NHS Hot Topic: NHS Whistleblowing

Prominent NHS ‘whistle blowers’ have been in the news recently, from doctors who raised concerns in the Lucy Letby case to calls for better protection for whistle blowers in the NHS. These cases can be complex and, as a medical school applicant, it can be difficult to make sense of these stories and how they might relate to a medical school application.

But understanding whistleblowing is important to answer interview questions and to understand what your ethical responsibilities will be as a doctor. We’ve put together everything you need to know about whistleblowing to help you prepare for your medical school interviews and future career!

Understanding Whistleblowing in Healthcare

“Whistleblowing” essentially just means raising concerns. NHS whistleblowers typically raise concerns around unsafe staffing levels, for example, or systems that do not work and may harm patients, like unsafe training.

Whistleblowing can also be used to raise concerns about a particular staff member, such as if they come into work drunk or bully their colleagues. Whistleblowing usually refers to taking concerns to an official channel, rather than discussing with colleagues directly.

It is also important to challenge colleagues and prevent mistakes on the ground, though, especially if there is an immediate risk of harm. Whistleblowing is very important to prevent harm to patients and staff: if no one speaks up, people will keep being harmed.

However, whistleblowing can also be challenging: it requires one person to stand up, often to colleagues or managers who have a lot of power over them. Whistleblowers should not face consequences in the workplace, but many of them have in the NHS. Ultimately, though, doctors have a GMC duty to blow the whistle to prevent harms to staff and patients.

Doctors will have workplace raising concerns guidelines to follow which vary between hospitals. In interviews, you don’t need to know exact processes for raising concerns. The key thing is to recognise that you would need to raise concerns and that there are official channels for you to do so.

It’s important to remember that medical students also have a duty to speak up if they see patients or staff being harmed! For example, many interview scenarios put you in the position of a medical student noticing a clinical error.

The NHS Whistleblowing Policy: Freedom to Speak Up

NHS England runs a policy called ‘Freedom to Speak Up’ which is designed to support people working in healthcare to raise concerns. As well as offering a lot of information on how to raise concerns, they also implement a Freedom to Speak Up Guardian in NHS workplaces, who can support staff on the ground to raise concerns.

Having official channels to raise concerns is important because it aims to prevent concerns being locally suppressed. Staff who want to raise concerns can speak to an independent Freedom to Speak Up Guardian and can be anonymous if they want to. Ideally, raising concerns will be considered a ‘protected disclosure’ which means staff should be protected from repercussions from speaking up.

Ethical Dilemmas and Barriers in Whistleblowing

On a personal level, whistleblowing can be challenging as someone will consider the risk to them of blowing the whistle, such as being fired from their job or even having their ability to practice medicine challenged. However, on an ethical level, whistleblowing is almost always the right thing to do. If you consider the four pillars of medical ethics, whistleblowing is beneficent and non-maleficent, as it aims to protect patients.

It potentially protects patient autonomy, as they are able to make informed decisions knowing about safety concerns. It also prevents patients receiving a worse standard of care in some hospitals, which addresses the pillar of justice. Because of this, doctors are understood to have an obligation to blow the whistle according to the GMC, although it can still take a lot of courage to live up to the ethical responsibilities required of a doctor.

Whistleblowing Mechanisms within the NHS

Within the NHS, there are several potential ways to raise concerns, and it will be down to the individual staff member to decide which one to follow. We’ve summarised some of the key ones below:

• Speaking directly to people involved: letting other people know about your concerns, if you feel comfortable, can be one way to address them on a local level.
• Speaking to your supervisor or line manager: they can escalate concerns for you.
• Speaking to the local Freedom to Speak Up Guardian: they can support you to find the best way to raise your concerns.
• Speaking to an external organisation, either the Care Quality Commission for hospitals or NHS England for other healthcare services

Whistleblowing in the NHS: Case Examples

Some case examples where NHS whistle blowers were ignored, failing to prevent serious harm include:

• The Lucy Letby case: senior doctors repeatedly raised concerns about neonatal deaths which were suppressed by the hospital trust 
• The Harold Shipman case: concerns were repeatedly raised by Shipman’s colleagues but were not investigated fully by police
• The Francis Reports which exposed poor patient care at Mid-Staffordshire hospital after a patient pressure group raised concerns in the media and to politicians 

Sadly, these cases all too often provide negative examples where whistle blowers were ignored or silenced, allowing harm to continue. Of course, situations where harms are quickly identified and stopped don’t tend to become major cases. These cases highlight the importance of listening to and supporting whistle blowers.

Preparing for Whistleblowing Questions in Interviews

Medical schools have generally moved away from asking case-specific questions, like “what do you understand about the Lucy Letby case?” as they can be unfair to some applicants. Of course, you should always read the interview information you’ve been sent carefully as it will have key information on what you will be asked about.

More general questions about what you have read in the media recently about healthcare are more common and can be a great opportunity to drop in all your knowledge about a whistleblowing case. 

You also might get asked to discuss an ethical scenario which involves whistleblowing. One example might be:

You are a work experience student in a surgical ward round. The surgeon is requesting a penicillin prescription. You talked to the patient earlier and they mentioned they are allergic to penicillin – what should you do?

Our top tips for responding to this scenario would be:

• Recognise your duty to speak up: even if you are very junior, you should act to prevent potential harm to a patient
• Know what you don’t know: at the same time, you may not understand the clinical reasoning. A good response might be to say that you would politely ask the surgeon to explain his reasoning when you thought the patient was allergic to penicillin – this raises the issue in a non-confrontational way.
• Consider multiple perspectives and show you understand why speaking out can be difficult: the interviewers aren’t just looking for the ‘right’ answer, they also want to see balance and respect
• Show an understanding of the underlying ethical principles: can you show where there is ethical conflict, or explain the case in terms of ethical principles?