The Royal College of Physicians (RCP) welcomes the announcement by the secretary of state for health and social care, Matt Hancock MP, that the government will strengthen protection for NHS whistleblowers.
The importance of speaking up
The announcement was made in the wake of the findings of the independent panel inquiry into Gosport War Memorial Hospital. The RCP was appalled by the finding that up to 656 patients died from lethal doses of opioids and sedative drugs given without justification.
Most alarming is that that the concerns of nurses in Gosport were not heeded. When concerns are dismissed, efforts to encourage people to raise issues locally are undermined. It is therefore understandable, although regrettable, that some professionals feel they have no choice but to circumvent internal procedures and proceed directly to whistleblowing.
But while those concerns should have been acted on, consultants and others should have been aware of what was happening anyway. While individuals should not be held to account for system issues - as we have made clear in our statements about the Dr Bawa-Garba case - poor practice must be identified and standards upheld.
The RCP supports guidance from the GMC and others that healthcare professionals should take prompt action if they have concerns about patient care, dignity and safety. Wherever possible, concerns should first be raised with a manager or other appropriate person in the organisation and escalated appropriately.
It is therefore important that all organisations – whether a large teaching hospital or a small ‘cottage’ hospital - have effective speaking up arrangements in place. Boards should consider NHS Improvement’s guidance and use the self-review tool to identify areas for development and improve the effectiveness of their leadership and governance.
Opioids and syringe drivers
It will be to the detriment of patients receiving palliative care if the public remains concerned about the use of syringe drivers as a result of what happened in Gosport. The syringe drivers in use at the time were banned in 2015, and in June of this year the government ordered officials to make sure no unsafe devices of the kind were still in use.
Syringe drivers are used for delivering medicine when it cannot be administered orally. They are particularly important for controlling symptoms of patients receiving palliative care, and are used on a daily basis.
While issues do arise with medicines and medical devices - as recently highlighted by the Association of Palliative Medicine and the Medicines and Healthcare products Regulatory Agency (MHRA) with regard to the McKinley T3 ambulatory syringe pump - there are many initiatives in place to make sure the sorts of things that happened at Gosport Memorial Hospital are not repeated:
- Concerns about medicines and medical devices can and must be reported via the MHRA Yellow Card Scheme.
- Staff can raise a concern about NHS or adult social care via the Speak Up whistleblowing helpline, or by approaching their Freedom to Speak Up guardian.
- Staff can raise concerns about the care being provided by their employer with the Care Quality Commission (CQC). The CQC inspects hospitals using five key questions and makes data available, including via end of life care ratings maps.
- The GMC provides detailed guidance on how to raise concerns.
The role of effective teams
The fostering of effective teams will also reduce the likelihood of events such as those that took place in Gosport. Effective team-working reduces medical errors, increases patient safety and improves patient mortality rate.
Our guidance on Improving teams in healthcare aims to promote such high-functioning teams in the clinical setting. We are working with Health Education England to implement some of our recommendations, as well as creating further resources to assist team education and development of the inter-professional modern medical team.
Despite these efforts, we recognise that whistleblowing is sometimes necessary. As recommended by Sir Robert Francis in his Freedom to Speak Up review, in 2016 NHS Improvement and NHS England published a national integrated whistleblowing policy. They expect all NHS organisations in England to adopt it as a minimum standard. In September 2017, NHS Improvement launched the Whistleblowers’ Support Pilot Scheme for Secondary Care, and we hope a full scheme will be introduced soon.
The Public Interest Disclosure Act provides some protection to whistleblowers, but it is in need of reform. For example, it does not force employers to have a whistleblowing policy, it does not protect whistleblowers if the disclosure they make in good faith turns out to be incorrect, and it does not prevent employers from refusing to hire people known to have made a disclosure. The RCP therefore looks forward to working with the government to make sure people forced to disclose concerns in the public interest are fully protected.
Alternatives to hospital at the end of life
Finally, we must do more to ensure fewer people are in hospital towards the end of their life. That includes providing alternative services and planning outside hospitals, which is why we recently urged the government to invest long-term in social care.
We must continue to learn from deaths in hospital through the National Mortality Case Record Review Programme. And doctors should have conversations with patients much earlier after the diagnosis of a progressive or terminal condition, including frailty, as outlined in our report Talking about dying. A person centred approach, with care focused on what the older person and those close to them say are important, is critical.