29. The Whistleblowers
29.1. Some insight into the complex nature of bringing allegations about bullying and harassment to the fore in NHSH can be gleaned from a consideration of the actings of, and responses to, the whistleblowing event of September 2018.
29.2. On 26th September 2018, a letter to The Herald was published in these terms:
"The culture of bullying at NHS Highland must change
AS senior clinicians at NHS Highland, we wish to make clear our serious concerns around the long-standing bullying culture that exists within the health board where we work.
It is our belief that, for at least a decade, this practice of suppressing criticism, which emanates from the very top of the organisation, has led to a culture of fear and intimidation. This has had a serious detrimental effect on staff at all levels of NHS Highland, but equally importantly, has had an adverse effect on the quality of care we are able to provide for patients.
With the recent publication of a report on governance at NHS Highland, and with the departure of the chief executive announced and now imminent, we feel now is the time to speak out and ensure effective action can be taken.
Indeed these recent events have seen more and more clinicians share with us their concerns on the impact this culture has had on them, the organisation and ultimately patients. While the majority are still fearful of speaking about these publicly, there have now been discussions at various forums for clinicians and we feel that, on behalf of the whole clinical workforce, it is vital this bullying culture is exposed and finally now dealt with.
Anyone working in our NHS needs to feel supported and able to speak out on issues as serious as this. Yet at NHS Highland, our belief is that some staff have not been able to raise concerns around bullying, or indeed some issues concerning patient care, due to the culture of bullying and fear that has pervaded across the organisation.
This is the moment that this has to change. We urgently need fresh leadership at NHS Highland to take the brave and extensive actions required to ensure NHS Highland is a safe positive place to work, based on a culture of openness, transparency, learning and honesty. That is the only way that we will be able to guarantee a safe environment, delivering high quality care for patients for the future."
29.3. The letter was signed by Dr Eileen Anderson, Chair Area Medical Committee; Dr Lorien Cameron-Ross, Vice Chair, Area Medical Committee; Dr Jonathan Ball, Chair, (GP Sub Committee and Highland Local Medical Committee Chair) and Dr Iain Kennedy (Professional Secretary, GP Sub Committee & Medical Secretary Highland Local Medical Committee), c/o Riverside Medical Practice, Ness Walk, Inverness.
29.4. Another doctor associated with the named whistleblowers explained:
"After much discussion, review and soul-searching, [we] felt we were left with no option but to make a public disclosure in the interests of patient and staff safety and to try and exert pressure on NHSH to take these allegations seriously."
29.5. This was the culmination of a number of attempts to persuade the Board to take seriously allegations of a bullying culture using the committee structures which had, so far as the signatories were concerned, failed. To the whistleblowers, the Board and others in senior management seemed closed to suggestions that there were deep-seated problems.
29.6. Many people who do not recognise a bullying culture are understandably unhappy with the way in which matters became public (and the damage that has caused). However, I am satisfied that those involved genuinely felt they had no option but to do so and that this was the only way to address matters, even with the costs which arose. That a number of senior professionals, from a variety of backgrounds and at considerable risk to themselves and their careers, came to that conclusion is itself an eloquent demonstration of how serious matters seemed to them to be and how inadequately it appeared to them that the Board was coping with the many concerns being expressed over a significant period of time.
29.7. As one whistleblower remarked:
"We have been accused of being troublesome malcontents. It would have been far easier to just continue doing the day job rather than highlighting the bullying culture but that would have been the wrong path to take."
29.8. As this Report has made clear, many of the concerns expressed in the letter have a sound basis. Many others within NHSH, with no association with the whistleblowers, have now come forward with their own stories. People are coming forward now because it appears possible to do so and they feel liberated because others are doing so. At the end of the day, my findings are not hugely influenced by the whistleblowers' allegations; they were ultimately a catalyst for others to come forward.
29.9. It has to be recognised that the effect of the whistleblowers' action is significant and, for many, damaging in its own way. Many people have been hurt and feel misrepresented and offended by what has appeared to them to be a brutal step. Individual reputations in a close community have been adversely affected. The assertion that there is an organisation-wide culture of bullying has been very distressing for those who do not have that experience and is perceived to be damaging reputationally and for patient confidence.
29.10. One respondent summed up the concerns of those shocked by the letter in this way:
"… we were deeply shocked to learn of allegations. We knew nothing about these concerns. There had been absolutely no forewarning that such a serious release was to be made to the press, at national level. You will I hope have learned that this shock was widespread across essentially the entire senior clinical workforce.
29.11. It is said that the group's decision to go to the press, the circumstances in which that decision was made, the "false claims" that the whistleblowers were speaking on "behalf of consultants and GPs", and the subsequent "lurid, extreme and even sinister" allegations that were made (for example of "cruelty spun into the thread of NHS Highland" and the need for "deep cleansing"), caused offence, anger, distress and a profound sense of bewilderment.
29.12. A nursing manager told me:
"From a professional nursing and midwifery perspective, it has felt disappointing that our medical colleagues have chosen to go down this way. We work in the highlands and that is a small community and we uphold the organisation as that instils public confidence. The allegations in the press have been very challenging for staff who have to field questions from the public. We have been powerless against the allegations. The actions of our medics have been divisive."
29.13. A member of the leadership team said: "It has been designed to create maximum impact. Left us with zero reputation, no name. I find that upsetting. This is my organisation. This is my area. My people. I find it particularly offensive."
29.14. There seems little doubt that certain assertions were too broad and without the support claimed: in particular the expressions "on behalf of the whole clinical workforce" and "the culture of bullying and fear that has pervaded across the organisation" imply a universality that goes beyond what this report records. It also implies that all clinicians are victims whereas it is clear that some clinicians are also viewed as perpetrators. I recall Sir Robert Francis' comments on the difficulty of making an organisation-wide assertion of bullying. And it appears that other aspects, such as the use of social media to wage a campaign, could have been conducted more thoughtfully and tactfully.
29.15. Regarding social media, one respondent expressed concern about "a personal attack as opposed to a reasoned argument in regard to the topic matter, given this is a public platform seen by many and not the few." There has been real concern about the use of expressions already mentioned such as "a thread of cruelty has purposefully been spun throughout NHS Highland"; "This thread of cruelty is now marbled into the culture of the organisation. It is so deeply ingrained that only deep cleansing will cure it." As one observer said: "'Deep cleansing' is an appalling phrase and has incredibly revolting connotations in a historical context."
29.16. I accept that the whistleblowers themselves did not anticipate the reaction which occurred and that they have themselves suffered distress also: "…whistleblowing has been.. difficult, soul searching, time consuming and unpopular," one commented. "It has been brutal and certain relationships are unlikely to recover." "I have been cornered on regular basis," said another. They are concerned about victimisation in the future.
29.17. All of this reinforces the need to establish a culture where this sort of action is not necessary and, if it is, where it can be done constructively and safely. Of course, none of this would have been necessary or would have developed as it did had the Board and management appeared to be open to a full exploration of the issues. As one whistleblower put it: "If they had said 'this sounds terrible, what can we do?' That's all it would have taken. Or 'Right, let's work together and sort this'."
Board and Management Reaction
29.18. It also appears that, as noted earlier, the initial response by some at board and management level to the whistleblowers' actions was not appropriate and signalled lack of full understanding and insight at best. It was perhaps unfortunate that the response to the letter in some quarters appeared to be to try to undermine the individual whistleblowers rather than to address the issues.
29.19. Certainly, if the reaction by some in management and on the Board was to downplay the concerns because of how and by whom they were expressed, that seems to have been a misjudgement, as it distracted the Board and others from appreciating and acknowledging how serious these concerns were.
29.20. It has been put to me that the NHSH Board publicity machinery moved to try to discredit and marginalise the signatories as well as deny the allegations, without any attempt to investigate them seriously. This observation sums up what some people have told me:
"Staffside Unions issued a statement saying they did not recognise a culture of bullying or have an awareness of bullying in NHSH. The Director of Occupational Health also issued a statement saying they were unaware of a bullying problem. … No attempt was made to take the allegations seriously but rather all efforts were directed at discrediting and marginalising the whistle blowers. …Instead of open minded listening given the potential for patient safety issues arising from the allegations of bullying, they chose to deny without evidence and attempt to undermine, discredit and marginalise the whistle blowers. Their actions and those of the Board have shown that being a whistle blower in NHSH is unwanted and unprotected. Energies are directed at discrediting allegations and concerns rather than welcoming them and trying to genuinely understand the issues and work collaboratively with those raising them in order to correct matters and improve the service."
29.21. Hopefully, with this experience and this report, NHSH will be able to take steps to ensure that there would be a different approach in the future. I comment further on this below.
Concerns about the Whistleblowers' Behaviour
29.22. In fairness and for balance, I am bound to record that there is some concern from a number of sources about the general behaviour of some of the whistleblowers. Social media activity can be unpleasant. A number of people say they have felt intimidated and bullied into conforming with the view that bullying has occurred.
"This has been a theme throughout this affair, where those who have raised allegations resent having them called allegations, resent the notion of other people having differing opinions about the situation."
29.23. It goes further for some:
"What we have felt and seen since the allegations of a bullying culture were made… is that fear has pervaded the organisation. This is a fear of those instigating the allegations and fear of doing anything which might incite an adverse response from this group."
29.24. In addition to these concerns about whistleblowing itself, one of the more difficult aspects of my review has been acknowledging that a number of respondents have commented on the manner of one or more of the whistleblowers more generally.
29.25. While it has been represented that this matter should not be mentioned in this report at all, I do so as it reinforces the complex, ambiguous and paradoxical nature of this situation. Ironically, this may be one of the reasons for some of the resistance the whistleblowers experienced. To be a whistleblower is not an easy thing. It does not seem right, however, that whistleblowing can provide automatic protection against allegations of inappropriate behaviour. In the future, it should not be necessary for whistleblowers to make themselves publicly known and this issue would not arise in this way.
29.26. Against this background, going forward, it seems essential to rebuild trust and confidence between and with some of the key people. This is a major and important task.
29.27. As one board member observed:
"… the one thing that worries me is the Board and the original 4. I worry about our relationship with those 4 doctors. Trying to renegotiate the primary care contract that has been agreed nationally and they all play a pivotal part. Somehow, we need to get back into the room with these people. I'm anxious about that. There's no doubt we've lost our trust with each other."
29.28. The whistleblowers may find it difficult but I believe that it will be important for them to show leadership in a new and open approach. They can demonstrate the change in behaviour which their initiative has sought. And those who have been angered by the whistleblowers' approach will need to build bridges from their side of the story. There is no other way. There is a rebuilding job to be done. It needs to start with those who have enabled this to come to the fore. I suggest that mediation could provide a way to achieve this.
An Appropriate Whistleblowing Facility
29.29. According to the All Party Parliamentary Group on Whistleblowing, a "Whistleblower" is defined as "a person who exposes any kind of information or activity that is deemed illegal, unethical, or not correct within an organisation that is either private or public. These individuals are vulnerable to retaliation for their actions and whilst there are laws in place purposed to protect them, sometimes the laws are not adequate or effective in their practical application."
29.30. One former consultant who resigned as a result of the way his concerns about patient care were dealt with told me that:
"NHS Highland was not willing to acknowledge that there had been shortcomings in the care provided to patients. They avoided addressing this issue by making a scapegoat of the whistleblower. Patients have been failed by NHS Highland by their unwillingness to investigate cases of neglect. The opportunity to improve services and prevent further instances of neglect has been lost. I feel that there needs to be a change in the way that managers of the organisation are held accountable for their behaviour towards patients and the staff of the organisation. Whistleblowers need to be able to raise concerns in the knowledge that they will be taken seriously, the concerns appropriately investigated and that they will not become the scapegoats. This will only happen if there is an independent body to which the concerns can be reported. It is not appropriate for Health Boards to investigate themselves."
29.31. I cannot comment on the accuracy of the statement about neglect but sense that the general point about the inadequacy of whistleblowing protection is an important one. It seems that whistleblowing provision which covers only patient safety issues is also not sufficient.
29.32. I heard from a number of further sources that the existing system did not seem to be effective:
"Talking to the Whistleblowing champion didn't help." "First, I went to the Whistleblower. I said I wanted to discuss it. I was told "that's not what we do". The Whistleblower was in London. …. I said: "if you get lots of calls from one organisation, who do you report it to?" and he said "nobody". He said they were a charity."
29.33. Others shared similar experiences:
"I whistleblew once and wouldn't do it again. There's a woman in NHSH who will not come and speak with you because she cannot bear to dig it up again. She was made to feel that her concerns were not valid. She's an alcoholic now."
29.34. I understand that a non-executive director has a whistleblowing champion role. My impression is that, despite that director's efforts, this has not functioned as effectively as it needs to.
29.35. I address proposals for better provision for whistleblowing later in this report.