Defamatory comments about any of these whistleblowers will from now be on reported to the Police. The Socialist Health Association is keeping a careful record of the IP addresses of these comments which have been made thus far.

Look at what happened in the biggest financial scandal ever to hit the United States. Driven by profit, company directors in ENRON turned a complete blind-eye to criminal fraudulent activity. They had a healthy relationship with the US government, which they wanted to impress. The shock waves from the ENRON scandal are felt still all around the world, and in the end the US had to legislate the Sarbanes-Oxley Act which does indeed contain provisions on ‘whistleblowing’. The NHS situation is quite different, in that there is much wonderful, safe, work done by brilliant clinicians. Not all managers deserve their demonisation by any stretch of the imagination. The report by Prof Don Berwick is the latest in the long line of reports on Mid Staffs, but this one has yet further emphasised the critical need for patient engagement. Berwick’s committee specifically say that this should not simply be seen as a ‘seen-to-be-engaging’ sop for patients – it is real involvement by patients in guiding policy. For those who wish to ‘cure’ the NHS, there is a real sense that patients are not being listened to, and at worst mistakes are being ‘covered up’. I feel there is now emerging a dual duty of the NHS – one of safety for the patient, and one of safety for its staff. I have long urged the NHS to deal with the mental welfare of its workforce, and to acknowledge the soul-destroying effects of making to work in an environment of fewer staff for greater ‘productivity’. But the two are linked.  That’s why the “Nursing Times Speak Out Safely” [@NursingTimesSOS] campaign has a very important part to play now.

[They] want:

1. The government to introduce a statutory duty of candour compelling health professionals and managers to be open about care failings
2. Trusts to add specific protection for staff raising concerns to their whistleblowing policies
3. The government to undertake a wholesale review of the Public Interest Disclosure Act, to ensure whistleblowers are fully protected.

It is all too easy to denigrate the entire workforce of the NHS including frontline staff and managers, but, across a number of different sectors, toxic cultures have bred a hostile, pessimistic workforce, driven away top talent and prevented organisations from reaching their full potential. While toxic work cultures are the end result of many factors, poor leadership has a big part to play. The fuel for toxic work environments is typically a combination of conflict, ego, gossip, and career ladder climbing, A banking consultant recently advised that establishing a solid operating culture starts at the very top of the organisation. He advised that, for banks, values need to be integrated with shared beliefs and a powerful business mission into an energising narrative that uniquely positions the bank for growth and profitability. The corollary for the NHS is a culture driven by patient safety not financial profitability (though increasingly many decisions about the NHS are being taken from a financial not clinical perspective.) If any organisational culture is managed incorrectly or (worse) left un-managed, it can become dysfunctional or toxic. In these situations the organisational culture of an organisation can become a liability, not an asset. It can even lead to the outright failure of that organisation.

“Speaking out safely” is a much less dramatic term than “whistleblowing“, but a whistleblower (whistle-blower or whistle blower)] is simply a person who exposes misconduct, alleged dishonest or illegal activity occurring in an organisation. The alleged misconduct may be classified in many ways; for example, a violation of a law, rule, regulation and/or a direct threat to public interest, such as fraud, health and safety violations, and corruption. Whistleblowers may make their allegations internally (for example, to other people within the accused organisation) or externally (to regulators, law enforcement agencies, to the media or to groups concerned with the issues). The term whistle-blower itself comes from the whistle a referee uses to indicate an illegal or foul play. Most whistleblowers are internal whistleblowers, who report misconduct on a fellow employee or superior within their organisation.

There is no doubt that whistleblowers have suffered in the past, and continue to do so, and that’s why the proof of the Berwick pudding is in the eating. The treatment of Dr. David Drew [@NHSWhistleblowr], a respected paediatrician with an unblemished 37-year career in the NHS, who was sacked in December 2010 for “gross misconduct and insubordination”, is shocking. Dr. Drew is a practising Christian, though far from a fundamentalist: indeed, he describes himself as “a Christian with questions” who has “coexisted peacefully with colleagues of all faiths and none for many years”. He told a tribunal that, when he was a senior paediatric consultant at Walsall Manor Hospital, he had emailed a well-known prayer by St. Ignatius Loyola, “To Give and Not to Count the Cost”, as an incentive to his staff. Later, when ordered to “refrain from using religious references in his professional communications, verbal or written”, Dr Drew asked the trust to provide examples of when such behaviour had been problematic: the only solid thing it came up with, he said, was the prayer. Dr. Drew has described the culture of the health service as one of “fear and oppression” that is “driven by the top”.

Gary Walker [@modernleader] has also spoken out against his horrific situation. Lawyers representing the United Lincolnshire Hospitals NHS Trust, where he used to be chief executive, had written to him threatening that if he went ahead with the interview, he would be in breach of a compromise agreement and that he might be forced to repay the settlement he had received as well as the Trust’s legal costs. The former head of an NHS trust last week also described the culture of the health service as one of “fear and oppression” that is “driven by the top”. Mr. Walker had been sacked the previous year on grounds of gross professional misconduct, the reason given that he swore in meetings. However, Gary Walker alleges that the reason behind his departure was far more complex – that because he made the decision to ignore government targets for non-emergency operations as there were more urgent cases to attend to, he was cornered into resigning from his post.

Patient safety should be the ever-present concern of every person working working under the NHS’ name. Berwick emphasised that the quality of patient care should come before all other considerations in the leadership and conduct of the NHS, and patient safety is the keystone dimension of quality. Berwick further argued that the most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end. Collaborative learning through safety and quality improvement networks can be extremely effective and should be encouraged across the NHS. Critical to understanding this approach is that the most effective networks tend to be those which are owned by their members, who determine priorities for their own learning. However, back to reality. According to Roger Kline, one quarter of the staff in the largest employer in Europe report that they were bullied at some point in the previous 12 months. The rate of reported bullying has doubled in just four years. This summer, the British Medical Association annual conference heard how a proper system of regulation needed to be introduced for managers so they could be held to account.

In Summer 2009, psychologists at the Occupational Psychology Centre (OPC) at the Open University undertook a safety culture review of 30 PCTs. Each PCT was questioned about how their NHS trust measured up against nine key building blocks that make up a safe culture. One of those safety culture building blocks was being a learning organisation. The OPC specialise in safety with particular emphasis within the healthcare and transportation sector. Their work has shown that safety critical organisations that embrace and work at being a learning organisation are more likely to have a strong safety culture. A NHS organisation that has a learning culture learns from its mistakes. It has a problem solving approach to safety issues, is responsive to change and adapts to change effectively overtime improving its systems, processes and procedures. It is argued that a learning organisation promotes and lives out a ‘just’ culture. Many frontline clinical staff will readily report the real sense of ‘firefighting’ which they have in any acute shift in the emergency room, and this will be the case even in the most well resourced departments in England. However, it is felt that employees must feel safe to raise safety issues in an open manner including those issues that they are personally responsible for. Their raised issues are then acted upon. This chimes very well with the ‘Nursing Times Speak Out Safely Campaign’.Some of the employees in organisations which have worked with the OPC inform the OPC hat they have a “blame culture” in their organisation. As a result they are reluctant or even worse are afraid to raise safety issues. This can be further toxic to any NHS entity in terms of its safety culture and safety performance. If these safety issues are not dealt with then they can be precursors to more serious safety critical safety incidents and accidents. One often hears of NHS staff saying that, ‘It was an accident waiting to happen. We have raised the issue before but no-one listens’.

Constructive steps can be taken against toxic cultures though.The first step is to identify the major problems by gathering information, This is easier said than done, as perpetuators of toxic environments are less than forthcoming with feedback. This makes it very difficult for managers to discover the root causes of problems and also to deliver solutions to improve the workplace, yet an anonymous employee survey can go a long way to uncovering what people really think about the workplace. However, it’s also really important for the leadership team to identify an ideal culture and values for their business, so that they can use that shared vision as their compass to guide them towards a more positive culture. Asking the question “What does an ideal day look like?” and getting very specific about capturing that ideal culture will be really useful to the leadership team in the coming months (and years) as the organisation begins to change its direction.Once an understanding of the major issues has been formulated, the HR team can develop the action plan.  Ultimately, guiding an organisation through cultural change is a long-term strategy, and it takes a “do what it takes” mentality from all stakeholders to really turn a corner. If HR communicates the strategy positively, honestly and continuously many of the team will jump on board very enthusiastically.

According to the Nursing Times, speaking after the publication of Prof. Don Berwick report into NHS patient safety, Ms. Cumming, the Chief Nursing Officer, said it was important trusts had the appropriate staffing level on their wards but called on staff to raise concerns where it was not.She said staffing would be monitored by the Care Quality Commissions new chief hospital inspector Sir Mike Richards. As previously reported by Nursing Times, staffing levels will not be used routinely to trigger inspections but CQC inspectors will check them during visits.She further highlighted the importance of the Speak Out Safely campaign, which is calling for nurses to be able to raise legitimate concerns without fear of reprisal or blame. So, bit-by-bit the pieces of jigsaw are falling into place. There is no doubt that the ‘Public Interest Disclosure Act’ has been a damp squib in terms of protecting whistleblowers’ interests. Likewise, it appears the NHS has gone “power mad” in getting out the cheque books to pay for compromise and confidentiality agreements, rather than listening to the views of the stakeholders.

But the silence of lambs is perhaps coming to an end at last. By this I mean, the lambs are not going to quit bleating. Quite the reverse. Instead, “the quiet man is here to stay, and he’s turning up the volume”, as someone quite famous used to say… Many would, further, add this does just not apply to the whistleblowers and staff who have been ‘silenced'; but the views of some patients have been massively ignored too. And on top of that a complaints system which doesn’t seem to work, and an overly complex regulatory system which appears to be struggling. A briefest look at all the NHS reconfiguration consultations with Trust special administrators might confirm problems with the ‘patient engagement’ process, but hopefully the NHS will move ‘excelsior’ before the law intervenes.