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Freedom to Speak Up

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Roll call
Dr Hayley Dare – sacked
Dr Raj Mattu – victimised
The Bupa 7 – bullied, threatened, lost industrial tribunal case
Sister Helene Donnelly – bullied and threatened
Dr David Drew – sacked

This is by no means a comprehensive list. Healthcare staff, be they porters, nurses, doctors, or the occasional manager, are being dismissed or bullied because they have dared to speak out about poor care, poor treatment of staff, lack of resources, or consultants’ moonlighting activities. In each case, there has been both a financial and emotional cost, not to mention how much the NHS has spent in defence.

Context
All organisations have their own cultures and foibles, particularly those whose employees are largely professionals; the bar, the police force, the NHS for example. Each of these professions will tell you that one cannot really understand their culture unless you have ‘been bought up in it’, so trying to change it is impossible. And perhaps that is true to a certain extent. How do you explain to your non-NHS friends how the use of black humour can make dealing with the most clinically or emotionally challenging patient/situation of your career to date a little less draining?

However, sometimes this culture can be less than fragrant. Staff used to tolerate the Lancelot Spratt/Hattie Jaques type style of management just because they were higher up the pecking order and that was the way of the world. It was not uncommon for a ward sister to only speak to the rotating student nurses as they were leaving their placement such was the gulf between them. ‘Cover-ups’ were not uncommon – closing of ranks around professional rather than team boundaries; admitting to a patient that a mistake had been made happened only once every Preston Guild.

Of course, the management of an organisation also contributes to its culture and success. And where resource savings have to be made, tension often arises between clinicians and managers who do not have a clinical background. When positions become intractable, an organisation can implode, as evidenced in Mid Staffordshire.

The First Francis Report
Robert Francis’s enquiry into the failings of the mid-Stafford NHS trust [1] made a number of recommendations to address organisational failings. Of particular relevance was this:
‘Ensure openness, transparency and candour throughout the system about matters of concern’

The point of this recommendation was to encourage staff to challenge and report poor clinical practice, bullying, and other issues which could affect the organisation, staff, and most importantly, patients within that organisation. Whistle-blowing is the act of reporting a concern about a risk, wrongdoing or illegality at work, in the public interest; it is an effective early warning system which gives managers an opportunity to put things right before anything catastrophic happens [2].

Despite this, whistleblowers were still finding themselves in the same situation. Indeed, an open letter to Jeremy Hunt (Health Secretary), written after he had met a group of whistleblowers, indicated that reporting poor practice was fraught with difficulties [3]. Hammond suggested that if one were in a witness protection programme, staying silent is rewarded by payoffs and relocation, whereas speaking up about the NHS gets you ‘buried in the woods’. Thus…”workers can never feel safe to raise the most serious concerns about patient care”.

The Second Francis report
Consequently, another enquiry led by Sir Robert was undertaken, resulting in the report ‘Freedom to Speak Up. An independent review into creating an open and honest reporting culture in the NHS’ [4]. In submitting the report to the Secretary of State, he wrote;
‘… In our survey, over 30% of those who raised a concern felt unsafe afterwards. Of those who had not raised a concern, 18% expressed a lack of trust in the system as a reason, and 15% blamed fear of victimisation. This is unacceptable. Each time someone is deterred from speaking up, an opportunity to improve patient safety is missed.’

He went on to outline the effect on those who had spoken out;
‘The effect of the experiences has in some cases been truly shocking… jobs being lost … serious psychological damage, even to the extent of suicidal depression. In some…cases, it is clear that the toll of continual battles has been to consume lives and cause dedicated people to behave out of character. Just as patients whose complaints are ignored can become mistrustful of all, even those trying to help them, staff who have been badly treated can become isolated, and disadvantaged in their ability to obtain appropriate alternative employment. In short, lives can be ruined by poor handling of staff that have raised concerns.’

Recommendations
In essence, to address these concerns, recommendations included:

  • Fostering culture change
  • Improved handling of cases
  • Measures to support good practice
  • Particular measures for vulnerable groups
  • Extending legal protection

The key aim of the review was to ensure that NHS workers in England…:

  • can make disclosures about any aspect of the quality of care, malpractice or wrong-doing at work and be confident that they will be listened to, and that appropriate action will be taken
  • know that they will not suffer detriment as a result
  • if they are mistreated as a result of them raising a concern, appropriate measures are in place to deal with those mistreating them

What to do

If you find yourself in a position where you need to speak out, there is information and support available. NHS Employers provides guidance under its ‘Raising concerns at work (whistleblowing)’ section. Guidance and tools are provided for both employer and employee [5]. Francis (2015) recommended that all organisations have a ‘whistle-blowing guardian’, although to date, this doesn’t appear to be happening in any meaningful way.

The Whistle-blowing Helpline suggests:

  • Use your organisation’s whistle-blowing policy/procedure (Raising Concerns Policy)
  • If possible, discuss informally, at supervision or team meetings. Consider approaching colleagues or the entire team if you think they may share your concerns. There is strength in numbers.
  • Check your organisation’s policy to find out who you should report your concerns to. Usually, this will be your line manager, unless your concern involves or implicates them, in which case a more senior manager should be listed within the policy. In a small organisation where there are no more senior managers, you might need to go outside of where you work, for example to a regulator.
  • For independent advice, contact the Whistle-blowing Helpline, your trade union representative, your professional body or a HR manager.
  • When you report your concern, focus on as much factual information or evidence as possible.
  • Check the process and ask your manager what will happen next.
  • Keep track of what is happening and keep a record in writing of any discussions relating to your concern.
  • Consider issues of confidentiality – you can ask for your identity to be kept secret, but this cannot always be guaranteed. Always ask for further advice if you are thinking of disclosing private or confidential information.
  • If you are not satisfied, use the sources of support and help available to pursue the matter. If there is nothing more you can do inside your organisation, then you can raise a concern with a regulator such as the Care Quality Commission or with the local Clinical Commissioning Group. You need to have reason to believe that the information you give and any allegation you make is substantially true – if you only suspect something then that is not enough when you report concerns outside of where you work.

Conclusion
There is a large dose of irony around whistle-blowing. Doctors, nurses and other health professionals try to advocate on behalf of their patients to prevent harm, as required by professional Codes of Conduct and the like, yet then are in turn, placed in a position where someone has to speak up for them.

Let us hope that appropriate whistle-blowing becomes the norm, and as a result of this, systems and organisations improve so that it becomes unnecessary to report poor care.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

  1. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry HC 947. 2013. Available at: http://webarchive.nationalarchives.gov.uk/20150407084003/http://www.midstaffspublicinquiry.com/report Accessed July 2015
  2. Brown C. When silence isn’t golden. Primary Care Nursing Review. 2015. Issue 6. May. https://pcnr.co.uk/articles/188/when-silence-isnt-golden- Accessed July 2015
  3. Hammond P. WE NEED A PUBLIC INQUIRY INTO NHS WHISTLE-BLOWING AND LEADERSHIP NOW. Blog. 2014. Available at: http://drphilhammond.com/blog/2014/06/19/private-eye/we-need-a-public-inquiry-into-nhs-whistle-blowing-and-leadership-now/ Accessed July 2015
  4. Francis R. Freedom to Speak Up. An independent review into creating an open and honest reporting culture in the NHS’. 2015. Available at: https://freedomtospeakup.org.uk/wp-content/uploads/2014/07/F2SU_web.pdf Accessed July 2015
  5. NHS Employers. Raising concerns at work (whistleblowing). Available at: http://www.nhsemployers.org/your-workforce/retain-and-improve/raising-concerns-at-work-whistleblowing Accessed July 2015

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