The Speaking Out Summit - nhsManagers.net

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The Speaking Out Summit Royal Society of Medicine 8 May 2014 nhsManagers.net

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Index

Acknowledgements ....................................... 13 attempts to protect Whistleblowers ............... 18 Commentary.................................................... 4 Future attempts to protect Whistleblowers ... 19 Increasing concerns ....................................... 15 NHS Employers and CQC ............................ 21 Practical solutions ......................................... 27 Responding to Mid Staffordshire .................. 20 Soft Skills for Hard Times ............................ 29 Speaker Profiles .............................................. 5 Thank You ...................................................... 3

This is what you said after the conference .... 31 Welcome ....................................................... 12 What are the influencing words .................... 24 What should organisations do ....................... 28 Where next for Whistleblowing.................... 22 Whistleblowing ............................................. 14 Whistleblowing and gagging ........................ 17 Who should we influence ............................. 23 Why do we need Whistleblowers ................. 16 Words for solutions....................................... 25 Words for the causes of whistleblowing ....... 26

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Thank You

This record is compiled on the work of Guy Howland who was our assiduous conference rapporteur. To him go the thanks of the delegates, speakers and I am sure, all the readers of this detailed document.

Guy may be contacted at [email protected]

Commentary

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I

came to the idea of the Speaking Out Summit from a genuine sense of frustration. Day after day my in-box fills with emails from whistle-blowers with horrendous stories and genuinely concerned senior managers talking about the frustrations they have; trying to separate the axegrinders from those with a genuine point. Whistle-blowing is, by no means, a one way street. It is clear; there are staff who have used the cover of whistleblowing to further grudges and hide bad behaviour. This, of itself, has helped to fuel the toxic, corrosive environment that surrounds this complex topic.

Stories from genuine whistle-blowers involving their experiences of courts, tribunals, sacking, lawyers, person stress, pressures and wasted careers and talents are a stain on the whole NHS and a blemish on its legacy and purpose. I think it is fair to say the Summit was a day full of energy. It could have so easily slipped into a morass of blame and depressing stories. It didn’t. Heaven alone knows there were speakers who could, justifiably, have taken us in that direction. They didn’t. Everyone was focussed on trying to find a way through, suggest solutions and look for answers. This report is peppered with ideas, thoughts, and creative concepts. Thank you to everyone who took part. Our hope is they will inspire you to look for your own answers, use our thinking as a source and stimulus for yours and provide you with ideas to run your own Summits, meetings and workshops. My conclusion? If the NHS is properly resourced, well run by skilful, thoughtful and careful managers and enthusiastically served by staff who are skilled, trained and valued… the problem will go away. Too idealistic? That’s a question only you can answer. Roy Lilley May 2014

The Speaking Out Summit – Speaker Profiles Roy Lilley Page | 5

Editor of nhsManagers.net, former Health Trust Chairman, broadcaster, commentator and prolific conference speaker; Chair for the Speaking Out Summit and will guide and facilitate the various Q&A sessions throughout the day.

Dr Phil Hammond

Phil Hammond is a doctor, journalist, broadcaster, campaigner and comedian. He qualified as a GP in 1991 and currently works in a specialist NHS centre for children and adolescents with chronic fatigue syndrome/ME. Phil is also a presenter on BBC Radio Bristol and has been Private Eye’s medical correspondent since 1992. In 2012, he was shortlisted with Andrew Bousfield for the Martha Gellhorn Prize for Investigative Journalism for a Private Eye Special Report about the shocking treatment of NHS Whistleblowers.

Dean Royles

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Dean was appointed as chief executive for NHS Employers in December 2010. Previous roles include director of workforce and education at NHS North West; director of HR and communications at United Lincolnshire Hospitals NHS Trust and deputy director of workforce for the NHS at the Department of Health, where he was responsible for developing a national HR strategy for the NHS.

Sir Robert Naylor

Sir Robert has been CEO of University College London NHS Foundation Trust since 2000, before which he spent 15 years as chief executive of a teaching hospital in Birmingham. He led the development of the largest single building project in the NHS to create the new world-class University College Hospital. In 2009 for the second time in the last decade the trust achieved the status of the top performing hospital in the NHS in the Dr Foster league tables. He was awarded a knighthood for services to healthcare in 2008

Dr David Drew

Dr David Drew was a Consultant Paediatrician at Walsall Manor Hospital until his dismissal in December 2010. He has now written a book about his career and related experiences that is being officially launched here at the Speaking Out Summit. A whistle blower who continues to bring thought provoking opinions and observations to the fore.

Gary Walker

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Gary Walker is a former United Lincolnshire Hospitals Trust chief executive who was dismissed in 2010 for ‘gross professional misconduct’. Giving evidence to the Health Select Committee in March 2013, he said that he was sacked because of a row over an 18week non-emergency waiting list target and was threatened by the East Midlands Strategic Health Authority when he flagged up capacity problems. A copy of his presentation may be downloaded here.

Professor Christopher Newdick

Chris Newdick is a barrister and Professor of Health Law at the University of Reading. His special interests concern the rights and duties arising within the NHS and he teaches a popular course on the subject in the Law School. His teaching and supervision is informed by his research in the area and his experience as a member of the Department of Health's Medicines Commission, as an Honorary Consultant to Berkshire West PCT, a member of the Berkshire Priorities Committee, an advisor to the BMA Working Party on NHS Rationing and the NHS National Prescribing Committee.

Dr Jenny King

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Jenny is Practice Lead and a Director of Edgecumbe Health – leading experts in the professional performance of doctors. She is a Chartered Occupational Psychologist, with a doctorate in Psychology from Oxford University. She is a Fellow of the Royal College of Physicians of Edinburgh.

Dr Suzanne Shale & Murray Anderson-Wallace

Dr. Suzanne Shale works as an independent consultant in the fields of healthcare ethics, healthcare leadership and patient experience. During 2013 the Royal College of Surgeons published her comprehensive guidance on enhancing clinical governance and raising concerns in surgery. Her co-presenter today is Murray Anderson-Wallace, an Executive Producer of PATIENT STORIES and an experienced specialist healthcare advisor, media producer and researcher.

James Titcombe & Dr Kim Holt

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James Titcombe is the National Advisor on Patient Safety, Culture & Quality at the CQC. James's fight for answers over the death of his baby son Joshua at University Hospitals of Morecambe Bay NHS Foundation Trust led to an independent inquiry being set up. Forced from her job in 2007 after she and 3 other doctors wrote to management at St Ann’s Hospital, Haringey warning that staff shortages and poor record-keeping would lead to a tragedy, she was sadly proved correct when, 6 months later, an inexperienced doctor who had replaced her failed to spot that Baby Peter was the victim of severe physical abuse. She also works at the CQC.

Paul Hodgkin

Paul was a GP for 25 years, before founding and leading Patient Opinion for its first nine years. He is now chair of Patient Opinion. He contributed to the Francis Inquiry around the terrible events at Mid Staffs as he was asked to provide expert comment on how to prevent and detect problems such as those that occurred.

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Dr Stuart Gowland

Dr Gowland is the visionary behind the Mobile Health Solutions project in Christchurch, New Zealand. A urologist, Dr Gowland was instrumental in leading a redesign of service delivery at Canterbury Hospital following a hugely critical report into high death rates there. The aftermath was extraordinary for him personally. He has travelled from Christchurch to be with us today.

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Welcome

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I find it inconceivable that managers don't beg their staff to tell them what is going on. It is a complete mystery to me why managers don't implore their people to tell them what they know. I can see no reason why managers wouldn't crawl on their hands and knees, from one end of a hospital to another and grovel, to be told what the front line knows. What infects a manager into the belief that because they are in charge they are in the know? How is it that something as simple as passing on the knowledge that something needs fixing has become tangled up in whistleblowing, fear and a soured culture of corrosive blame? Something has gone horribly wrong. I cannot tell you the number of emails I am getting from frontline NHS staff who are ignored, silenced and frankly, oppressed. Where has it all gone wrong? In fairness there are two sides to the story. Whistleblowing has been used as a lever by the disgruntled, the axe grinders and the campaigners. Unions are not blameless, either. Whistleblowing (better we call it ‘speaking out’) has acquired a bad reputation. Second it occurs to me that management have become jaundiced; they know there are fault lines in their organisations - the kind of San Andreas faults they are powerless to do anything about, so they cover them up and cover their ears and eyes. They have to deliver and tales of what is going wrong don't help. If delivering the target is the only target, nothing else matters. The dislocation between those responsible for delivery and the deliverers plays an important role in this dysfunctional process. By making speaking out a special event, people treat is as 'special'. It is wreathed in process, procedures, special hearings and the law. We must get back to talking about what we do (good and bad) naturally, inquisitively and the normal chit-chat of the day to day. As natural as a conversation about last night's game or what was on the telly.

I say it's possible to change any organisation with three questions: What do you think? How can I help? Tell me what we've learned? The problem is you have to really want the answers. In response to the worryingly large post bag I receive on speaking out, it occurred to me; what if we get some really good people - senior bosses, managers, experts on organisational dynamics, whistle blowers, lawyers and administrators all in one room and see if we can thrash out something practical, doable and useful. This is that room – and you are all very welcome. Thank you for speaking out.

Roy Lilley. Editor, nhsManagers.net

Acknowledgements Page | 13 Many thanks to all of our speakers for giving their time and expertise so graciously. Special thanks to Dr Stuart Gowland for travelling all the way from Christchurch, New Zealand! Thanks to our sponsors, Salix Consulting and NHS Professionals who provided bursaries to allow 20 delegates to be here whom otherwise could not have been. Thanks also to Dame Ruth Carnall, previously Chief Executive of the London Strategic Health Authority and now a special advisor to the Mayor of London, who personally provided funding for 2 further bursaries. Thanks to all of our whistle blowers and speak-outers, who come here to share their experiences and provide the grounded evidence to galvanise our commitment to a better NHS information culture. Thanks also to the health managers who have come here to demonstrate their commitment to playing a full role in re-shaping and enabling processes by which issues are addressed.

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Whistleblowing … is a mechanism through which concerns – real or imagined - can be raised. Historically, NHS Whistleblowers – where they have been listened to at all – have often been sanctioned by employers and in the most extreme cases prevented from working in the NHS again, at enormous cost to our health system in terms of both wasted talent, energy and money. More recently, there has been a growing interest in utilising the passion and commitment for improvement often found in NHS Whistleblowers as part of a renewed drive to improve patient safety. NHS Managers.net’s conference at the Royal Society of Medicine on 8 May 2014 considered the case for finally bringing the often maligned whistleblower into the mainstream of patient safety improvement.

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Increasing concerns about the quality of NHS Patient care and what to do when things go wrong? There have been many attempts over the past 25 years to drive up standards within both public life in general and NHS Patient Care in particular, with mixed results. Some examples include:      

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The Patients’ Charter, 1992 – which set general standards that patients’ should expect Standards in Public Life, 1995 - which now form part of the Ministerial Code Bristol Royal Infirmary Report, 2001 – into high death rates in children’s heart surgery Code of Conduct for NHS Managers, Department of Health ,2002 Good Medical Practice, Code of Conduct, GMC, 2006 –duty to disclose when things go wrong Nursing and Midwifery Council Code of Conduct, 2006 –duty to disclose Healthcare Commission Report into Stoke Mandeville, 2006 – 33 people died from hospital acquired infection during two outbreaks of Clostridium difficile Healthcare Commission Investigation into outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust – where from October 2005 to September 2006 more than 500 patients developed the infection, and the Healthcare Commission estimated that there were approximately 60 deaths where C. difficile was definitely or probably the main cause. The NHS Constitution, 2009 Mid Staffordshire Foundation Trust Inquiry , 2010-2013 – system failure of NHS at all levels through an over focus on finance and targets over patient safety.The first inquiry report was published on 24 February 2010. It contained damning criticism of the care provided by the Trust, drawing out a number of conclusions, including: The culture at the Trust was not conducive to providing good care for patients or providing a supportive working environment for staff; there was an atmosphere of fear of adverse repercussions; a high priority was placed on the achievement of targets; the consultant body largely dissociated itself from management; there was low morale amongst staff; there was a lack of openness and an acceptance of poor standards; Francis Report recommendations , 2013 -five things are needed: First, a structure of clearly understood fundamental standards and measures of compliance, accepted and embraced by the public and healthcare professionals, with rigorous and clear means of enforcement. Secondly, openness, transparency and candour throughout the system: Thirdly, improved support for compassionate caring and committed nursing: Fourthly strong and patient centred healthcare leadership. Finally, accurate, useful and relevant information.

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Why do we need Whistleblowers? Estimates suggest that between 400 and 1200 excessive deaths may have occurred at Stafford Hospital between 2005 and 2008, and yet of the 120 to 150 doctors at the hospital, and many more nurses: few raised concerns. Problems in Stafford and elsewhere could have been lessened arguably by learning the lessons of earlier major NHS whistleblowing. For example: Dr Stephen Bolsin in Bristol had highlighted unwarranted variation in outcomes at the Bristol Royal Infirmary in Children’s heart surgery, which resulted ultimately in a fall in adverse events but left him unable to work in England. Dr Raj Mattu raised concerns about poor post operative care at the Walsgrave Hospital in Coventry and suffered a series of "detriments" after he spoke out about what he saw as dangerous conditions, including too many patients' beds being squeezed together causing dangerous overcrowding. He voiced alarm at the hospital's "five-in-four" policy, under which – to save money – an extra fifth bed was placed in a bay intended for only four patients. The Commission for Health Improvement, the then NHS watchdog, condemned the practice and criticised the hospital, which it said had a much higher death rate than should have been expected. Dr Mattu was sacked by University Hospitals Coventry and Warwickshire NHS Trust in 2010, nine years after he first aired his concerns publicly. Dr David Drew in Walsall raised concerns about nursing shortages and their impact on patient care and child protection and subsequently institutionalised bullying within the Paediatrics Department. He was sacked in December 2010 for “gross misconduct and insubordination”

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Whistleblowing and gagging: part of a wider NHS culture of secrecy and cover up? According to Secretary of State for Health, Jeremy Hunt, speaking to the Daily Mail newspaper: "Mid Staffs happened because there was a culture of covering up problems” While 60% of Whistleblowers are still ignored, of the 40% who do receive a response, 1 in 3 currently end-up being sacked. Mr Gary Walker , a former chief executive at United Lincolnshire Hospitals Trust, told the BBC that demand for emergency hospital beds in 2008 and 2009 became so acute that he felt he had no other choice than to abandon the 18-week Whitehall national target for nonemergency cases. Frequently He said the message from the East Midlands Strategic Health Authority was to hit the targets "whatever the demand" and that he was ordered to resign when he refused to back down. Mr Walker said he had no choice but to sign an agreement linked to a confidentiality (gagging) clause in April 2011, preventing him from speaking out.

Asked Questions Helpful summary here

There are thought to have been between 400 and 1000 compromise agreements over the past 10 years which prevent Executives speaking out on a range of issues including patient safety. In response to Mr Walker’s case, in particular, the Secretary of State for Health, Jeremy Hunt, has said: 'The era of gagging NHS staff from raising their real worries about patient care must come to an end.’

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Early attempts to protect Whistleblowers There have been some early attempts to protect Whistleblowers but they have met with limited success to date. The British Standards Institute has created a definition: “…when someone who works in or for an organisation…...raises a concern about a possible fraud, crime, danger or other serious risk that could threaten customers, colleagues, shareholders, the public or the organisation’s own reputation.” The Public Disclosure Act 1998 sought to offer some protection: “An Act to protect individuals who make certain disclosures of information in the public interest; to allow such individuals to bring action in respect of victimisation; and for connected purposes.” The GMC produced guidance for doctors: ‘You must protect patients from risk of harm posed by another colleague's conduct, performance or health. The safety of patients must come first at all times. If you have concerns that a colleague may not be fit to practise, you must take appropriate steps without delay, so that the concerns are investigated and patients protected where necessary. This means you must give an honest explanation of your concerns to an appropriate person from your employing or contracting body, and follow their procedures.” Government proposals for a statutory duty of candour, currently subject to consultation, represent the latest attempt to introduce more openness and transparency into the health and social care system - and may provide a safer framework within which Whistleblowing may take place - but the extent and effect of these regulations remains unclear at present.

Future attempts to protect Whistleblowers Mr Gary Walker suggested 5 ideas to protect Whistleblowers - if you like, a charter for Whistleblowers. These include: Page | 19

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Believe in Whistleblowers – even when they are wrong - and stop trying to discredit them Declare Whistleblowers an asset and not a liability Act on Whistleblowers concerns (and don’t shoot the messenger!) Sanction those who victimise Whistleblowers Publish how you support those who raise concerns

Currently most people believe that if they raise concerns that they won’t be listened to or worst still that they will lose their job or that they will be subjected to bullying Mr Dean Royles (NHS Employers) suggested that the best way to overcome this would be for:    

System regulators to provide the right tone for leadership on Whistleblowing Whistleblowers need to be protected even if they are wrong Organisations need to focus on the substance of complaints and concerns and not the individuals making them Complaints need early assessment and Whistleblowers and organisations need to be supported through mediation

According to Dr Phil Hammond there was also a role for:             

NHS minimum standards of care Professional representative bodies and Royal Colleges Trades Unions Independent representation for Whistleblowers within their own NHS organisation Independent Board member (accountable officer) with responsibility for Patient safety including Whistleblowing Collaboration across NHS Foundation Trusts and other NHS bodies to create ‘safe havens’ for Whistleblowers Incorporation of Whistleblowing into a wider and revamped Patient Safety movement Blame –v- learning organisational cultures Formal arrangements for mediation between organisations and whistleblowers Opportunity to escalate Whistleblowing ( via secure NHS email) externally embedded into every NHS organisation A clearly defined Inspectorate role to go in early and investigate Whistleblower complaints A requirement for CQC to annually look at Whistleblower ‘ red flags’ as part of their inspection process Wider use of ‘real time’ technology and full electronic audit trails to support Whistleblowing.

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Responding to Mid Staffordshire and other failures of care Some NHS Foundation Trusts have already responded to the lessons learned at Mid Staffordshire. Sir Robert Naylor gave an overview of progress at University College London Hospitals (UCLH), an FT with a turnover of £1 billion and around 9000 employees. The Chief Executive holds regular team briefings and these monthly team meetings are replicated across the organisation to ensure staff are all fully briefed about developments within their organisation. This is supplemented by the Trust’s monthly magazine – Inside Story- which is circulated routinely with pay slips. At UCLH medical staff are encouraged to play an active part in management and as many as 80 of the 800 doctors do. The trust aspires to an open and honest culture, with visible leadership and a clear vision , values and objectives. Objectives are circulated and owned by staff and all staffs’ objectives are aligned to common corporate objectives.

Top Tips for Employers Guide here

Appraisal measures staff performance against common values notably:    

Safety Kindness Team working Improvement

In addition, the Chairman and Chief Executive read all complaints and the Chief Executive signs all complaints response letters ensuring that the Top of the Office within the Foundation Trust remains fully connected to what’s going on in the organisation be it positive or negative.

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NHS Employers and CQC Both NHS Employers and CQC are introducing support mechanisms to assist members of staff to raise concerns at work. NHS Employers have published a booklet entitled ‘Raising Concerns at Work : Whistleblowing guidance for workers and employers in health and social care’ , which includes a flowchart setting out the Whistleblowing process and a helpline number to call for free advice 08000 724 725. CQC have similarly set up a Whistleblowing hotline 03000 616161 which received almost 9500 calls in 2013 (7818 social and 958 health care)

CQC know that more needs to be done and are considering how best to incorporate Whistleblowing into CQC inspections. Mr James Titcombe of CQC set out some potential future options for CQC which included:    

CQC inspectors to interview Whistleblowers Monitoring and review of Whistleblowing complaints Monitoring of bullying complaints Sample of compromise agreements to be audited

Top Tips for Whistleblowers Easy to read reference guide Here

The Big Conversation : Where next for Whistleblowing? Page | 22 Delegates had many good ideas for harnessing the learning offered by Whistleblowers (1) Tackling the causes The causes of whistleblowing were multifactoral but included : secrecy, patient safety, targets, fear, fraud, staffing levels, poor relationships between managers and other professionals.

(2) Starting to find solutions Starting to find solutions involved : leadership, truth, courage, valuing people, risk taking and reconciliation.

(3) Practical solutions Practical solutions included : Raising concerns is acceptable and needs to be supported by national expectations and consistent standards for the management of Whistleblowing, a new name for Whistleblowing or ‘speaking out’, early mediation and investigation of complaints to prevent escalation, safe havens for Whistleblowers in adjacent organisations, and a clear separation of Whistleblowing from Top Tips for bullying and other employment issues. Managers (4) How can organisations help?

Helpful Guide here

Organisations can support Whistleblowers through:  Visible leadership  Examining the root causes of Whistleblowing  Providing support, encouragement , training and mentorship to Whistleblowers  Listening, analysing & responding to Whistleblowers in a positive & safe way  Learning the lessons of Whistleblowing and using them to strengthen the organisation.

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Who should we influence?

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What are the influencing words?

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Words for solutions

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Words for the causes of whistleblowing

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Practical solutions

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What should organisations do?

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Soft Skills for Hard Times Following the conference, delegate Phil Hawthorn posted a must read, reflective blog about the conference and whistleblowing. You can find the full version here. It is now almost a week since The Speaking Out Summit, chaired by Roy Lilley. (nhsmanagers.net) Here are my (very) edited highlights of the day. Roy Lilley quoted himself: “I don’t know why managers don’t crawl on their hands and knees, from one end of a hospital to another and grovel, to be told what the front line knows.” The tone was set. The aim? “Get the right people in the room (administrators, whistle blowers, lawyers, senior bosses, managers), and see if we can thrash out something practical doable and useful to help people to speak out”. Easier to write than do, of course, but there was energy in the room. Dr. Phil Hammond felt he was very inspired by whistle blowers. “Difficulty is the excuse history never accepts”. (I told you the day was full of thought provocation!) If we think of whistle blowing (which is still too pejorative a phrase, and is tainted with ‘snitch’ mentality), but turn it around to feel it is about constructive dialogue for clinical accountability – think of it positively – then we may be on the right journey? You got the feeling that as lawyers may be complicit in covering up the stench of raking over the masses of dirty linen, the level of inaction on what can only be described as avoidable deaths may well still be occurring? Dean Royles from NHS Employers gave the management view and presented us depressing stats: 54% of complaining staff feel they are never listened to. If you raise concerns and it is acted on, courageous whistle blowers know that they are likely to lose their jobs. As soon as lawyers get involved, then there is allegation-tennis, claim and counter, and money being wasted. This was the first mention in the day of mediation being a logical start for all, and keep the lawyers out. It has worked in Construction – another seriously litigious sector.

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It was great to hear from our first ‘celebrity whistle blower’. Dr David Drew, former Paediatrician. ‘Former’ – that is the reality of whistle blowing. Trumped up and spurious allegations to blacken the reputation of the complainant. And we all lose the services of a good medical practitioner. It just feels so sad. Our second celebrity WB, Gary Walker, was a CEO of a trust. Boards were running hard to hit targets. I got the feeling that target chasing can yield needless deaths? Isn’t that sobering? I loved Prof Christopher Newdick, from University of Reading. The disasters that have occurred (and he took us through many) centred around core problems: a lack of leadership, a lack of accountability, and a lack of infection control causing a Clostridium Diffcile outbreak in one hospital. In Stafford, 120 to 150 clinicians ‘knew’ what was happening. Chris again brought up the target driven mentality leads to the wrong things being done, such that concerns about patient safety, morbidity and mortality were lower down the list of objectives than they should ever be. 700 days is the average tenure of an NHS CEO. Bucking the trend is Sir Robert Naylor with 14 years at UCLH. Showing and sharing the vision, leadership, empowerment and sharing of the objectives – like a proper organisation should be run – were the cornerstones of clinical excellence. He would be the CEO crawling on hands and knees to find out more from the front line… I’ve mentioned James Titcombe and the avoidable death of his son in my last blog. It does make all the rest of the day pale for me. We just have to do more to make speaking out work quickly and effectively. And that’s where we ended up. A final brain storm of what to do next. Roy and the team are currently working on Best Practice Guidelines. I want the emphasis to change to rewarding speaking out. Let’s think of Speaking Out as the equivalent of Suggestion For Improvement boxes that some organisations still have. And if the suggestion – any suggestion (investigating poor clinical practice, saving a wasteful methodology, adding a new operating procedure, removing a poor system, pointing out outlying HSMR and why), and lumping them all in together as positive, then we have the change in mentality that is necessary. And, so we can then offer incentives if the suggestion leads to savings. It just might help the change in behaviour we so desperately need.

This is what you said after the conference

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After the conference all the delegates and speakers were sent a copy of this document in draft and invited to add a comment of not more than 100 words, to the final version. Thank you to those who did. It is significant that even after the conference and in a document like this, some contributors asked for their identity to be withheld… -oOoMy ideas for improving and encouraging speaking out are as follows. I am not sure that they would work and I am sure there would be unintended consequences, but...: 1. Consider a standard of care backed by statute on whistleblowing and link this to money, a sort of CQUIN for whistleblowing. This is to reflect the power and culture of meeting targets and money and is using this power to support a worthwhile aim. I appreciate that this would be fraught with difficulties, but using an enemy’s strength against them is a key component of martial arts and works. 2. The CQC, where names are known, should interview every whistleblower from an individual organisation that they are reviewing/inspecting. This should be done at a time and place of the wistleblowers choosing, but should form a key component of their inspection and should be anonymous if required. Anon Senior NHS manager -oOoI agree that we need to turn this thing on its head. We need to stop talking about “whistleblowing”; instead we need to identify and celebrate instances where speaking out works without persecution/vilification; we need to storify those instances, and we need to use those who spoke out, and more importantly those managers who reacted in the right way, as champions for change.” Rob Darracott, Pharmacist

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Below is an abridged version of the Society of Radiographer’s principles which have been condensed to fit the 100 word discipline. We are happy for you to include them in your document as our principles for encouraging speaking out. The NHS and other healthcare providers need to 1. Commit to always improve patient care. 2. Employ leaders who trust the clinical judgment of staff allowing them space to exercise their judgment. 3. Employ healthcare professionals committed to the continuing development of patient care based on rigorous analysis of techniques and procedures. 4. Regard speaking out on clinical and professional matters as a key mechanism facilitating this development. 5. Investigate errors of judgment as part of the continuing development process and not solely and immediately to apportion blame. 6. Show clear commitment to the continuing professional development of all healthcare professionals.

-oOoI can only endorse the call for independent mediation; MANDATORY mediation in all cases where the primary concern is patient safety. Anne Noble

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'Whistleblowing encompasses the hardest challenges the NHS faces. What should we do to reduce the harm caused to patients by avoidable error and unwarranted variation in standards of care, and the harm done to whistleblowers who speak up about it and threaten professional, political and corporate interests? The solutions have to be sought collaboratively. Competition exacerbates vested interest and a machismo that tends to bury bad news. This summit, by getting views from all sides, is the start of constructive, cooperative approach that acknowledges complexity and builds on justice, safety and freedom of speech. We need to do it every year, and to celebrate the successes of speaking out as well as learning from its failures.' Dr Phil Hammond Doctor, writer and broadcaster.

-oOo-

Effective leadership is all about vision, communications and trust – leadership and followership is a two-way street. Hospitals are complex dynamic organisms, designed to deal with some of the most emotional and stressful experiences in our lives. Engaging with and listening to staff and patients is just about the most important job for the CEO and the Board. Creating opportunities for staff to design organisational values and objectives and for the leadership to be honest and open about good and bad news is essential. Patient complaints and staff concerns should be valued as opportunities for learning and improvement. Sir Robert Naylor, Chief Executive, UCLH NHS Foundation Trust. [email protected]

We shouldn’t feel we need to choose between targets and safety; making the most of our resources is just as much of a civic duty as is making sure our patients are safe; we should be able to do both. The existence of targets is not the problem – its people who are prepared to ignore safety/quality in order to achieve them. Page | 34 As a former social worker, I think the NHS across all groups needs more training in empowerment and providing services which are led by the patient (client). If patients feel empowered, they will tell us what’s not working (this is not to say social services are exempt from providing poor or abusive services!) I am a fan of Patient Opinion, but its hard work getting our patients to use it – if we could get all our elderly admissions to do their own stories whilst on wards, change would have to come. We need grown up conversations with the public – mistakes are made and shit sometimes happens. NHS staff often treat the public in the same way as politicians do (deny anything has gone wrong), but most of the time an apology and an explanation of how we work is well-received. If it was accepted that things go wrong even in healthy (in a functional sense) systems, it would be easier to deal with things which are not working. Thanks Chris Kearton Practice Manager -oOoAs I manage Adult Health &Social Care service delivery in a third of the County of Gloucestershire, we can make that third better and more open, as a starting point! I pledge that I will add a ‘whistleblowing’ agenda item to every Locality Board monthly agenda, and encourage staff across the Community Hospitals and Integrated Community Teams can bring something they are concerned about, have it recorded, discussed, actioned, and forwarded onto the Exec Team as part of our regular reporting upwards. This agenda item will be above and beyond the usual ‘Performance Reporting’ system we currently operate. Margy Fowler Locality Manager, Forest & Tewkesbury Localities Gloucestershire Care Services NHS Trust

There are different stages and the terminology gets applied to them inconsistently: Raising a concern (often not a problem).

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Repeatedly raising a concern because the employee feels their concern has not been properly addressed (getting to be more annoying). Expressing the concern outside the organisation. Many will understand the term whistleblowing only to refer to this. And I'm not sure if PIDA applies to anything but this. Managers/employers don't like whistle-blowing because they're struggling to do a difficult job with limited resources and they don't want to be told they've got it wrong. Especially if harm has actually occurred. I did suggest that it might be a concrete expectation, e.g. addressed in appraisal, that staff should raise concerns. With incident reporting, we encourage lots of incidents to be reported. Then, if we have a high ratio of minor to major incidents being reported we can be confident that we are hearing about all the major ones. Maybe could adopt something similar with raising concerns? Encourage all concerns, no matter how minor, to be reported? Then hopefully get all the major ones. Thanks for organising the conference - I found it very engaging and may want to get more involved in this area in future. Best wishes Dave Curtis -oOoI would like to see something included along the lines of ' if we don't challenge or expose poor practice then we are essentially colluding with it. I would like to see a culture where all staff are expected to give 'feedback'- I have previously changed induction processes to incorporate a period of 'free consultancy' when staff first start (before they go native)- during this period they are expected to jot down three things - what surprises them - what delights them - what concerns them This encourages a culture of speaking up and provides feedback at department/ward / team level. All the feedback is then collated centrally and provides the Trust with themes that they need to pay attention to. It is about making it part of our daily business but new staff offer a fresh eyes perspective that we seldom capitalise on. Hope this helps Prof Susan Fairlie. Managing Director. Mindset Matters Ltd.

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There is not a single solution. Those raising concerns must do so in the most effective way possible, and those receiving them must understand what the concern is and what change is needed. When raising concerns: * Describe in sufficient detail what you saw; * Explain succinctly why this puts patients at risk; * Be clear about what you believe should happen. In responding to concerns: * Assume the concerns are real; * Act promptly and follow organisational governance procedures; * Make the change; * If no action needed, ask yourself why. And doctors, whether raising concerns or responding to them, must follow GMC guidance. With kind regards Mike Dr Michael Devlin LLM MBA FRCGP FFFLM Head of Professional Standards and Liaison MDU -oOoThe problem is so insidious that it would be unrealistic to expect a quick fix. My own, 100 words re solutions are: We need an immediate independent reporting system for staff that raise concerns and are then bullied, suspended, disciplined or experience any other retaliation as a consequence. HSC advice that no staff raising concerns should be taken through internal disciplinary procedures, fitness to practice or employment tribunals needs high profile implementation in all NHS organisations. CQC should be mandated to investigate individual cases reported to them. Meanwhile we continue to press for some kind of inquiry in public. That should put a shot across the bows of some of the managerial types behind all this. David

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