Intended for healthcare professionals


Raising and responding to frontline concerns in healthcare

BMJ 2019; 366 doi: (Published 19 August 2019) Cite this as: BMJ 2019;366:l4944
  1. Russell Mannion, professor1,
  2. Huw Davies, professor2
  1. 1Health Services Management Centre, University of Birmingham, Birmingham, UK
  2. 2School of Management, University of St Andrews, Fife, UK
  1. Correspondence to: R Mannion r.mannion{at}

Frontline staff are well placed to identify failings in care, but speaking up requires a supportive organisational culture to be effective, say Russell Mannion and Huw Davies

The independent inquiry into Liverpool Community Health NHS Trust announced in June 20191 is the culmination of a well worn path. Concerns about care are raised and ignored, staff are denigrated or bullied, the situation escalates into whistleblowing to outside authorities, and eventually—often years later—a formal inquiry is set up to get to the bottom of things. The long line of inquiries in the UK and elsewhere highlights the sentinel role of staff “speaking up” when they see unsafe or poor quality care.234 But exhortations to speak up (encapsulated by the statutory duty of candour introduced in the NHS after the Francis inquiries into failures at Mid Staffordshire NHS Trust45) belie the complexity and ambiguity that it creates for staff.


Raising concerns about care can be as simple and everyday as making an observation or suggestion to colleagues while delivering care. Informal commentary or intervention, gentle reminders, humour, or sarcasm may be used to draw attention to perceived concerns.6 If this doesn’t work, staff have the option of stronger measures such as more explicit conversations; drawing the attention of coworkers and line managers to the concerns; placing critical observations “on the record” within formal accountability, appraisal, or performance management systems; or seeking remedial action plans. If the problem still remains they can leapfrog traditional line management hierarchies to report to someone more senior. As a last resort staff may decide to “blow the whistle”7 to outside authorities (such as regulators, professional bodies, or trades unions), political representatives, or the media.

Individuals voicing concerns should be commended for their insights and challenge, but sometimes their observations …

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