Whistle blowing: a curse on ineffective organisations

Better management, not gagging, is the answer

This editorial, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1883902/pdf/bmj00102-0008.pdf which I wrote more than 30 years ago, came to my mind as I read “Time to Think” by Hannah Barnes, a book that tells the story and ultimate closure of the Gender Identity Development Service (GIDS) at the Tavistock Clinic. Multiple people went to management about problems in the service over several years, but the response was inadequate. Eventually the media covered the story, contributing to the demise of the service.

Since I wrote my piece there have been multiple scandals in the NHS, not least that in Mid Staffs. The story of internal worries being pushed to one side is constantly repeated . The managers and board members who fail to act are not, I’m sure, “bad people,” but the incentives within an organisation are for them to put what they think is good for the organisation first and play down the worries.

Over the years I have been contacted by many whistleblowers, and I always say to them two uncomfortable truths. Firstly, if you have seen what you think are serious failings or misconduct you must act, which will mean contacting the media if you are not taken seriously within the organisation. Secondly, all the evidence shows that whistleblowers are damaged, even when everything that they allege is found to be true.

Since I wrote the editorial the UK has passed legislation protecting whistleblowers, and most organisations, including within the NHS, have policies on whistleblowing. But the GIDS story shows how failures continue, and it remains true that whistleblowers suffer.

Competent managers have nothing to fear from whistle blowing. They have no reason to write clauses into employees’ contracts forbidding them to talk to the media. Indeed, such gagging clauses are highly likely to create the conflict that managers are trying to avoid. Rather than wasting time trying to gag staff, managers should be concentrating their energies on creating organisations where whistle blowing and gagging are both irrelevant.

One of the best analysed episodes of whistle blowing began in February 1991 when a doctor at the Christie Hospital went to the media about a woman with renal cell carcinoma who was denied treatment with interleukin 2-supposedly on grounds of cost.(1) Huge publicity resulted, and the woman was eventually given the drug. An inquiry conducted by Michael Orme, professor of clinical pharmacology in Liverpool, concluded, however, that the publicity was “almost totally counterproductive”: staff and patients lost confidence in the hospital; some patients were worried that they had not got the treatment they should have had on grounds of cost; and fund raising was made more difficult.2

The background to the story was that interleukin 2 had no product licence, and its usefulness in renal cell carcinoma was still unclear. The drug’s use had been considered by the hospital’s drug and therapeutics committee, but the oncologists, it emerged, had no faith in the committee. Most of Professor Orme’s recommendations related to improving the decision making mechanisms within the hospital. The episode showed that management by media is hopeless.

Most organisations eventually have to take tough decisions. Difficult choices, particularly over allocating resources, have long been part of working in the NHS. The choices will become tougher, and there may be more losers than winners. The fear that the losers will tell all to the media is what leads managers to reach for their gags. They make a mistake. Instead, they need to create organisations-be they hospitals or health authorities -where employees feel enough part of the decision making process not to need to blow their whistles.

You begin by letting everybody know what is going on. If the rhetoric is glossy brochures full of the word “quality” and the reality is elderly patients with pressure sores in back wards with peeling paint, then staff will become cynical and demotivated. They need to be convinced that the available resources are used fairly, efficiently, and effectively. The surest way to convince them is to involve them in decision making. The decisions that are made must be clearly and honestly communicated. Staff must have a chance to come back on poor decisions, and managers should not be afraid to reverse decisions that are wrong.

If staff understand the true circumstances of the organisation and feel that their views have been given serious attention then they will accept tough decisions. But if seemingly arbitrary decisions appear from nowhere then staff will be unhappy and one or two will contact the press. Managers who try to create a climate of fear will neither stop whistle blowing nor run an effective health service. Managers also have a broader responsibility to their local communities, and being honest with the local media is no less important than being honest to staff. A long term relationship with local journalists that includes discussing difficulties will produce much richer returns than a cloud of obfuscation and a brisk “No comment” after somebody has blown the whistle. Letting arguments be conducted in public is no bad thing in a public service and may also help to make the public aware of the complexities of many of the issues.

Every employee should, however, have the right to blow the whistle when all else fails. There sometimes comes a point when doctors and others must draw public attention to iniquities. Some of what has been happening in Britain’s special hospitals and prisons provides good examples ofwhere whistle blowing was needed. In circumstances where the public gain from whistleblowing is substantial the law should offer protection-as in the United States. (3)

Although we need legal reform, the main message is that managers worried about whistle blowing should concentrate their energies on improving the management in their institutions rather than on trying to gag staff. Similarly, staff should insist first on good management and only secondly on the right to blow the whistle-because whistle blowing usually achieves little.

1 Walker A. Interleukin 2 denied on grounds of cost. BMJ 1991;302:372-3.

2 Smith R. Christie Hospital reports on interleukin 2 controversy. BMJ 1991;302:1041.

3 Greene D, Cooper J. Whistle blowers. BMJ 1992;305: 13434.