Most NHS staff know how to raise concerns and feel safe doing so but ‘most’ is not enough, says Dean Royles

Do you know that “dammed if you do, dammed if you don’t” feeling? I get it a lot right now.

Talk about some of the challenges facing the NHS and you’re accused of attacking a well-loved institution for political gain. Talk up the remarkable and wonderful things it does day in and day out and you’re accused of being naive, of not understanding the deep issues – and you become portrayed as part of the problem. Try to introduce some context into a serious issue and you’re told you’re in denial.

But we can’t just accept the version of events from those that shout loudest – tempting though that can be for a quiet life. So what to do? I go with my head and look at the evidence.

Dean Royles

‘We have two problems with whistleblowing in the NHS: staff can be victimised for their efforts, and this is presented as being commonplace’

A case in point is this week’s Commons health committee on whistleblowing and raising concerns. We have two problems with whistleblowing in the NHS. The first is that some staff raise concerns internally then, if they’re not addressed through the normal process, they rightly blow the whistle and can be deliberately victimised for their efforts. It’s not fair, it’s unsafe, it’s bad for culture and it’s bad for patients.

The second problem is this is often presented as commonplace, as though the first reaction all boards have when someone raises a concern is to find ways to shut them up. This is not true. I’m not saying it doesn’t happen, I’m just saying it’s not the norm and it’s often much more complex than it is presented in the media. Here’s a little case study.

Prickly issues

Consultant A raises a concern about the clinical practice of Consultant B with the HR director, citing a particular patient’s case. It’s about clinical practice so the HR director meets with the medical director and Consultant A.

The medical director reviews the case notes and it appears there may be an issue. The medical director approaches Consultant B about the issue. Consultant B demands to know who raised the issue. He says he suspects it is Consultant A, saying Consultant A is always trying to undermine him and has been doing so ever since he started a relationship with a Consultant A ‘s previous partner. (Still with me?).

Consultant B now suggests Consultant A’s expenses for international travel bear close scrutiny, suggesting there is a lack of probity and waste of taxpayers’ money that could be spent on patient care. He says he has raised this issue before with the clinical director.

The medical director speaks to the clinical director who says it is well known that Consultant A and Consultant B intensely dislike each other and have not been speaking to each other for well over a year. The clinical director says she has raised the issue but no one can find any record of it.

Various attempts at mediation, support and Royal College reviews are attempted and rejected. The situation deteriorates, with allegations and counter-allegations of bullying. The trust starts formal procedures. All three people – Consultant A, Consultant B and the clinical director – send letters via the lawyers alleging they are being victimised for raising concerns.

Sound familiar?

At some point someone needs to make a judgement. That judgement may be right, it may be wrong. It may end in an employment tribunal. It may settle down, only to blow up again a few months later with allegations of a lack of leadership when it could have been nipped in the bud.

This doesn’t mean that people who raise concerns shouldn’t be believed. They absolutely must be listened to. In fact, in the case above, I’m sure all the parties believe their concerns are valid and legitimate.

Different approaches

The NHS staff survey tells us:

  • 90 per cent of staff know how to raise a concern
  • Most feel safe to do so (10 per cent do not – and that’s 10 per cent too many)
  • 90 per cent of staff who saw issues affecting care say they raised them
  • 60 per cent reported they had not received feedback. This is a significant issue.

It is clear that people can and do raise concerns. The Care Quality Commission receives 8,000 calls annually to the helpline; around one in 10 are about the NHS.

‘We need to help those in decision making positions who often need the wisdom of Solomon in what can be very complex cases’

I raise these issues not because I’m in denial. I know some nasty stuff goes on – just look at the referrals employers make to the regulators. I raise them because I don’t want staff to believe they face the sack if they raise concerns within their organisation or approach regulators to whistleblow. That belief, if it prevents issues being raised, is just as bad for patient care as the actuality of being dismissed for such actions.

Raising concerns and whistleblowing are different things, but we have to support and listen to staff who do both. And we need to address any inappropriate, defensive responses to people who blow the whistle but, having followed procedures, have not been listened to. I know this piece may offend those who have been victimised or lost their jobs and livelihoods so I don’t write it lightly. I hope people will see the balance I’m trying to strike.

Equally importantly, however, is the fact that we need to help those in decision making positions who often need the wisdom of Solomon in what can be very complex cases where judgement is needed. If they aren’t forthright and sophisticated in their handling of concerns, they may find themselves accused of presiding over poor care, and lacking leadership and judgement.

How would you resolve the case study above?

Dean Royles is chief executive of NHS Employers