Whistleblowing: why people should be supported to raise concerns

Financial restraints and the huge changes facing the NHS are having an impact on workforce motivation and confidence, especially when it comes to raising concerns about patient safety. Last week I participated in a roundtable debate with the Health Service Journal and 14 other healthcare experts, looking at the challenges of whistleblowing and proposing solutions in the wake of the Francis report.

It is difficult to estimate the scale and nature of poor care, and the majority of those present said they feared that things will get worse before they get better in the NHS. There was agreement that poor care is a particular risk for vulnerable people – the frail elderly, those with mental health difficulties and children.

The key problem for staff looking to raise concerns is that there are different types of 'poor care'. Sometimes care clearly breaches accepted best practice, but more general poor ‘care’ and a lack of compassion are harder to describe in an evidence-based manner. Even when the definition of harm seems to be unambiguous, comparing rates between hospitals is difficult as we have demonstrated with our research on central line infections.

The best way to address such failures is to raise concerns before patients are harmed. In a nutshell, I think there are three types of concerns and they might need different routes of reporting:

1. concerns about resources (staff, equipment and expertise)
2. concerns about non compliance with best practice guidance (ie negligence) and
3. reporting concerns raised by patients and families.

Reporting some of these can be more problematic than others. While some focus purely on the issue of negligence, I think staff often have more difficulty in reporting concerns about resources as this could be a direct threat to their line manager – they might need to report to a third party instead. This third party might be a middle manager who are themselves stressed and performance-managed against access and finance targets – again, this could inhibit reporting (whether intentional or not).

For either type of concern, a system for ensuring psychological safety is needed. This might be reporting concerns to an independent body, as happens in the airline industry, or it might be protecting staff from disciplinary action if they raise concerns (as happens in Denmark through their 2003 Patient Safety Act).

One participant at the roundtable mentioned a report by Public Concern at Work which examined whistleblowing experiences across different industries. It found that most whistleblowers would only raise concerns once, especially if the middle manager didn’t respond initally.

Having the confidence to report in the first place can only become a reality if concerns raised are taken seriously and if individuals are, in return, respected for their input. As far as I know, there is no evidence of widespread malicious reporting by staff and, in my experience, the majority of NHS staff take pride in their work and strive to make their workplace and the patient experience the best it can be. They should be supported to identify threats to patient safety rather than alienated by systems that are unable to respond appropriately.

Elaine is an Assistant Director at the Health Foundation