Kim Holt (BMJ 2015;350:h2300 ) speaks sense, and her argument is eloquent. However, the cynicism and disengagement will continue until the underlying philosophy is agreed after open debate. If professionals feel the politicians are “gagged”, how can they be expected to behave differently? A public enquiry will only scratch the implementation management, and NOT the strategic management.
Whistleblowing in the NHS is now a mainstream topic, thanks in part to two key reports published in the first three months of 2015: the Freedom to Speak Up review, chaired by Robert Francis, QC,1 and Anthony Hooper’s review into how cases involving whistleblowers are handled by the General Medical Council.2 Despite these reports, and the interest and attention of the secretary of state for health, the health select committee, and the media, speaking up about patient safety remains both a duty and a huge personal risk—a “catch 22” situation for health professionals that cannot be allowed to continue. Raising concerns without fear is central to patient safety, and much remains to be done to make it happen.
The Freedom to Speak Up review is clear that the NHS has a serious problem. Francis writes: “I have concluded that there is a culture within many parts of the NHS which deters staff from raising serious and sensitive concerns and which not infrequently has negative consequences for those brave enough to raise them.”
This conclusion was not reached lightly, but after consideration of a wealth of evidence from 612 individuals, 43 organisations, and a thematic review of over 400 of the individual responses. Francis met with several people who had raised concerns and then been badly treated, including vexatious referrals to the GMC and blacklisting from obtaining another NHS post.
My organisation (Patients First) made representations to both Francis and Hooper, in person and in writing. The representations to Francis reflected the experience of over 70 NHS whistleblowers.3 It is clear that these experiences chimed with the wider evidence.
Neither review compelled any person or organisation to give evidence or respond to inquiry; neither review was commissioned to look in detail at individual cases, although both heard from many individuals. Yet both reviews reached authoritative conclusions and formulated recommendations for good practice. Employers must review their understanding of what a whistleblower is—it is anyone raising a concern—and action needs to be taken urgently to prevent the bullying that can (and often does) follow.
Francis found that the problem was widespread and systemic within the NHS: “I heard shocking accounts of the way some people have been treated when they have been brave enough to speak up . . . The number of people who wrote to the review who reported victimisation or fear of speaking up has no place in a well run, humane and patient centred service.”
He also found that the law is weak and does not protect whistleblowers, something campaigners have been reporting for some time. However, by not calling for a public inquiry Francis has missed an opportunity to clear the air, ensure silenced voices are heard, and protect patients.
The recommendations of Francis’s review need to be implemented in full to achieve what the best organisations are probably already doing. What remains a real concern, as exemplified by one person’s submission,1 is the lack of accountability and inconsistent intervention by health regulators. People are passed from place to place with raised expectations, only to be left high and dry after many weeks or even years of stress. Patient safety concerns are lost in the confusion.
The GMC (and other professional regulators) recognise the importance of speaking up to protect patient safety. All health professionals have a duty to do so. The fact that it remains risky and difficult is little short of scandalous.1
The GMC has also consistently reported a culture of bullying when doctors try to speak up, and Hooper confirms that: “An employer might use the process of making an allegation to the GMC about a doctor’s fitness to practise as an act of retaliation against a doctor because he or she raised concerns, or, simply, as an inappropriate alternative to dealing with the matter in-house.”
As his report recognises, the prospective loss of a career is a particularly harsh consequence for a doctor willing to speak up to protect patients.
“Since the main objective of the GMC is to protect, promote, and maintain the health and safety of the public,”4 the Hooper report recommends that if a doctor has raised a concern this will be “material, if not highly material” to any examination of his or her fitness to practise. Hooper’s recommendations are largely directed at referrals from health employers, including NHS trusts. He urges the GMC to be cautious in the early stages of these referrals and recommends effort is made to ensure they are not reprisals. This might include looking at any concerns that have been raised about patient safety by the doctor involved, and establishing a clear timeline of events to put any organisational referrals into their proper context. He also recommends that referrals are supported by a statement of truth declaring that the facts are genuine. His recommendations are welcome and should be implemented.
In summary, the Freedom to Speak Up review offers models of good practice for employers and agrees with campaigners that victimisation of whistleblowers is widespread. Furthermore, whistleblowers must navigate a bewildering, complex, and unaccountable system to make their disclosures. When they need protection it just isn’t there.
The Hooper review is a welcome acknowledgment that something is not right within the GMC. These reviews underline how much more needs to be done and how the broader health and legal systems need reform. Only a public inquiry can reveal the systemic failings and the underlying reasons that have led to such a damaging and defensive culture within the NHS.