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Patient Safety and Whistle Blowing

Patient Safety and Whistle Blowing

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Published by Help Me Investigate

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Published by: Help Me Investigate on Apr 03, 2012
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278
Whistleblowing and patientsafety: the patient
s or theprofession
s interests at stake?
Stephen Bolsin
1
Rita Pal
2
Peter Wilmshurst
3
Milton Pena
4
1
Department of Clinical & Biomedical Sciences, The Geelong Hospital, Geelong, Australia
2
Independent Medical Journalist, UK
3
Royal Shrewsbury Hospital, Shrewsbury, UK
4
Tameside Hospital, Ashton-under-Lyne, UKCorrespondence to: Stephen Bolsin. Email: steveb@barwonhealth.org.au
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 of Commons 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
?
Awhistleblower is defined as a person who raisesconcern about wrongdoing. The term is quintes-sentially English derived from the practice of police 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 reviewofthe clinical outcomes ofawhole 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 forwhistleblowers
The 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 and‘9
/
11’ the US has developed systems to protectwhistleblowers. The National WhistleblowingCenter (see http:
//
www.whistleblowers.org) hasprovided 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 arewhistleblowers whowere individuallyinvolved in some of the cases referred toin the article. Theirwhistleblowing hasbrought them intoconflict with medicalauthorities, and insome cases with theGMC
Funding
None
Ethical approval
Not applicable
Guarantor
SB
Contributorship
All authorscontributed equally
Acknowledgements
None
J R Soc Med 2011: 
104: 
278–282. DOI 10.1258 
/
 jrsm.2011.110034 
ESSAY
 
Role of the General MedicalCouncil (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 UK’s 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 conductand performance of doctors at Stafford Hospitalafter referral by the Medical Director for failingto report poor care. Essentially, the doctor is‘damned if they do and damned if they don’t’report their concerns. The current situation is at best confusing where it appears that a doctor’sregistration can be held over their head like a‘Sword 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 themselvesmembers of the GMC.As a result, whistleblowing in the NHS is atraumatic 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 theproblem of high complication rates following joint replacement surgery in treatment centres inthe UK.
12
This is despite the exhortation of theGMC that doctors are obliged to report poor carethat 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 playa 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 P’affair 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 Commission’s Reportnoted, ‘One in ten patients admitted to hospitalswill suffer from an error and around half of these 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 largenumbers 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
J R Soc Med 2011: 
104: 
278–282. DOI 10.1258 
/
 jrsm.2011.110034 
Whistleblowing and patient safety: the patient
s or the profession
s interests at stake?
279
 
medical practitioners remains a constant possi- bility and we would agree with two of NevilleGoodman’s quotes in this journal that help todefine the solution. Firstly ‘there is no perfect sol-ution’. Secondly there ‘must be systemsto 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 of professional 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 of medical 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
<
5% at theend).
18
Economic impact
In 1999, the Institute of Medicine, in a seminalpublication entitled
To Err is Human. Building aSafer Health System
, attributed $17–29 billion of healthcare spending annually to the effects of sys-temic healthcare error in the US, and there is noevidence that the NHS is a safer healthcare provi-der.
20
Consequently the failures, deterrents andobstructions faced by whistleblowers in the NHSmay be having a severe impact on the publicpurse as well as public safety. This year the Treas-ury has spent well over £3 million gagging whis-tleblowers, which will ensure that improvementsto patient care will not occur.
21
Martin Fletcher,Chief Executive at the National Patient SafetyAgency, has said: ‘Good reporting is the corner-stone of patient safety. Safety cannot be improvedwithout a range of valid reporting, analytical andinvestigative tools that identify the sources andcauses of risk in a way that leads to preventativeaction.’
The management side
The past failures of medical managers and the DHto show moral leadership and support for whistle- blowers, makes it unlikely they will be in the van-guard of change. The emphasis on financial goals,thelackofeffectiveresponsibilityforthe outcomesof care and of any widely accepted code of ethicsfor medical managers makes it unlikely that theycan currently catalyse the necessary change.
22
The House of Commons Health Committee con-firms that the lack of achievement of the Depart-ment of Health in dealing with harmed patientsis ‘appalling’.
3
Need for change
Who can achieve the necessary change?
The medical schools will find the role of ‘changeleader’ difficult because they select, encourageand perpetuate these undesirable norms.
23
Whatis less obvious, but equally logical, is that themajority of the medical profession, who have been trained in medical schools, with these beha-viours and reflect that training, may also struggleto lead the change, although it may be possiblewith support.
7,24
This potentially sweeping exclu-sion of change leaders would automaticallyinclude the GMC, whose track record in this areais at best inconsistent, having attempted a com-plete U-turn in the last 21 years.In the absence of the professional groupsputting their heads together the problems of reporting poor care have not gone away but havepossibly multiplied, as predicted by the
Lancet
atthe time of the GMC verdicts on the Bristoldoctors.
3,25
The prediction was inevitablewithout a serious change of attitudes at the topof the profession. In view of this professionalintransigence, we would add the British MedicalAssociation (BMA) Council to those from whomleadership in this area should not be expectedwithout some difficulty. Like the professionalmembers of the GMC, the BMA Council iselected by the profession and is therefore notlikely to support reporters of poor care.
9,19
Thelogic is two-fold. First, the BMA is representative
J R Soc Med 2011: 
104: 
278–282. DOI 10.1258 
/
 jrsm.2011.110034 
Journal of the Royal Society of Medicine
280

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