 strokes). Is £21 million really going to be needed for
HASU and ASU services in London as derived from the detail of the
modelling? Only £1 million has so far been committed to rehabilitation.[3]
If the Committee of Public Accounts MPs had listened and acted on
concerns back in 2006 perhaps the NAO’s 2005 stroke report and its
underpinning economic research modelling may have been more effectively
and closely scrutinised at that stage. Similarly, more timely stroke
expert challenge and comment in 2005 and 2006 of the sort in the BMJ in
2009 [3] may have given less prominence and influence to the NAO’s stroke
report and its economic modelling than it has enjoyed over the recent
years. A more balanced development and investment approach to stroke
services for Londoners may even have resulted with a fully funded and
comprehensive stroke service being commissioned by the JCPCT at its 20
July 2009 meeting [7] covering all aspects of care from prevention through
to long term community support. Instead, there is no guarantee from the
JCPCT at this time that rehabilitation will be developed and funded in
London to the same standards and with the same levels of co-operation and
co-ordination as the hyperacute and acute hospital services.
Blowing the whistle can be a very disappointing experience. A culture
of candour and transparency needs to be positively developed and
encouraged by the Department of Health and its ministers; turning a blind
eye and not breaking ranks needs to be seen as a bad choice to be actively
discouraged especially when patients may be harmed by individuals or by
systems’ deficiencies and failures.
[1] Cassidy J. Name and shame. BMJ 2009;339:b2693
[2] Dudley N. Misleading messages about safety and thrombolysis
effectiveness http://bmj.com/cgi/eletters/330/7501/1167-a#107649
[3] Sudlow C, Warlow C. Getting the priorities right for stroke
care. BMJ 2009;338:b2083
[4] National Sentinel Stroke Audit: Phase 1 organisational audit
2008. www.rcplondon.ac.uk/clinical-standards/ceeu/Current-
work/Documents/Public%20organisational%20report2008.pdf
[5] Price C, Clement F, Gray J, Donaldson C, Ford GA. Systematic
review of thrombolysis service configuration. Expert Review of
Neurotherapeutics; 2009:9(2) 211 - 233.
[6] Appendix 10. Outline of the modelling approach. (18/07/2008)
www.healthcareforlondon.nhs.uk/stroke-project-documentation/
[7] Healthcare for London. Consultation assessment.
www.healthcareforlondon.nhs.uk/jcpct-meeting-in-public/
Competing interests:
None declared
Competing interests: No competing interests