Antecedentes de Calidad

New recruits to an organisation were told as part of their induction that it was an organisation which accepted that people made mistakes. What was important was that staff spoke up when mistakes or near misses occurred, so that they could be investigated, addressed and learning shared.

5.3.18 There have been several attempts to standardise and embed the process of raising concerns in the NHS. For example, the right to raise concerns and a commitment to encourage and support staff to speak up is already enshrined in the NHS Constitution69_{. There are also helplines,} best practice guidance and model policies (see chapter 2). However, these have not succeeded in normalising the raising of concerns because ‘normalisation’ cannot be achieved by process and procedure alone. Process and procedure need to sit within a culture that inspires confidence that raising concerns will be dealt with in an appropriate way. Fear of speaking up

5.3.19 People can be reluctant to speak up because of fear of being:

• blamed or made a scapegoat

• discriminated against

• disbelieved

• seen as disloyal

• seen as disrespectful in a hierarchical system

• bullied

• fear of wider consequences for a career.

5.3.20 Raising a concern can also be particularly intimidating for:

• students and trainees who are dependent on a placement being signed off

• junior staff working in hierarchical settings

• staff in close knit teams who might be afraid to ‘rock the boat’.

“ …many staff are still afraid of raising concerns for fear of upsetting colleagues, especially more senior ones.”

5.3.21 Organisations may also be ‘afraid’ to talk about the type of concerns being raised internally, just as previously they feared talking about patient complaints.

Freedom to Speak Up – A review of whistleblowing in the NHS

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5.3.22 All of these issues need to be overcome. Normalising speaking up will contribute to achieving that.

The term ‘whistleblowing’

5.3.23 I have considered whether the term ‘whistleblowing’ itself contributes to the barriers. I see three problems:

• there is confusion about what qualifies as whistleblowing. Some people consider whistleblowing to be about something concerned with criminal wrongdoing such as fraud rather than a patient safety concern. Some consider it applies when escalating a concern outside the normal management chain, or about a more senior colleague. Some believe it only applies when raising a concern outside the organisation, or even that it is limited to disclosure to the media or otherwise into the public domain

• the meaning of the term ‘protected disclosure’. The complexity of the legislation and confusion among contributors about what constitutes a ‘protected disclosure’ is unhelpful

• the term has negative connotations, or can imply something separate from, and more serious than raising a concern as a normal activity.

5.3.24 I gave serious consideration to recommending that the term ‘whistleblower’ should be dropped, and some other term used instead. Although I still have reservations about the term, I have been persuaded that it is now so widely used, and in so many different contexts, that this would probably not succeed. Instead we should focus on giving it a more positive image. I believe that the measures recommended in this report will do much to promote the acceptance of ‘whistleblowing’ as normal and positive behaviour in healthcare.

Conclusion

5.3.25 NHS organisations need to have an integrated strategy to normalise the raising of concerns supported by an integrated policy and a common procedure for reporting incidents and raising concerns. I advise that NHS England, NHS TDA and Monitor should take joint responsibility for producing and cascading a standard policy and procedure taking into account the existing model policy developed by the Whistleblowing Helpline. This should not distinguish between reporting incidents and making protected disclosures, and should incorporate the good practice described in this report. NHS organisations may adapt the procedures to fit with local structures, provided they retain the principles and practice described in this report.

5.3.26 It is acceptable to suggest that staff raise concerns within their organisation before going to an external organisation. If there is a culture where it is safe and normal to speak up, this should not be a problem and is the most effective way of getting a concern addressed promptly. However staff should never be made to feel hesitant about raising an issue with a relevant authority outside of the organisation, such as the CQC, or to raise it anonymously if that is what they want to do. It is much better that a concern is brought to light in this way than for it not to be raised at all. Therefore policies must not be expressed, whether or not intentionally, so as to prevent or deter anyone from raising concerns directly with any prescribed person or any commissioner. They should also explicitly permit concerns to be raised anonymously (see 6.3).

5.3.27 A reluctance to raise a concern internally first, may indicate that there is some cultural barrier to taking that course. Insightful reflection on the causes for external referral of concerns should be a matter of routine, provided, of course, that this does not in itself promote a blame culture.

Chapter 5 – Culture 101