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Whistleblowing and the Laws of Physics; or, what would Joseph Heller have made of the NHS?

September 15, 2013

On Ward 22, a concern for patient safety in the face of staffing shortages that were real and immediate was a sign that you were compliant with the Guidance on Escalating Concerns. You knew you were understaffed, you asked for more staff. All you had to do was ask. If you didn’t ask, you were not compliant with the Guidance and could be disciplined; on the other hand – because there was never any hope of getting extra staff – if you did ask, you were clearly crazy and your colleagues would be justified in reporting you because the Guidance stated they had a duty to take action in any situation where care could be compromised because of a nurse’s state of health. Bel was moved very deeply by the absolute simplicity of Ward 22’s management policy, and let out a respectful whistle. “That’s some ward, that Ward 22” she observed.
If Joseph Heller were alive today and living in the UK, I think he might be writing about the NHS. Its internal contradictions would have attracted him – on the one hand, an organisation committed to the delivery of a first-class service; on the other, an organisation desperate to save money. In the lonely no-man’s-land between the two: the whistleblower – a type of employee now much in the limelight. His or her particular power lies in their potential to disturb the balance between these conflicting discourses which usually co-exist peacefully – if uneasily – within all large, publicly-funded organisations. For this reason, the whistleblower is greatly feared.
Quoting the American Merriam-Webb Dictionary, Wikipedia defines Catch 22 as ‘a problematic situation for which the only solution is denied by a circumstance inherent in the problem or by a rule’. Applied to the worker, what this produces is a kind of entropy, an inability to do anything except go with the flow. From the employer’s point of view, this is helpful because it builds stability and discourages extreme actions. There’s a sense in which the NHS couldn’t function unless those who work for it find a way of accommodating within themselves the double-think at the service’s heart.
When you look at at it like this, it’s not really surprising that recent research by the charity Public Concern at Work suggests that the most likely reaction whistleblowers experience from management when they voice their concerns is silence. According to their report Whistleblowing: the Inside Story ‘60% of those who called our advice line did not report any response from management (either negative or positive)’. Managers do not like to admit to those lower down the food chain that they have the power to disrupt. By discouraging this belief, they promote the ‘steady state’ which they believe is ultimately beneficial to everyone.
In this context, at least one part of the NMC’s updated Raising Concerns guidance for Nurses and Midwives represents a very daring step. In the ‘Role of Clinical Leaders’ section (page 16), managers are enjoined to ‘keep the employee who raised the concern up to date with what’s happening. This will give them and others confidence in the system’ (para 36.5). It will be interesting to see how strictly this guidance is adhered to; will a mumbled “yeah, we’re still looking into it” as your manager rushes past you in the corridor be deemed sufficient?; will managers who are not on the register feel that they need to be held to NMC guidance at all?
In a recent BBC Radio 4 programme Whistleblowers: Saints or Stirrers? David Morgan, a consultant psychotherapist, offered a definition of a whistleblower. He said a whistleblower is a person who is unusual in that they place moral security above personal security. In a public-service organisation like the NHS, the idea that excessive morality is a  problem may be surprising, but it becomes so if it disrupts equilibrium .
Dr Morgan also described the effects of being a whistleblower as they are experienced by those who have been brave enough to go through with it. He talked about loneliness and rejection, sometimes even by the whistleblower’s own family. He said “most [of them] tend to be isolated and managing it fairly alone” and concluded “if you know someone who’s going to blow the whistle, encourage them not to…or help them to understand what a risk they are taking”.
Fear of reprisals and fear of isolation are almost certainly the biggest disincentives to whistleblowing. The major weakness of the NMC guidance is that it can’t force Trusts to do anything to support whistleblowers and help them to deal with the unenviable situation in which they might find themselves. Compared with the strong words of the consultant psychotherapist quoted above, the guidance’s advice to registered practitioners that ‘if you experience any negative reactions within your workplace after raising a concern appropriately, you should contact your professional body or trade union for support and advice’ (page 4, para 4) seem pathetically inadequate.
The fact is that Trusts will be left to decide for themselves how best to support whistleblowers –  and a quick trawl of various local policies available online suggests that most are pretty vague on this point. The unwritten consensus seems to be that the whistleblower has to make his or her own arrangements – or not. So the encouragement that the NMC is giving with one hand might well convince Trusts that they are justified in taking it away with the other. In this context, it’s very interesting to read in this week’s Nursing Times that after six months of campaigning, a mere thirty out of a potential three hundred plus NHS Trusts and Clinical Commissioning Groups have signed up to its pro-whistleblowing ‘Speak Out Safely’ pledge. Does that sound like wholehearted commitment to you?
The unknown quantity in all this is the new Health and Social Care Act, under the terms of which NHS services can now be provided by private agencies. So where once the whistleblower stood on a continuum with the public good at one end and his own good at the other, he now finds himself in a triangle, with corners composed of the public good, his own good and the good of the company. Because a triangle is harder to hold in a steady-state than a continuum, the temptations for the employer are either to attempt a strong link between himself and the employee (because it is not in the employee’s interest for the company to go out of business) to the detriment of the patient; or to crack down hard on any potential disruption. In either case, the client is likely the loser.
What would Joseph Heller have made of it? I think we already know the answer to that question. It’s to be found in one of the most celebrated episodes of Catch 22, the bit when Milo, under contract to the enemy, persuades his men to bomb their own airbase.
“Frankly” he explains afterwards “I’d like to see the government get out of war altogether and leave the whole field to private industry. If we pay the government everything we owe it, we’ll only be encouraging government control and discouraging other individuals from bombing their own men and planes. We’ll be taking away their incentive”.
‘Milo was correct of course’ says Heller ‘as everyone soon agreed…’

Grumbling Appendix salutes the genius of Joseph Heller and acknowledges a grateful debt of thanks.

For the revised NMC guidance for nurses and midwives on Raising Concerns, see http://www.nmc-uk.org/Documents/NMC-Publications/NMC-Raising-and-escalating-concerns.pdf

For the Public Concern at Work research on whistleblowers, Whistleblowers: the Inside Story, see http://www.pcaw.org.uk/files/Whistleblowing%20-%20the%20inside%20story%20FINAL.pdf

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