patient safety and whistle blowing

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278

Whistleblowing and patient

safety: the patients or the

professions interests at stake?

Stephen Bolsin1 Rita Pal2 Peter Wilmshurst3 Milton Pena4

1Department of Clinical & Biomedical Sciences, The Geelong Hospital, Geelong, Australia2Independent Medical Journalist, UK3Royal Shrewsbury Hospital, Shrewsbury, UK4Tameside Hospital, Ashton-under-Lyne, UK

Correspondence to: Stephen Bolsin. Email: [email protected]

Introduction

Whistleblowing has a tortured history in the NHSalthough it has been recognized by authoritativereviewers as making an important contributionto patient safety.1,2

In a highly critical 6th Report the House ofCommons Health Committee stated The NHSremains largely unsupportive of whistleblowing,with many staff fearful about the consequencesof going outside official channels to bring unsafecare to light. We recommend that the Departmentof Health (DH) bring forward proposals on how toimprove this situation.3

Encouraging the medical profession to reportpoor care and to report incidents that occur intheir practice has been problematical in modernhealthcare although there are notable excep-tions.4 This article discusses why a change inthe attitude of the profession is required,what the benefits will be and how it can beachieved.

Why blow the whistle?

A whistleblower is defined as a person who raisesconcern about wrongdoing. The term is quintes-

sentially English derived from the practice ofpolice officers blowing their whistles to alert col-leagues and the public when they saw a crimecommitted and needed assistance.

There are four common situations in which aclinician may consider raising concerns, althoughthere is overlap in each situation:

(1) Reporting on the systemic failure of a trustto provide adequate nursing resources (e.g.Tameside General Hospital);

(2) Requesting review of the clinical outcomes of awhole department (e.g. Bristol paediatriccardiac surgery);

(3) Reviewing poor clinical outcomes involving asingle individual over a period (e.g. HaroldShipman);

(4) Anticipating and reporting a single cata-strophic event (e.g. Baby P affair).

Current protection for

whistleblowersThe Public Interest Disclosure Act (PIDA) of 1998,passed to protect whistleblowers in the wake of

the Bristol paediatric cardiac surgery scandal,has not been as effective as anticipated.5 Lewisconcluded, PIDA 1998 has not adequately pro-tected whistleblowers, adding, common stan-dards for their protection still seem a long wayoff.5 By comparison since the Enron scandal and9/11 the US has developed systems to protectwhistleblowers. The National WhistleblowingCenter (see http://www.whistleblowers.org) has

provided support for many US whistleblowers.Although 31% of US physicians remain reluctantto report impaired colleagues and 12% fear retri-

bution for doing so these figures are better thanUK junior doctors.6,7 In 2003, the European Com-mission acknowledged the part that whistle-

blowers can play in the fight against corruptionurging Member States to provide protection forthem, but positive advocacy has not followed inthe UK.

DECLARATIONS

Competing interests

The authors are

whistleblowers who

were individually

involved in some of

the cases referred to

in the article. Their

whistleblowing has

brought them into

conflict with medical

authorities, and in

some cases with theGMC

Funding

None

Ethical approval

Not applicable

Guarantor

SB

Contributorship

All authors

contributed equally

Acknowledgements

None

J R Soc Med 2011:104: 278282. DOI 10.1258/jrsm.2011.110034

ESSAY


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Role of the General Medical

Council (GMC)

In the NHS Professional bodies may reinforcetheir members natural reluctance to whistleblow

by producing disciplinary codes which presentadditional obstacles.8 This reluctance can betraced back to the 1980s edition of the BlueBook that cites depreciation by a doctor of theprofessional skill, knowledge, qualifications orservices of another doctor could amount toSerious Professional Misconduct. There have

been cases where the GMC has investigated andin some cases prosecuted doctors who haveraised legitimate concerns.9 There continue to beechoes within the UKs regulatory and pro-

fessional bodies that criticism of colleagues issomehow unacceptable. Additionally the obli-gation GMC members feel to those who electedor appointed them represents a conflict of interestthat prevents the GMC from working for the goodof the public.9 Recent regulations stipulate theAppointments Commission makes appointmentsto the GMC but this possible conflict of interest,

by elected and appointed custodians of standards,remains.

Following the Mid-Staffordshire HospitalInquiry the GMC is investigating the conduct

and performance of doctors at Stafford Hospitalafter referral by the Medical Director for failingto report poor care. Essentially, the doctor isdamned if they do and damned if they dontreport their concerns. The current situation is at

best confusing where it appears that a doctors

registration can be held over their head like aSword of Damocles if they do blow the whistle,

but conversely doctors have been investigated, orsanctioned, for failing to whistleblow.10 TheGMC may not act even when those who failed toreport concerns must have known they shouldhave done so, because they were themselves

members of the GMC.As a result, whistleblowing in the NHS is a

traumatic undertaking and generally not to be rec-ommended.2,11 There is scant evidence for ethi-cally sound disclosures, by morally and legally

justified professionals, designed to improve out-comes for patients, delivering the requisitechanges without repercussions. One examplemay be a surgical specialty in dealing with the

problem of high complication rates followingjoint replacement surgery in treatment centres inthe UK.12 This is despite the exhortation of theGMC that doctors are obliged to report poor care

that they witness in their practice. Thus if theGMC is to be involved in improvements to report-ing poor care it is imperative that the Councilurgently write clear and unequivocal guidanceconcerning whistleblowing. It should be compre-hensive and recognize the dangers posed to allmedical whistleblowers. The role of organizationssuch as the Care Quality Commision, Links, theParliamentary Health Select Committee, Monitor,and others should be clearly stated and accessibleto all doctors. It is vital for patient safety that stat-utory bodies play a leading role in assuring poten-

tial whistleblowers that they will not be penalizedfor raising concerns.

The question then remains How can it be thatselfless and ethically sound behaviour continuesto be punished by the medical establishment?This is after inquiries into the Bristol Scandal,the serial killer Dr Harold Shipman, the Mid-Staffordshire NHS Foundation Trust, the Baby Paffair and the North Staffordshire Ward 87debacle, have all confirmed that whistleblowersplayed a crucial and constructive part in theidentification of poor patient care prior to deathsand patient harm attributable to that poor care.What chance in this environment does a reporterof poor care have? High profile scandals appearto produce recommendations with very littleimpact and even less improvement on the shopfloor. In 2008, the Health Commissions Reportnoted, One in ten patients admitted to hospitalswill suffer from an error and around half ofthese could have been avoided.

Unfortunately those inquiries did not addressthe fact that the analysis of routinely collectedoutcome data would have identified two of themore heinous episodes well before large

numbers of patients perished.13

Vexatious whistleblowing

Recent examination of the CNEP Trials inStoke-on-Trent have raised the issue of vexatiouswhistleblowing involving parents and press.14

The possibility of unsubstantiated claims against


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medical practitioners remains a constant possibility and we would agree with two of NevilleGoodmans quotes in this journal that help todefine the solution. Firstly there is no perfect sol-

ution. Secondly there must be systems to supportand investigate suspicion rather than systems thatgo out looking with suspicion.15 Although thesolution proposed for the vexatious whistle

blowing seen in the Stoke-on-Trent episoderelated to alleged research misconduct, such asystem in clinical and research practice wouldseem to be designed to deal adequately with justi-fiable and unnecessary concerns in both fields ofprofessional practice.16,17

Role of medical education

The medical profession is experienced and adeptat promoting bad behaviour around reportingpoor care, and can influence the behaviour ofmedical students during their training.18 This be-haviour change has been attributed to the infor-mal or hidden curriculum of medicine and iswell described.19 Of even more concern is the dis-tribution of ethical responses from the students atthe start of their undergraduate training (only 13%of students would consider reporting a senior col-league at the start of their training and


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of the profession, made up of doctors trained inmedical schools, where whistleblowing is covertlydiscouraged; and second, the obligation electedand appointed members may feel to their pro-

fessional colleagues will conflict with empathyfor a whistleblower.9 Therefore the BMA leader-ship is unlikely to lead change in supportingpoor care reporters, who are reviled by sectionsof the profession.2,26 This applies particularly toreporters in situations 2 and 3, involved in report-ing a colleagues performance. A counter argu-ment is that some groups within the BMA, mostnotably the BMA in Scotland, have produced con-structive suggestions for encouraging medicalwhistleblowing. The most important of these is aretrospective review of responses to cases where

doctors have spoken out and is one way forward.

The way forward

After excluding these groups, who is left to dealwith reports of poor patient care? The answershould include some doctors with knowledgeand experience in the area and patient and com-munity representatives along the lines of Insti-tutional Research Ethics Committees. Thoseacknowledged as most representative of their con-stituents, elected members of the House ofCommons, have recognized the problem for avery long time. The comments of Members ofParliament have so far been supportive of clinical

standards and whistleblowing in relation to ortho-paedic specialists and complication rates in UKTreatment Centres (see pages 5 and 6 of http://www.official-documents.gov.uk/document/cm77/7709/7709.pdf) and patient safety.3 Theseexposures of lower standards of clinical outcomesin non-NHS hospitals indicate the difficultiesassociated with clinicians working in unrelatedhealthcare providers (e.g. private and NHS hospi-

tals). These observations also add considerableweight to the inclusion of publicly elected andappointed professional and lay representatives,

with no perceived conflict of interest, to thosehandling reported poor care. It would be necess-ary to resource and train these groups to reviewreports of poor care brought to them on behalf ofhealthcare professionals (including doctors),patients and their relatives so that equable andfair review without punitive retaliation against

the reporter could be achieved to improve thequality of services irrespective of their source(NHS hospital, primary care, treatment centresor private providers) or their provenance

(medical, healthcare or patient-related sources).These groups should help to change the cultureof the profession and could identify potential vex-atious whistleblowers at an early stage.14

Our recommendations are firstly that the pro-fession, through the GMC or BMA Council,should commission a Consultation Group onReporting Poor Care. This Group will examinethe consequences to all parties from incidents ofreported poor care. Second, the Governmentshould consider establishing a Health Select Com-mittee Review of Whistleblowing that would

make impartial recommendations to Governmentand the profession. Third, the Governmentshould consider setting up and resourcing aNational Whistleblowing Centre similar to thatin the US. We believe that only by open publicscrutiny will constructive change be cementedinto exemplary clinical practice.

One question to answer

The question that individual medical professionalsmust answer is Which doctor would you prefer

for your relatives or yourself? A doctor that is pre-pared to report poor care to improve your, or yourrelatives outcome, or one that is not prepared todo so regardless of the consequences to your rela-tive or yourself? When the profession can truth-fully answer that question they will be able to putin place the necessary structures for change.

The people who deserve this most are our long-suffering patients.

References

1 Donaldson L. Whistleblowing & Clinical Governance. In:Whistleblowing: changing the way we work. London: BMAHouse, 1999

2 Bolsin SN. Whistle blowing. Med Educ 2003;37:29463 Health Committee. Patient Safety. London: House of

Commons, 20094 Freestone L, Bolsin S, Colson M, Patrick A, Creati B.

Voluntary incident reporting by anaesthetic trainees in anAustralian hospital. Int J Qual Health Care 2006;18:4527

5 Lewis D. Ten Years of Public Interest Disclosure Legislationin the UK: Are Whistleblowers Adequately Protected? JBusiness Ethics 2008;82:497507


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6 DesRoches CM, Rao SR, Fromson JA, et al. PhysiciansPerceptions, Preparedness for Reporting, and ExperiencesRelated to Impaired and Incompetent Colleagues. JAMA2010;304:18793

7 White C. Doctors mistrust systems for reporting medical

mistakes. BMJ2004;329:128 Davies M. Chapter 13: Whistleblowing. In: Medical

Self-Regulation Crisis and Change. 1st edn. Aldershot:Ashgate Publishing Ltd., 2007:24665

9 Wilmshurst P. The General Medical Council a personalview. Cardiology News 2006;4:1315

10 Dyer O. Consultants who misled Shipman inquiry arefound guilty of misconduct. BMJ2005;331:1042

11 Gooderham P. Changing the face of whistleblowing. BMJ2009;338:20902

12 Cannon SR. Quality of elective surgery in treatment centres.J Bone Joint Surg Br 2009;91-B:1412

13 Spiegelhalter D, Grigg O, Kinsman R, Treasure T.Risk-adjusted sequential probability ratio tests:applications to Bristol, Shipman and adult cardiac surgery.Int J Qual Health Care 2003;15:713

14 Wright T. The Stoke CNEP Saga how it damaged allinvolved. J R Soc Med 2010;103:27782

15 Goodman NW. The policing of science. J R Soc Med2004;97:25961

16 Abbasi K. The CNEP trial: how a good trial was turnedrotten. J R Soc Med 2010;103:1212

17 Hey E, Chalmers I. Mis-investigating alleged researchmisconduct can cause widespread, unpredictable damage.

J R Soc Med 2010;103:133818 Goldie J, Schwartz L, McConnachie A. Students attitudes

and potential behaviour with regard to whistle blowing as

they pass through a modern medical curriculum. Med Educ2003;37:36875

19 Rennie SC, Crosby JR. Students perceptions of whistleblowing: implications for self regulation. A questionnaireand focus group survey. Med Educ 2002;36:11314

20 Kohn CT, Corrigan JM, Donaldson MS. To Err is Human.Building a Safer Health System. Washington, DC: Institute ofMedicine, 1999

21 Bousfield A. Buried in the Treasury vaults are secrets weneed to know. Independent 2010 August 2

22 Kennedy I. Learning from Bristol. 2001. See www.bristol-inquiry.org.uk

23 Faunce T, Bolsin SN, Chan W-P. SupportingWhistleblowers in Academic Medicine: Training andRespecting the Courage of Professional Conscience. J MedEthics 2004;30:403

24 Firth-Cozens J, Firth RA, Booth S. Attitudes to andexperiences of reporting poor care. Clinical Governance

2003;8:331625 Anon. First lessons from the Bristol Case. Lancet

1998;351:166926 Yamey G. Protecting whistleblowers. BMJ2000;320:701


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