The Infected Blood Inquiry report has laid bare how thousands of people died unnecessarily through receiving infected blood that was supposed to save their lives, and how both the NHS and the Government frustrated justice for decades.
The Inquiry found no conspiracy to mislead victims and their families, but rather successive governments were prioritising reputational management over telling the truth. The cover up instead ‘was more subtle, more pervasive and more chilling in its implications. To save face and to save expense there has been a hiding of much of the truth.’
In practice the NHS ‘closed ranks’ rather than investigate and apologise for patient deaths, and the Government- civil servants and Ministers- pushed a line that the best treatment was being provided at the time, which was not based on evidence: either they knew this was untrue or were not curious enough to ask enough questions to dig at the truth.
The Inquiry places whistleblowing at the centre of its programme of change for the NHS, creating a culture which learns from mistakes and holds those in power to account.
Whistleblowing culture has not changed in the NHS
The Inquiry backs the well-established view that whistleblowing is vital to uncover patient safety, but often those who speak up are not welcome, and their concerns not listened to. The report is clear that a change is needed, ‘what most needs to be valued is ensuring that reporting near misses (“sentinel events”) as well as harmful acts is prized, so that we may learn how to avoid them next time a similar situation occurs.’
The Inquiry goes a step further stating that changes to the law, policy and the creation of new organisations have not changed the culture:
An expectation that ‘near misses’ are reported
The first plank of the Inquiry’s plan for reform is to create an expectation on NHS staff to raise ‘near misses’ in patient safety. Drawing examples from aviation, mining, and the handling of hazardous chemicals the Inquiry concludes the following:
This is a laudable ambition – and we agree that safety is the responsibility of all. While the experience of Boeing demonstrates that the just culture in aviation is not infallible, there is certainly a very different expectation there from the NHS – individuals should not be blamed for “owning up” to something going wrong. However, the report goes a step further and suggests that whistleblowing should be an obligation and those who do not speak up should be blamed for silence. In a culture that simply is not willing to listen to concerns, then an obligation to speak up means staff are being asked to navigate between a rock and a hard place: speak up and end your career or be blamed for silence.
It is vital that this change goes together with an expectation that leaders in the NHS will listen.
Holding senior NHS leaders to account
The second plank to the Inquiry’s plan is to make senior leaders ‘accountable for how the culture operates in their part of the system, and for the way in which it involves patients.’ Connected to this is to extend the duty of candour- a legal duty on the organisation to be open and honest to patients about mistakes- introducing a new obligation on senior leaders to be candid and to listen to reports raised. The Inquiry proposes regular audit to ensure changes have been implemented from the learning from admitted mistakes. These changes the Inquiry see as vital to creating a more open culture.
These changes are crucial: too often in the NHS there is an expectation on staff – particularly those with professional duties – to raise concerns but very few requirements on the organisation or senior managers in how they should respond. This gap is not limited to the NHS: the current legal protection for whistleblowers, found in the Employment Rights Act 1996, gives a whistleblower employment rights if they are dismissed, forced out or victimised by their employer for blowing the whistle. But the law is silent on what the employer should do to respond to the concerns raised.
The Inquiry suggests that “it should be considered a serious disciplinary matter on the part of the person in authority to whom a report of a sentinel event is reported not to consider it adequately”. We agree – but the Government did not accept a similar recommendation of the Kark Review five years ago which suggested that treating a whistleblower badly should be seen as serious misconduct, enough to lead to the dismissal or barring of a leader from working in the NHS.
Creation of the new patient safety management system
The final plank of the reform is the creation of patient safety and risk management system, which the Inquiry notes doesn’t exist in the NHS but does in industries such as aviation, mining etc. This can be achieved by creating a single body in the NHS with a focus on patient safety and creating risk management system to manage these risks. Building the argument the Inquiry examined the status quo through several past reports from the Mid Staffordshire Hospital Inquiry to the recent Ockendon Review and came to this conclusion:
It can be daunting for whistleblowers to raise concerns given the number of organisations that exist in and around the NHS, so a general principle that a single body could make the landscape a lot easier to navigate. In Scotland there is a single Independent National Whistleblowing Office – that sets standards and is the final recipient of concerns from the NHS. What we don’t know at this point is whether any new body would take concerns from whistleblowers, we will push for them to do so, but we will need to see the detail first.
Conclusion
The overall assessment from the Inquiry is blunt. The NHS’s attitude to whistleblowing is still one of indifference to the concerns raised, and aggression to those that speak up, and senior managers are not held to account when this is their organisation’s response. The Inquiry makes a compelling case to create a culture that is much more focused on patient safety, overseen by a single body, with an expectation on staff to raise concerns backed by a legal duty on senior managers to create a system where the concerns are acted on.
In our view only a system that has both elements – where staff are expected to raise concerns and with a legal requirement that senior managers are responsible for how the concerns are addressed and the culture in which they are raised – will be effective.