National policy is in place to encourage whistleblowing, but employers need their own strategies to promote a truly transparent culture. Jennifer Taylor finds out how to remove the barriers to openness.

There has always been a certain amount of stigma attached to the word “whistleblowing” - it’s not something that sits comfortably with everyone. Legally, it is defined as “a person, usually an employee in a government agency, public, private organisation or company, reporting a concern about mismanagement, corruption, misconduct or some other wrongdoing either to the public or to those in authority”.

There is a misconception that whistleblowing means reporting to the tabloids, but this is generally a last resort. Reporting “to those of authority” includes employers, professional regulatory bodies, or regulators - such as Monitor or the Care Quality Commission.

NHS organisations have always been bound by a duty of care and staff have had professional codes of conduct, these responsibilities have been further reinforced by amendments on whistleblowing which were incorporated within the NHS constitution earlier this year. “There’s a duty on employers to support and respond appropriately, as much as there is an expectation on staff to report,” says Nyla Cooper, programme lead on professional standards at NHS Employers. “If these don’t work hand-in-hand then there’s a problem.”

While the policy levers to support whistleblowing are there, employers need strategies to encourage and promote a truly open culture; only then will staff feel confident that their concerns will be taken seriously and be addressed. Ms Cooper says: “Employers need to be able to identify and understand what the risks are, and have that early intervention in place to prevent a whistleblowing issue happening in the first place. We all know that things can go wrong in healthcare, but there remains a failure to communicate this to staff and reflect on lessons learned. Equally, there is a need to share good news stories and celebrate successes.”

Missed opportunities

The responsibility to embed cultural change and encourage staff to report concerns lies at different levels in NHS organisations. The board needs to make clear that it is committed to having an open and transparent culture, and that protecting patients is of paramount importance. In the main, employers continue to work hard to improve policies and procedures for reporting, however, key messages coming out of the Mid Staffordshire Foundation Trust public inquiry highlights that opportunities are being missed to resolve issues at an early stage. The inquiry chair, Robert Francis QC, is scheduled to report further findings in October this year and will make recommendations to drive this agenda forward.

“It is absolutely essential that safe patient care remains the number one concern, and it is important that organisations enable their staff to report concerns early on rather than wait for an incident to escalate” says Ms Cooper.  “This needs to be part of a longer term behavioural and cultural change that needs to be widely communicated and continuously reinforced.”

Managers themselves need to have support and training so they fully understand their roles and responsibilities to support staff and can deal with any concerns raised with them appropriately. Human resources play an important part in continuously reviewing and improving policies and procedures for reporting concerns about patient safety and it is essential that they ensure this is done in partnership with staff and health unions to make sure they are effective.

The 2010 NHS staff survey found that staff are more aware of their organisation’s policies and process for reporting concerns, and that they understand how to raise concerns about risks to patient safety. In the last 12 months, a number of professional regulatory bodies have also reported an upward trend in the number of referrals they have received about patient safety or misconduct issues - both from employers and their members. While this is a leap forward, the survey also highlighted that staff are still not confident that their organisation will fully support them and act on their concerns.

This was similarly reflected in the recent Medical Protection Society survey of 1,500 doctors which reported that 49 per cent perceived that there would be repercussions if they reported a concern. “There are many discussions around important areas such as regulation of managers and healthcare assistants because regulation plays a key role in safety, but the most important steps are probably more around understanding what the real issues are, and affecting cultural and behavioural changes in the NHS,” says Ms Cooper.

Help at hand

Support is available for both employers and employees. Many NHS trusts have already set up internal helplines which offer confidential advice and guidance to their staff. Alternatively, staff can seek advice through the national health and social care whistleblowing helpline launched in January this year.

Additional guidance is available from Monitor, the CQC, and professional regulatory bodies. The NHS Social Partnership Forum published the guidance ‘Speak up for a Healthy NHS’ in June 2010. It contains a model whistleblowing policy for NHS organisations which supports staff to raise concerns.

Gail Adams, head of nursing at Unison, says the primary barrier to reporting concerns on the frontline “is the fact that [staff] don’t think their concerns will be acted on or taken seriously”.

She adds: “At the moment, because of the cuts that are happening in the service and the reduction in managerial posts, there are fewer people around to report concerns and equally nurses feel that when they do raise those concerns they’re ignored.”

There is also an issue around the level of documentation. When a clinical or management incident occurs, staff complete a serious untoward incident or clinical incident form. “I think sometimes people feel that by documenting those their concerns are being articulated,” says Ms Adams. “Just completing a serious untoward incident form, whilst it’s documenting your concerns, it isn’t about you using your professional judgement to say this isn’t safe.”

Employers, unions and regulators need to work in partnership towards the shared aims of removing the stigma and breaking down the barriers to staff reporting concerns early. Ms Adams says that good relationships are in place between trade unions and NHS Employers at a national level, but need to be improved at a local level.

Blame culture

Ms Adams adds that the NHS still operates within a blame culture. When things go wrong, trusts investigate through the disciplinary procedure. “We look at an individual’s failure rather than it being a cultural or systemic issue at how we manage the service,” she says.

Staff feel that when issues are dealt with internally there isn’t a level of independent scrutiny. Ms Adams would like to see a mechanism of peer review developed whereby staff who have the relevant clinical skills and work in another organisation in the same geographical area come in to help look at what happened. She says: “I think some of those steps help to develop a culture which is seen to be open and transparent and seen to look with genuine concern at what happened, when it happened and why it happened, and look to learn the lessons.”

She concludes: “If it gets to a point where you’ve got a whistleblower then there’s something wrong with the system. A good organisation will welcome staff raising concerns irrespective of what they are and see it as a really healthy opportunity to learn and to consider how they can improve services.”

For more information on whistleblowing, including resources for employers and a staff communication toolkit, please visit