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A change in culture within the NHS is needed to ensure that managers are less resistant to hearing, and acting upon, bad news, research led by the University of Birmingham has found.

Research led by the University’s Health Services Management Centre found that any future whistleblowing policies must deal with the ‘deaf effect’ amongst NHS managers, where entrenched status and power differences between different professional and occupational groups can limit open reporting cultures.

The report, ‘Understanding the knowledge gaps in whistleblowing and speaking up in health care’, funded by the National Institute for Health Research (NIHR) , is the first comprehensive review to look at existing literature, analyse legal issues related to whistleblowing, review formal inquiries following significant failings in NHS care and interview with key officials from within the NHS.

The research, led by Professor Russell Mannion, Professor Martin Powell , Dr Ross Millar and Professor Jean V. McHale, with colleagues from Northumbria University, University of Hull and the University of St Andrews, found that existing practices were not adequate in responding to informal concerns when they are raised, that many stages for learning prior to blowing the whistle are not dealt with adequately and that whistleblowers could benefit from enhanced legal protection, as is the case in the Republic of Ireland.

When reviewing a range of previous formal inquiries, including the Shipman and Francis and the most recent Government led Freedom to Speak up Review, they found an inconsistent understanding of what made a whistleblower and that the inquiries focused disproportionately on patient complaints rather than on a staff voice.

In fact of 6 formal inquiries examined, with some 820 recommendations, only eight of those were directly concerned with whistleblowing. Even the Shipman Inquiry, which stressed the role of health professionals in raising concerns, had only 3 of its 190 recommendations focused on whistleblowing.

Reflecting on the failures that led to these inquiries, the report finds that many of them could have been dealt with more effectively and in a more timely way if managerial cultures were more appropriately attuned to ‘hear’ signals of challenge, highlighting the importance of open cultures within the NHS.

Professor Russell Mannion , Professor of Health Systems at the Health Services Management Centre said:

“Frontline staff are often best placed to identify and speak up about unsafe or deficient care. Yet in many parts of the NHS it is apparent that staff are reluctant to voice concerns, and when they do, some organisations respond inappropriately, for example by ostracising individuals or by undermining legitimate concerns.

“Any attempt to address speaking up in the NHS must deal with the challenging organisational dynamic of resistance to bad news, especially by those in positions of power, who have a duty to nurture organisational cultures where frontline voices can be aired and responded to appropriately.”

In 2015, the Care Quality Commission introduced a duty of candour for the NHS, following the publication of the second formal inquiry from Sir Robert Francis QC, which places a duty on healthcare providers to ‘promote a culture that encourages candour, openness and honesty at all levels’. In fact the term duty of candour has been widely used in a range of inquiries and is often vaguely defined. It also remains to be seen what sanctions are applied to those who fail to display their statutory duty of candour.

Professor Jean V. McHale , Professor of Health Care Law at Birmingham Law School said:

“While there is some existing statutory protection for NHS whistleblowers, these remain insufficient. The existing legal frameworks around whistleblowing require reconsideration by the Government both in relation to the NHS and more generally. Possible options for the future could include oversight by a regulatory agency, greater protection for early-stage whistleblowers, additional compensation claims being available to whistleblowers who suffer detriment and review of the continued use of confidentiality or so called “gagging” clauses in the NHS.”

Researchers also found that policies primarily deal with those wishing to raise the alarm internally, however, they often made no or little provision for ‘bell-ringing’ or outsider whistleblowing. This could take the form of relatives or professionals from other agencies, such as social workers. This is significant as the NHS increasingly seeks collaborations with other sectors to respond to the challenges of an ageing population, meaning that external staff and other stakeholders are increasingly exposed to, and in a position to speak up about, poor quality care.