Intended for healthcare professionals

Careers Careers Clinic

How do I raise patient safety concerns, and when does this become whistleblowing?

BMJ 2018; 361 doi: (Published 19 April 2018) Cite this as: BMJ 2018;361:k1659
  1. Abi Rimmer
  1. The BMJ

It can be difficult to know how and when to raise a concern, but help is available, Abi Rimmer finds

“Know what to do if concerns aren’t resolved”

Francesca West, chief executive of Public Concern at Work

“‘Raising concerns,’ ‘speaking up,’ and ‘whistleblowing’ are all essentially terms that describe telling someone in authority about wrongdoing, be that your manager, chief executive, regulator, or even the media. However, each of these terms can feel quite different.

“Often ‘whistleblowing’ is used as a term when a concern feels unwelcome or when it’s external, and ‘speaking up’ is seen as being at the softer end of the spectrum, when a staff member first raises a concern. But we know from experience on our advice line that difficulties and opportunities exist at each stage of raising a concern, so this distinction can be misleading.

“The reality is that they’re all part of the same spectrum, and knowing what to do if your concerns aren’t resolved at an early stage or if you’re unable to raise the matter locally is an important part of protecting patients. Escalating these issues and having the support to do so, no matter what the process is called, is what should be in place at any organisation with a good culture.

“What matters is that the concern is resolved. All organisations should have a policy in place to help you do this. More importantly, a ‘freedom to speak up’ guardian should be appointed at your organisation to assist you if, for whatever reason, you don’t feel able to raise your concern through the usual channels or if it’s been difficult to do so.

“Ultimately, if you feel worried, fear speaking up, or need help to raise your concern further you can seek free, confidential advice from Public Concern at Work.”

“If in doubt, escalate”

Anthea Mowat, chair of the BMA Representative Body

“The freedom to raise concerns without fear of reprisal is vital for patient safety. As a doctor you have a professional duty to report any concerns, though it can often be difficult to establish when you should raise an issue and how to go about this.

“If you’re in doubt about whether to raise a concern you should always err on the side of escalating to your manager/immediate superior, and you should do it as soon as possible. It may be useful to ask yourself whether, if you let the situation continue, it’s likely to result in harm to others.

“All employers should have a formal policy for raising serious concerns, and it will generally be advantageous to follow the procedure set out in your employer’s policy, which should serve as protection for you. Additionally, freedom to speak up guardians are now in place at every English NHS trust to support NHS staff who can’t successfully voice their grievances through their usual line management chain.

“It can sometimes be difficult to ascertain whether a concern about malpractice falls within the legal framework of whistleblowing. While you may highlight an issue in relation to a personal matter at work, ‘whistleblowing’ refers to the act of a worker raising a concern, in the public interest, about malpractice at work. Under whistleblowing legislation a worker can make a ‘protected disclosure,’ meaning that the worker is protected against dismissal and victimisation regarding the disclosure.

“Raising concerns and dealing with difficult or unlawful consequences can be very stressful. If you have concerns but are not sure how to raise them you can call the NHS and Social Care Whistleblowing Helpline on 08000 724 725. For confidential support you can use the BMA Counselling and Doctor Advisor service.”

“We are working to change the culture”

Georgina Charlton, deputy freedom to speak up guardian at Guy’s and St Thomas’ NHS Foundation Trust

“The act of ‘whistleblowing’ has a troubled history in healthcare. Too often it’s been seen as synonymous with ‘disloyalty to your team’ or ‘shopping your colleagues.’ The treatment of whistleblowers by their fellow workers is testament to how much needs to be done. In all too many cases people’s mental health and careers have suffered: they and their families have sometimes even received death threats.

“At Mid Staffordshire NHS Foundation Trust—one notorious example that hit the headlines—a culture of fear, secrecy, and bullying prevented people from doing their jobs properly, resulting in devastating consequences for its patients. I, and my fellow freedom to speak up guardians throughout the NHS, are working to change this dangerous culture.

“It’s because of the negative connotations of the term ‘whistleblowing’ in healthcare that the preferred expressions now are ‘freedom to speak up’ and ‘raising a concern.’ Robert Francis QC, in the wake of the Mid Staffs scandal, has provided further guidance to drive a coordinated approach to the cultural change the NHS desperately needs.

“Essentially, raising a concern and whistleblowing amount to the same thing: speaking up if you see something wrong, particularly if it relates to patient safety. How far you have to go to be taken seriously will depend on the structures in place where you work, as well as the professional integrity of those around you.

“Ideally, you should be able to go to a senior colleague who will sort it out. But if you’re not heard, or if maybe that colleague is the root of the problem, what do you do then? Don’t be deterred: seek another route to raise your concerns internally. Many organisations have confidential email addresses, speaking-up advocates, and anonymous phone lines.

“The appointment of a named freedom to speak up guardian is now mandatory in all NHS trusts. Find out who your guardian is: they should be safe sources of independent and confidential advice. Ultimately, you always have the option of going externally, but do seek legal advice first to protect yourself.

“Do what you can in your professional life to help build a shared belief at all levels of your organisation that raising concerns is a positive thing, providing a valuable opportunity to learn, improve and—most importantly—prevent patients from being harmed.”

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