Changing the face of whistleblowing
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b2090 (Published 27 May 2009) Cite this as: BMJ 2009;338:b2090All rapid responses
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Dear Editor,
Another story about an NHS hospital is reported in distressing terms,
including allegations of hundreds of unnecessary deaths. [1] In my BMJ
editorial about whistleblowing earlier this year, I anticipated further
scandals and regrettably it appears that this was accurate. [2]
As I discussed then, a remarkable feature of the aftermath of
Stafford was the readiness of ministers, the Care Quality Commission (CQC)
and others to blame NHS staff for not raising concerns. It soon became
apparent, particularly in evidence given to the House of Commons Health
Committee, that in fact staff had raised concerns, but they were not acted
upon. This included the comment, "The concern which has been reported back
to us is that people felt those incident forms were going into a black
hole or into a waste paper basket."[3]
Another attempt by the authorities to blame frontline clinical staff
for managerial failings will not be acceptable. I would therefore suggest
that as part of the investigation of what happened at Basildon, the actual
concerns raised by staff should be assessed, together with evaluation of
actions taken as result. Staff who raised important concerns should be
thanked and, if they wish, publicly recognised.
The CQC, which makes much of its powers, should urgently consider
weighing in with active support for NHS staff who raise concerns. Not to
do so would be to miss a very important opportunity.
I wrote to the Chairman of the CQC on 17th April 2009 asking, among
other things, what protection it proposes for whistleblowers, and what
obligation it proposed on managers to investigate concerns. I have not
received a reply.
[1] R. Smith, 'Failing hospital condemns hundreds to death,' Daily
Telegraph, 27 November 2009.
http://www.telegraph.co.uk/health/healthnews/6665429/Failing-hospital-
condemns-hundreds-to-death.html Accessed 27 November 2009.
[2] P. Gooderham , 'Changing the face of whistleblowing,' BMJ
2009;338:b2090, doi: 10.1136/bmj.b2090 (Published 27 May 2009)
[3] House of Commons Health Select Committee. Uncorrected Oral
Evidence, 3 June 2009, at
http://www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/uc151-
vi/uc15102.htm Accessed 27 November 2009
Competing interests:
None declared
Competing interests: No competing interests
Unless there is a complete change in culture forget whistle blowing
even those who try to improve established "Bad practises" risk isolation.
Other than the formal route there are very many ways in the modern NHS to
sideline what the establishment considers as "trouble makers”. Steve
Bolsin is probably the extreme end of this spectrum. Due to the libel laws
in UK it is also difficult to raise issues easily because unlike Erin
Brockovich the ordinary coal face doctor does not have the wherewithal to
stand up to the clout of the establishment. We had an example of a
prominent doctor’s forum recently clamping down on all discussions on a
dismissed doctor. First we need to establish "Freedom of speech" and
reasonable protection from libel laws before we can have any kind of
transparent and free discussion
Competing interests:
None declared
Competing interests: No competing interests
Are there any doctor like me, who are getting fed-up with what is
going on in the National Health Service and feel sad and helpless?. If you
are one and thinking of blowing the whistle or motivating yourself to do
something about this, please do not listen to these pundits who write and
encourage you to blow the whistle. If you have family with young children,
please think twice because your family and friends will also start blaming
you for being foolish.
If you still decide to blow the whistle, please be prepared to feel
lonely, isolated and watch the tower you built over the years crumble
right in front of your eyes. Even the patients who once trusted and adored
you will move away from you, making you feel as if you are a child
molester.
This is sad scenario, because the GMC and BMA publish articles to
encourage would-be whistleblowers should seek advice from their defence
bodies, and possibly the BMA or Public Concern at Work but are they
supportive?.
You will be doing a big mistake if you write a letter expressing your
concerns about policy decisions or clinical practice implemented by the
government that is supported by some doctors. Soon you will be the one who
will be investigated, even though you point out and have documents to
prove gross discrepancy in clinical practice, treatment and management.
The PCT & health authorities will ignore your concerns, continue
their investigation and will threaten to refer your name to GMC or
Clinical Performance Advisory Group. The torture you will be subjected to
for months based on some flimsy evidences will turn your life upside down.
After the investigation is over they may tell you that they have no
evidence to discredit you or your clinical practice, but the damage is
alredy done. What ever the outcome may be, you are the one who will
suffer, loose the enthusiasm, confidence to continue working as a doctor.
Its sad to see doctors who uphold and defend "Medical Ethics" are the
ones who have been shunned away and prosecuted. If our GMC expects us "NOT
TO HARM" our patients, and come forward to report if we notice, then why
are they turing a blind eye and allowing the authorities to walk all over
the doctor who speak the truth to defend "Medical Ethics"?
Reference
(1) Changing the face of whistle blowing :Editorial;BMJ
2009;338:b2514
(2) Whistle blowing is crucial for a "world class" NHS; BMJ 2009;338:b2514
Competing interests:
None declared
Competing interests: No competing interests
The fundamental problem in our NHS is lack of true leadership and NHS
culture.
There are three types of NHS cultures and/or leaders.
1. True leadership and 'Fair and Open' culture - In these Trusts
whistle blowing is encouraged, maliciousness is dealt firmly, patients are
protected, doctors and nurses are helped, supported and guided. Success is
celebrated, clinicians are valued, errors are accepted, lessons are
learnt, accountability is encouraged, and punishment is the last resort.
One can see brilliant Clinical and Medical directors.
2. Blame culture - Clinical and Medical Dictators, Club culture, 'Old
Boy's network', punishment is rife, errors are not tolerated or covered up
depends on whether you are a member of inner circle or not, if you are in
the inner circle then errors are ignored even if it affects patient
safety, action taken depends on who you are and not what you did,
appraisal, revalidation and Multi-source feedback is used as a tool to
blame and get rid of 'unwanted' doctors and nurses and fear is rife.
3. Anything goes - Poor medical leadership, full of clinical and
medical deadwoods, people are chosen for the wrong reasons, no one has any
interest, passion or commitment, tick box exercise, managers dominate,
clinicians are ignored, cover up is rife, poor in dealing with complaints,
litigation, clinical incidents, no one knows who is in charge of what,
ivory tower management and Board, whistle blowing is ignored, bullying,
harassment are ignored, everyone thinks he/she is in changed, full of
confusion.
So, there is nothing wrong with the whistle blowing but the question
is what happens once the whistle is blown and sadly it depends on the
leadership or lack of it.
Competing interests:
None declared
Competing interests: No competing interests
Mr Gooderham, presumably a lawyer, makes mistakes when discussing
“whistleblowing” and, like medical-politicians and other doctors, is
mesmerised by the term such that it becomes the driver of his thinking.
The real issue is single elementary clinical errors, and how best to make
the perpetrators promptly accountable so the errors cease and serial
disasters are nipped in the bud. And, by the way, the blowing of whistles
did not start with Bristol; or even a decade earlier at Cleveland [1].
Indeed, it preceded even the diazepam prescription madness of the 1970s.
“A whistleblower is a person who informs on another ...”, writes
Gooderham. If so, then the chief whistleblowers (and the most numerous and
important ones) are patients. They of course, nationwide and daily, are
seldom listened to. They may receive an earnest, perfunctory apology (as
if that is punishment enough for the doctor). But there is no bringing of
the doctor to book: no fines: no certainty ‘lessons have been learned’.
“Whistleblowing”, he writes, is “hazardous” for doctors and nurses.
Patient complaints are pretty hazardous too for patients. They and their
family often have to return to same doctor whom they complained about.
That doctors are more worried about their careers being blighted than
righting a wrong speaks volumes for the prevailing mentality of the UK
State NHS [2]. Stay quiet: keep your salary. Never be astonished that
patients resort to help from the press who are still the only potent
regulators of those on a State payroll.
Gooderham and others should carefully note that the surfeit of in-
house regulations to which doctors are being constantly subjected (to
ensure their salary), are of a supreme irrelevance to the prompt
identification of elementary clinical errors. These vaunted regulations
are but a conspicuous (and expensive) ruse to publicly claim the medical
stables are being cleaned. By writing his article, Gooderham, unwittingly
one suspects, at least illustrates their uselessness with regard to
clinical accountability.
William G Pickering.
wgpi@hotmail.com
June 5th 2009
References:
1. Pickering W G. Glasnost and the medical inspectorate. J of the RC
of GP. Nov 1988. p517.
2. Pickering WG. Systematic clinical accountability is required. BMJ
Nov 2003; 327: 1109; doi:10.1136/bmj.327.7423.1109
Competing interests:
None declared
Competing interests: No competing interests
The practice of punishing whistleblowers is as common in the US as in
the
UK.
And perhaps part of the problem is in how whistleblowers are viewed
against
the larger practices and institutions of a society.
The most minimal kind of analysis or introspection demonstrates how
ludicrous
it is to punish someone for exposing dangerous or illegal activities,
particularly
in healthcare. And who on Earth could defend such behavior?
Yet the delusion continues to guide practice when it is incorporated
into
"instutional practices" or "protecting the organization or profession."
An institution that fosters and promotes fear regarding exposure of
harm is
an institution that needs to be rethought from the bottom up.
Whistleblowing
should be renamed and rethought of as part of professional standards and
standards of good citizenship. And not exposing harm should be what
people are afraid of.
Competing interests:
None declared
Competing interests: No competing interests
Peter Gooderham states that we need "Statutory protection, support
from regulatory bodies and a culture change" to support the propogation of
whistle blowing.
I would argue that we need to consider more carefully the professions
attitudes and opinions of whistle blowing. In a study we conducted of
medical students at a Scottish Medical School in 2000 only 40% of students
felt they had a responsibility to blow the whistle if necessary and only
13% would actually do it [1].
Interestingly when the data was analysed by years it was revealed
that as students progressed through medical school they appeared to become
more antagonist to whistle blowing.
Factors given as motiviation not to blow the whistle on peers
included camaraderie, retaliation by peers, the view that although
behaviour is wrong -it is an accepted norm, self-preservation, not
student's responsibility, no clear guidelines, futility, requirement of
proof and uncertainty regarding what constitutes misconduct.
Factors given as motivation to blow the whistle included consequences
for patient, maintenance of standards, perpetrator needing help, personal
morality, vindictiveness against peers, to ensure peers are punished.
These views were from medical students, - they have become todays
doctors. We need a similar study of doctors views to inform any whistle-
blowing policies.
1. Rennie SC, Crosby JR. Students' perceptions of whistle blowing:
implications for self-regulation. A questionnaire and focus group survey.
Med Educ 2002; 36:173-9.
Competing interests:
None declared
Competing interests: No competing interests
People's willingness to highlight justifiable concerns is predicated
upon their working in a safe, sound and supportive context.
The term 'whistle-blowing' implies that such a function is special or
exceptional. It should better be a thoroughly systemic and systematic part
of any organisation's gathering of feedback-intelligence that informs it
how well, or not, it is doing? Just as there is a good argument for the
effectiveness of early intervention in many clinical conditions, it seems
perverse that the NHS, as a self-claiming 'earning organisation' is nor
regularly factoring in all available experiences and feedback to inform
and optimise its functions.
The message from many who have worked with doctors who have blown
their cover, as well as any whistle, and then lost their jobs and careers
in the NHS, is "don't do it", at least alone. The rhetoric and the
policies are full of worthy words, but many have mortgages to pay off and
families to educate, as well as any duty of care to the public and those
they manage, employ or treat.
The best way of ensuring that the NHS is never "world class" will be
to create the climates of fear, bullying and despair that prevent good,
honest and aspiring employees from being able to talk about how they feel
about their work and what they are asked, cajoled or forced into doing.
It's not good enough to expect individuals to do this alone; psychotoxic
and perversely incentivised behaviours now need to be rooted out from the
top down. Many taxpayers and citizens have little or no understanding of
how the NHS functions behind its front-end. It is time they did; in just
the same way as party political systems are now coming under the same
scrutiny.
Yours Sincerely
Dr Chris Manning
Competing interests:
None declared
Competing interests: No competing interests
With Margaret Haywood becoming the latest casualty of blowing the
whistle in the NHS, I am beginning to wonder if we have made any progress
at all. This culture of “threats and bullying” [1] was uncovered and
published following the Bristol Royal Infirmary Scandal 10 years ago, yet
steps taken to improve the system are still failing individuals like
Margaret Haywood.
In 1999, then Health Minister John Denham stated that the government
was committed to, “freedom of speech and creating a climate of openness
everywhere in the NHS.” He launched the initiative of appointing a ‘truth
protector’ within hospitals and health authorities, whose role was to
“deal with employees' concerns and help launch investigations.” [2] The
government is intending to have implemented new responsible officers by 1
October 2009. [3] Their duties are set to include “Handling complaints and
concerns relating to the conduct and performance of individual doctors.”
Whilst I understand they will have other roles (including revalidation),
there seem to be striking similarities in their job descriptions. [4]
Perhaps these new officers will be the catalysts for a change in
attitude towards whistleblowers, but I remain skeptical. How will they be
more effective at changing the climate in the NHS than their truth
protector predecessors have been over the last 10 years?
References
1. BBC News. Doctors ‘must root out bad care.’ 2009 April 16.
http://news.bbc.co.uk/1/hi/health/8002900.stm.
2. http://news.bbc.co.uk/1/hi/health/434789.stm 1999 September 1
3.
http://www.dh.gov.uk/en/Managingyourorganisation/
Humanresourcesandtraining/Modernisingprofessional
regulation/ProfessionalRegulationandPatientSafety
Programme/TacklingConcernsLocally/ResponsibleOfficers/
index.htm
4.
http://www.dh.gov.uk/en/Managingyourorganisation/
Humanresourcesandtraining/Modernisingprofessional
regulation/ProfessionalRegulationandPatientSafety
Programme/TacklingConcernsLocally/ResponsibleOfficers
/FAQ/DH_084876#_10
Competing interests:
None declared
Competing interests: No competing interests
Whistleblowing and Europe
Protection for whistleblowing varies between countries. The first law
specifically to protect whistleblowers was the Lloyd-La Follette Act of
1912 in the United States. The framework of legal protection is more
recent in the UK; Employment Rights Act 1996, amended as Public Interest
Disclosure Act 1998. However, at this time Stephen Bolsin from the
Bristol Royal Infirmary had to leave England for Australia.(2) In 2010,
the success of a whistleblowing claim is news.(3) Unfortunately, it
means that it may still be exceptional.
By contrast, whistleblowing has no legal recognition in other
European countries. Worse still, the Conseil d’Etat, the highest
administrative court in France, has always judged that servants must
remain silent (“obligation de réserve”). Too many European Union
directives are useless, but here is a good case for harmonisation.
1 Benkimoun P. Doctor’s sacking is setback for French public health,
supporters say. BMJ 2010;340:c711
2 Gooderham P. Changing the face of whistleblowing. BMJ 2009;338:
b2090
3 Dyer C. Doctor who was excluded for raising patient safety concerns
is entitled to substantial damages. BMJ 2010; 340: c739
Competing interests:
None declared
Competing interests: No competing interests