The editorial, Doctors’ duty to report poor practice (BMJ 2012;344:e1695), by Cathy James, identifies a crucial problem facing both clinicians and the GMC. She points out that “the GMC should take the organisational culture into account when deciding whether an individual’s failure to speak up should affect his or her professional registration”. But, irrespective of the organisational arrangements of a NHS trust, how can the GMC be expected to assess the kind of culture that convinced whistleblower Stephen Bolsin he would have to leave the country to resume his career? Such a corrupt corporate culture is meticulously covert and, even when a confidential reporting system may be in place, quite obscure.
For more than two decades honourable medical professionals have had to learn the hard way that their careers can be ruined if they speak up about bad practice. They now know that it only takes a grimace from an unprofessional CEO for his/her acolytes to subtly ensure that an unwanted clinician knows where he/she stands. Such clinicians also know that resorting to the Public Interest Disclosure Act 1998 in the hope that they can retain their positions is likely to result in them being gagged. But when no laws are being broken, how can this corporate assault on professional duty and careers be dealt with?
In my view, what has been happening in NHS trusts over these last decades is as damaging to present-day medicine as the corruption of the early 19th century that Dr Thomas Wakely fought against with his Lancet. Knowing the power of the early 19th century private medical establishment, Wakely decided that its wrongdoings would, initially, have to be exposed anonymously by those who were close to what was happening. That was how he started to “lance the boil” of jobbery, nepotism and corruption and helped to transform it from a private interest profession into one in the public interest. It was one of the most important events in the history of our learned professions. But we now know that the CEOs of some NHS trusts have harmed patients by concealing wrongdoing for irresponsible commercial interests in much the same way that the medical establishment of the early 19th century damaged patients for private interests.
But this abuse of the power entrusted in NHS trusts by some CEOs has been allowed to fester for far too long and, in my view, it is time to make it clear to them that imposing a culture of fear and silence will no longer serve to conceal bad practice. To do this I believe clinicians need the help of fellow professionals who are beyond the reach of NHS trust CEOs. The nascent Centre for Professional Integrity (CPI)(see BMJ2009:339:b3055) has found that there are, potentially, any number of professionals, particularly the semi-retired and retired, who are prepared to help in the process of anonymising the concerns of NHS trust clinicians. Together, they can help to make it quite clear to CEOs that that only by creating a genuinely open culture can the management ethos of trusts be made compatible with both commercial prudence and professional principles. And the identification of trusts where medical professionals have been able to properly honour their duty without career-damaging reprisal will clearly demonstrate their corporate social responsibility. Moreover, in future, CEOs will know that they cannot intimidate and isolate honourable clinicians since a contingent of deeply concerned fellow professionals will always be at hand to provide them with genuinely independent and confidential support.
The CPI sees volunteer professionals, working in pairs, making themselves available to discuss in the strictest confidence a matter that seriously concerns a trust professional. Firstly, they would satisfy themselves that it is based on objective evidence and can be unequivocally substantiated. They would then mutually discuss with the trust professional how he/she wishes it to be handled and the way it can be raised so as to protect his/her identity. It should be noted that the trust professional will remain in strict control of the whole procedure as he/she would have intended had there been no personal threat. Furthermore, the procedure would follow that recommended by the BMA, starting with careful approaches to line management and only extended beyond the trust if, and when, after very careful mutual consideration it is absolutely necessary in the public interest.
The problem Cathy James has identified concerns the trust that is the very heart and soul of professionalism. This being so, a few errant CEOs of NHS “trusts” cannot be allowed to debase that word by infecting the NHS ethos such that honourable clinicians have no option but to become the obedient lieutenants of an irresponsible corporate culture or end their careers. After all, the principles the GMC safeguards are there in the interests of patients and cannot be allowed to be trampled underfoot by the contemporary equivalent of early 19th century medical establishment practice.
JG Roddick CEng MIStructE, Current Coordinator, Centre for Professional Integrity
Rapid Response:
Re: Doctors’ duty to report poor practice
The editorial, Doctors’ duty to report poor practice (BMJ 2012;344:e1695), by Cathy James, identifies a crucial problem facing both clinicians and the GMC. She points out that “the GMC should take the organisational culture into account when deciding whether an individual’s failure to speak up should affect his or her professional registration”. But, irrespective of the organisational arrangements of a NHS trust, how can the GMC be expected to assess the kind of culture that convinced whistleblower Stephen Bolsin he would have to leave the country to resume his career? Such a corrupt corporate culture is meticulously covert and, even when a confidential reporting system may be in place, quite obscure.
For more than two decades honourable medical professionals have had to learn the hard way that their careers can be ruined if they speak up about bad practice. They now know that it only takes a grimace from an unprofessional CEO for his/her acolytes to subtly ensure that an unwanted clinician knows where he/she stands. Such clinicians also know that resorting to the Public Interest Disclosure Act 1998 in the hope that they can retain their positions is likely to result in them being gagged. But when no laws are being broken, how can this corporate assault on professional duty and careers be dealt with?
In my view, what has been happening in NHS trusts over these last decades is as damaging to present-day medicine as the corruption of the early 19th century that Dr Thomas Wakely fought against with his Lancet. Knowing the power of the early 19th century private medical establishment, Wakely decided that its wrongdoings would, initially, have to be exposed anonymously by those who were close to what was happening. That was how he started to “lance the boil” of jobbery, nepotism and corruption and helped to transform it from a private interest profession into one in the public interest. It was one of the most important events in the history of our learned professions. But we now know that the CEOs of some NHS trusts have harmed patients by concealing wrongdoing for irresponsible commercial interests in much the same way that the medical establishment of the early 19th century damaged patients for private interests.
But this abuse of the power entrusted in NHS trusts by some CEOs has been allowed to fester for far too long and, in my view, it is time to make it clear to them that imposing a culture of fear and silence will no longer serve to conceal bad practice. To do this I believe clinicians need the help of fellow professionals who are beyond the reach of NHS trust CEOs. The nascent Centre for Professional Integrity (CPI)(see BMJ2009:339:b3055) has found that there are, potentially, any number of professionals, particularly the semi-retired and retired, who are prepared to help in the process of anonymising the concerns of NHS trust clinicians. Together, they can help to make it quite clear to CEOs that that only by creating a genuinely open culture can the management ethos of trusts be made compatible with both commercial prudence and professional principles. And the identification of trusts where medical professionals have been able to properly honour their duty without career-damaging reprisal will clearly demonstrate their corporate social responsibility. Moreover, in future, CEOs will know that they cannot intimidate and isolate honourable clinicians since a contingent of deeply concerned fellow professionals will always be at hand to provide them with genuinely independent and confidential support.
The CPI sees volunteer professionals, working in pairs, making themselves available to discuss in the strictest confidence a matter that seriously concerns a trust professional. Firstly, they would satisfy themselves that it is based on objective evidence and can be unequivocally substantiated. They would then mutually discuss with the trust professional how he/she wishes it to be handled and the way it can be raised so as to protect his/her identity. It should be noted that the trust professional will remain in strict control of the whole procedure as he/she would have intended had there been no personal threat. Furthermore, the procedure would follow that recommended by the BMA, starting with careful approaches to line management and only extended beyond the trust if, and when, after very careful mutual consideration it is absolutely necessary in the public interest.
The problem Cathy James has identified concerns the trust that is the very heart and soul of professionalism. This being so, a few errant CEOs of NHS “trusts” cannot be allowed to debase that word by infecting the NHS ethos such that honourable clinicians have no option but to become the obedient lieutenants of an irresponsible corporate culture or end their careers. After all, the principles the GMC safeguards are there in the interests of patients and cannot be allowed to be trampled underfoot by the contemporary equivalent of early 19th century medical establishment practice.
JG Roddick CEng MIStructE, Current Coordinator, Centre for Professional Integrity
Competing interests: No competing interests