the-challenges-of-whistleblowing

This is a ‘hot topic’ currently and there have been a number of high profile cases in recent times. It is very actively discussed on social media, and I recently attended the first conference of Patients First that was jointly hosted with the BMA.

Much of the anxiety, with good reason, is centred on why senior managers like myself seem all too often to suppress concerns that are raised, and seek to silence or even punish those who raise them. No right-thinking person would support such actions, and it is to be condemned when it is found to occur.

But, in my own experience, there are other facets to this complex topic that are much less often discussed, particularly when a doctor is either the whistleblower, or the target of a whistleblower.

Firstly, any concern raised about a colleague is very often followed by a counter claim of either poor performance or poor behaviour. This means there are very quickly two ‘whistleblowers’, with opposing concerns, raising the possibility that one is dealing with a relationship difficulty rather than a genuine concern about clinical standards.

This is compounded by the high frequency of antecedent relationship difficulties involving either the two individuals, or their clinical grouping. This does muddy the waters because there may be a motive that is not patient safety or well being. Should this be treated as whistleblowing, or as a behavioural/team working issue? It depends on the circumstances of course, but it is one reason why a ‘whistleblower’ may feel appropriate action is not being taken.

The second difficulty that we face is the sheer difficulty of following up concerns that are raised about the performance of a doctor. How does one determine whether an individual doctor is performing well, or poorly? What measures should we use?

Over ten years after Bristol and the Kennedy report, it is still only the cardiothoracic surgeons who are measuring and publishing outcomes (and I gather they stopped for a while and only recently re-started). So pity the poor CEO or Medical Director who has the job of investigating the concerns that have been (usually legitimately) raised.

I realise I am in contentious territory here, and I have not mentioned the other aspect of whistleblowing that might be further explored, at another time, which is that it is frequently used as a defence against accusations of poor performance by management.

The common denominator here is the measurement of an individual doctor’s performance. Until we work out how to do this – fairly, appropriately, and in a meaningful way, then we will continue to struggle when concerns are raised.

We can of course continue to berate managers for failing to listen or, worse, for suppressing individuals who raise concerns. And we should. But we should also acknowledge that it is very difficult for them to act, because the profession is still resistant to addressing the challenge of measuring and monitoring the effectiveness of doctors.

It is a gap that will be filled, I’m sure. If the profession do not do it, then others will. And they will be less likely to successfully address the huge complexities involved.

This blog was originally posted on the HospitalDr website here on 10 December 2012

Harry Longman

You are so right Mark. I have had personal experience of whistleblowing on financial fraud, to find a letter going to my boss complaining of my general incompetence, rudeness and so on. The organisation was later found twice as deep in as I had suspected.
In another case of scientific fraud I called, again the character assasination followed, closing of ranks, failure to investigate.
I think the whistleblower has to face the fact that this often happens, and be prepared for the worst. Cases are all around us, many much higher profile and more serious than my own.

A question: are there any cases where a whistleblower was listened to in the first instance, prompt and proper independent investigations were carried out, the guilty punished and the whistleblower given due credit?

Perhaps that would make a difference. There are many in power who have reason to fear such cases. Let’s be clear: this is about power.

MarkN

Thanks Harry, much to think about in what you say. My experience has been that once concerns have been raised, and investigations started, it all becomes very confused with counter-allegation and argument over data and evidence, or lack of it. I think much of this relates to our generally poor performance management in the NHS – we are not good at recognising and addressing performance issues, whether it be penalising poor performance or rewarding excellence.

I get a steady stream of issues raised by staff, mostly minor, and these are addressed without much fuss. Serious issues tend to proceed as above. I’m sorry to say I cannot immediately bring to mind an instance of the sort you mention – I will keep thinking!

Thanks for your interest.

Sometimes I see things in black and white terms. I once worked in a financial services business where after a while I realised that white was black and black was white. Terrifying. It was run by a psychopath. I joined the NHS to find that white was white, but black was white too. Cuddly at first, rather undemanding, but then I found that black was hiding behind white, aware that white would not believe in the possibility of black, at least not anywhere close, and so, afraid of discolouration, would rather conceal it.

Elaine

Is it naive to believe that improved information on clinical outcomes will reveal poor performance amongst individuals? Currently, how often are people having “corridor conversations” which identify concerns but leave them in the shady realms of gossip and never take the step to express formal concern for fear of becoming embroiled in a bureaucratic nightmare.
Governance should lead us out of this but not if it is the province of box tickers and weak management. It requires courage and passion to do the thing right.

simonjd

I think that the Radio 4 programme linked by Norman should be required listening for all in the NHS (encourage you to follow the link and “enjoy” an uncomfortable listening experience) , sobering illustration of the need for transparency and follow through in very challenging circumstances for any senior team.

Mark Easton

How does one determine whether an individual doctor is performing well, or poorly? What measures should we use?

You don’t mention, Mark, the tools we do have, namely the GMC process and the National Clinical Assessment Service. Neither of these processes is perfect, but it does bring some objectivity to an otherwise messy and contentious area.

Peter English

I wish I shared your faith in NCAS! Happy to discuss why off line. I’m @petermbenglish on twitter.

Thanks Mark. My experience is that NCAS can be helpful with conduct and behaviour issues, but they tend to be less so on performance concerns. I suspect this is for the same reason that we struggle – there are few hard measures and agreed outcome standards?

As a doctor with an interest in this subject I am also aware that managers are often extremely poor at identifying genuinely unsafe practice and, and have a strong tendency when an issue is raised to identify a doctor as a scapegoat. Once this has been started a treadmill starts which cannot be stopped until several years later, during which time much harm is done to the doctor identified – often grossly unfairly – and vast sums of public money have been spent.

Thanks for commenting Peter. Often the ‘managers’ are medical colleagues of course. Is the lack of agreed measures and standards of medical performance not one of the problems here? I suspect this is one reason why matters may becomes protracted.

Norman Briffa

A balanced view, Mark as usual. I can see how difficult it is for management to deal with the nightmarish scenario of a dangerous doctor.
I have never talked about this publicly but several years ago I was the victim of a malicious whistle blowing claim. I was never worried about the consequences as i knew my outcomes were not only good but much better than expected. The MD at the time told me he could not ignore it & just had to investigate it. I understood his point of view (although he did take an inordinately long time about it!) Dealing with the aftermath can be tricky.
On the other hand there are cases when claims or the results of investigations that follow, are ignored . This was highlighted in the recent programme on radio4. http://www.bbc.co.uk/programmes/b01p42wj
At the end of the day, the consequences of missing poor performance are so much worse than those of over investigation.

Thanks Norman that’s a valuable insight. I agree with your last comment although it must be hugely stressful for the individual concerned.