Sounding the alarm: the importance of whistleblowing in primary care

‘Whistleblowing’ has long been a dirty word. Yet, whistleblowing has the potential to stop medical catastrophes in their tracks. It is vital – so how should you, as practice manager, lead by example and create a culture of productive whistleblowing in your practice?

As practice manager, you oversee the running of your practice. You iron out problems as they arise, working to keep business smooth and patients satisfied within a primary care system that can sometimes feel a bit like a pressure cooker. You rely on your practice employees, your colleagues, to help you keep order. However, do you think they would divulge concerns if they had any? Would they keep them to themselves, not wanting to trouble you? 

Whistleblowing can feel like an unnatural thing to do; creating conflict is often something we fear, and it may be particularly difficult in healthcare settings – where stakes are high, and jobs can feel precarious. 

The news seems to be awash with NHS whistle-blowing disasters. On February 17th, the HSJ reported that a senior nurse had been unfairly dismissed for invoking her trust’s whistleblowing policy, and Chris Day, a junior doctor, took his whistleblowing catastrophe to The Guardian. He highlights how, after he made a ‘protected disclosure’ raising concerns about the safety of his patients in intensive care, he found himself victim of several counter-allegations by colleagues. 

Yet we are also made aware of medical disasters that could have been halted by whistleblowing. In the infamous ‘Mid Staffs’ scandal, where 400-1200 patients died as a result of poor care between January 2005 and March 2009 at Stafford hospital, it emerged that NHS staff had been deterred from speaking out by an atmosphere of fear and bullying. The scandal prompted Robert Francis QC to publish the Freedom to Speak Up Review. The report, commissioned by the government, highlights 20 principles and actions which aim to create the right conditions to enable NHS staff to whistleblow. 

Here are those principles, and how you can apply them to your own practice – so that whistleblowing is accepted and employee voices are valued in your surgery.  

Principle 1 – Culture of safety. Every organisation involved in providing NHS healthcare should actively foster a culture of safety and learning in which all staff feel safe to raise concerns. As practice manager, you can do this by being both a proactive and empathetic leader. Staff should be told, from the outset, that their voices are valued and their concerns important, not only for the health of their patients but also for the smooth running of the practice.

Principle 2 – Culture of raising concerns. Raising concerns should be part of the normal, routine business of any well-led NHS organisation. Once staff feel safe to disclose their concerns, they should also know exactly how to do so. As practice manager, you may be the first port-of-call for practice employees who wish to whistleblow, while clinical concerns may be raised with a GP partner. Once you have decided who in the practice handles employee whistleblowing, your staff should be told exactly who to raise the alarm with, and how. 

Principle 3 – Culture free from bullying. Freedom to speak up about concerns depends on staff being able to work in a culture which is free from bullying and other oppressive behaviours. Although you cannot control the actions of others, you can actively work to create a culture of teamwork and empathy in your practice. You should make sure all criticism is constructive, and lead by example; a practice manager who does not stand for bullying and practices compassion will, by default, encourage their team to do the same. 

Principle 4 – Culture of visible leadership. All employers of NHS staff should demonstrate, through visible leadership at all levels in the organisation, that they welcome and encourage the raising of concerns by staff. As practice manager, it is important you practice visible leadership. Once staff see how you raise concerns, and encourage others to do the same, whistleblowing will become less of a taboo in your practice. 

Principle 5 – Culture of valuing staff. Employers should show that they value staff who raise concerns, and celebrate the benefits for patients and the public from the improvements made in response to the issues identified. Introducing a ‘suggestions box’ to enable both staff and patients to contribute allows you to keep improving as a practice, as well as demonstrating you value their voices. Small changes such as these weave whistleblowing into the everyday fabric of the surgery – making it second nature. 

Principle 6 – Culture of reflective practice. There should be opportunities for all staff to engage in regular reflection on concerns as part of their work. Hosting a weekly practice meeting to discuss concerns allows you to tackle problems as they arise. 

Principle 7 – Raising and reporting concerns. All NHS organisations should have structures to facilitate both informal and formal raising and resolution of concerns. As practice manager, you might draw up a practice ‘whistleblowing’ policy, outlining exactly how employees can raise their concerns, who to raise them with, and which external authorities may need to be involved. 

Principle 8 – Investigations. When a formal concern has been raised there should be prompt, swift, proportionate, fair and blame-free investigations to establish the facts. 

Principle 9 – Mediation and dispute resolution. Consideration should be given, at an early stage, to the use of expert interventions to resolve conflicts, rebuild trust or support staff who have raised concerns. As practice manager, you should establish when expert intervention is needed, and which experts to turn to in different situations. Ask yourself: do you need a medical negligence lawyer? Is a police investigation warranted? Can this concern be dealt with in practice or does it need escalating? 

Principle 10 – Training. Every member of staff should receive training in their organisation’s approach to raising concerns and in receiving and acting on them. You can decide whether you source specific training outside of the practice or whether you will train staff in your own whistleblowing policy and how to raise the alarm. Training, including a practice whistleblowing induction, should be offered to all new employees, and to existing ones if practice policy changes. 

Principle 11 – Support. All NHS organisations should ensure that there is a range of people to whom concerns can be reported easily and without formality. They should also provide staff who raise concerns with ready access to mentoring, advocacy, advice and counselling. As practice manager, you should become proficient at signposting employees to the right professionals. 

Principle 12 – Support to find alternative employment in the NHS. Where an NHS worker who has raised a concern cannot, as a result, continue in their current employment, the NHS should fulfil its moral obligation to offer support. 

Principle 13 – Transparency. All NHS organisations should be transparent in the way they exercise their responsibilities in relation to the raising of concerns, including the use of settlement agreements.

Principle 14 – Accountability. Everyone should expect to be held accountable for adopting fair, honest and open behaviours and practices when raising, or receiving and handling concerns. There should be personal and organisational accountability for: 

  • poor practice in relation to encouraging the raising of concerns and responding to them; 
  • the victimisation of workers for making public interest disclosures; 
  • raising false concerns in bad faith or for personal benefit; 
  • acting with disrespect or other unreasonable behaviour when raising or responding to concerns; and 
  • the inappropriate use of confidentiality clauses.

Principle 15 – External review. There should be an independent national officer resourced jointly by national systems regulators and oversight bodies, authorised by them to carry out the functions described in this report. In a similar vein, you may wish to pursue a role related to whistleblowing within your primary care network (PCN) or, if one doesn’t exist, enquire about what such a role may look like, and how you think it would benefit the PCN. 

Principle 16 – Co-ordinated regulatory action. There should be co-ordinated action by national systems, and professional regulators, to enhance the protection of NHS workers making protected disclosures and of the public interest in the proper handling of concerns.

Principle 17 – Recognition of organisations. CQC should recognise NHS organisations which show they have adopted, and apply, good practice in the support and protection of workers who raise concerns. Practice managers can ensure their whistleblowing cultures and policies are ‘bullet-proof’ and fit to result in a positive CQC inspection report. 

Principle 18 – Students and trainees. All principles in this report should be applied with necessary adaptations to education and training settings for students and trainees working towards a career in healthcare. Primary care is a hub of medical student training; any medical students you have on placement in your practice need to be briefed on your whistleblowing policy and made to feel that their voices are just as valued, and as valid, as those of all other members of the practice team – their ‘student’ status does not disqualify them from raising their concerns. 

Principle 19 – primary care. All principles in this report should apply with necessary adaptation in primary care. Robert Francis identified that it was “Surprisingly hard to get a clear understanding of the options open to staff who work in primary care” and that, “little, if any, thought seems to have been given to it since the Health and Social Care Act 2012”. 

Now 8 years out of date, it is important you are a pioneer and champion of primary care whistleblowing. As practices are small business, it is all the more important that employees can raise concerns with a party external to the practice; this is especially true if their concern is about senior figures. Although not pleasant to think about, it is important your employees know who to turn to if they need to raise concerns about you as the practice manager. Federations of GP practices may be able to appoint a ‘freedom to speak up guardian’; others may be able to sign up the services of their local NHS trust’s guardian. 

Principle 20 – Legal protection should be enhanced. Although wider legal policy is outside of your control, you can make sure your understanding of whistleblowing legality is up-to-date and that your practice has stellar legal contacts in case you need them in the future. 

Whistleblowing should not be a forbidden word in primary care. By implementing the above recommendations in your practice you are sure to generate a culture that welcomes critical feedback. Your team will work together more cohesively, your employees will feel valued, and your practice will run more smoothly as a result. Practice managers are best placed to respond to these recommendations and champion whistleblowing in practice settings. 

For more information, visit the NHS website for guidance on how NHS employees can whistleblow. 

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