Saturday, February 14, 2015

Speaking up in the NHS

Robert Francis' report on NHS whistleblowing, Freedom to speak up, seems a little bland to me. Maybe this is because, although he heard evidence from individual cases, he hasn't described any specific details of any of them in the report. As he says, "cases are not always clear-cut", but I'm not sure if this justifies his decision to describe generalities only, including ruined lives in some extreme cases. Still, a Guardian article highlighted four cases.

Nor does Francis really attempt to explain the context for the problem. As another Guardian article says, the issue is at least partly managerialism in society in general, not just the NHS. But I think there have been, historically at least, specific elements in the NHS. The financial cost of delays to disciplinary proceedings hardly impinges in some NHS trusts, so that cases take too long to resolve. And, there was a particular phase of command and control leadership in the NHS, associated with the previous chief executive (see eg. previous post), that encouraged a bullying culture (eg. see another previous post). Problems with healthcare regulation related to the annual health check (e.g. see previous post)  and the Healthcare Commission (see another previous post) led to the Care Quality Commission (CQC) being formed, which had to be revamped after going through a rough phase (eg. see another previous post). CQC is still improving its methods and I'm not sure how valid its ratings always are. Nonetheless, special measures do seem to have been helpful for NHS providers that have been through the process (see Independent article, although I'm not sure how much should be made of the mortality statistics), and there may well be benefits from using them more widely.

The exhortation for a healthcare professional to speak up about concerns about the conduct, performance or health of others is important, but this can be misused. Clinical practice is not always objective and there may well be uncertainty about the best course of action for medical interventions. Francis did hear evidence that some people raise concerns for dubious motives. The increasing regulation of doctors over recent years, following the case of Harold Shipman, may have contributed to a climate of fear and culture of defensive practice (eg. see my BMJ letter). This is promoted by managerial over-reaction. Medical errors are not always manifestations of incompetence, carelessness or recklessness (see previous post). Naming, blaming and shaming may not always be the most appropriate response. The form of statements of intent can easily be persuasive, whereas the content doesn't really relate to quality. For all the merits of revalidation, for example, it is easily diverted into a bureaucratic exercise.

As I have mentioned before (see previous post), I am someone who has been suspended twice in my career. I have also been further investigated without being suspended (eg. see another previous post).  My first suspension was related to ideological conflict about critical psychiatry (see THES article). My second was a professional conflict with management, with me raising concerns that relationships between management and consultants needed to be improved. Instead it was me that was accused of bullying, and found guilty, in my view wrongly.

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