Creating a culture of whistleblowing for pharmacists

In 1988, following his appointment at Bristol Royal Infirmary in the UK, anaesthetist Stephen Bolsin noticed that operations to correct congenital heart defects in babies were taking longer than at his previous workplace. So, he collected data and brought his findings to the hospital management. No action was taken. Rather, Bolsin found himself ostracised by his colleagues.

Bolsin’s experience is far from unique. In the past two decades, there have been a series of incidents in which patients have died or been seriously harmed because alarms were either not sounded or ignored when triggered.

“Experience shows that people will not speak up if they fear retaliation or they think to do so would be futile,” says Cathy James, chief executive of the national whistleblowing charity Public Concern at Work. “Even when they do speak up, they will try once, perhaps twice and then give up,” she adds.

There is a need to improve whistleblowing policies within healthcare, including pharmacy, and provide support and protection to staff who raise concerns about the practice.

The big one

One of the most shocking and long running cases of patient abuse in the UK could have been stopped if somebody had alerted the right authority, and they had taken action. General practitioner Harold Shipman serially murdered at least 215 of his patients in Todmorden, West Yorkshire, and Hyde, Greater Manchester, over 24 years before finally being discovered in 1998. An inquiry led by Dame Janet Smith concluded that, while several people had their suspicions of Shipman years before he was discovered, they were all too afraid of not being believed to come forward.

In the mid-1990s, a warden at a shelter, where several of Shipman’s patients lived and died, noted some of Shipman’s visits coincided with unexpected deaths. A friend advised her to “do nothing; people will say you are mad”, but her concerns made her ill so she told her supervisor, who dismissed her fears as an obsession with death. Meanwhile, a taxi driver noticed that several of his regular elderly customers — who were Shipman’s patients — died unexpectedly, so he started to keep a note of the deaths. He did not go to the police because his wife convinced him that if the allegation turned out to be untrue, Shipman could sue him.

Experience shows that people will not speak up if they fear retaliation or they think to do so would be futile

It finally took two funeral directors to share their concerns with GPs at the practice next to Shipman’s after they noticed that they were signing an unusually large number of cremation certificates. The GPs contacted the coroner, who passed the matter to the police. Shipman, a well-respected doctor, was only superficially investigated. It was not until the death of another patient later that year, whose daughter suspected her mother’s will had been forged, that Shipman was properly investigated and caught.

Nothing much changed until the inquiry by Sir Robert Francis^[1]
into poor care being linked to the deaths of hundreds of patients at Mid Staffordshire NHS Foundation Trust between 2005 and 2009.

The inquiry noted that a nurse, Helene Donnelly, had repeatedly raised concerns with her managers about poor patient care on her ward. Donnelly subsequently suffered retaliation to such an extent that she was too scared to walk across the hospital car park. The Francis inquiry’s recommendations focused on the need to make the healthcare and social care sectors more open and transparent, and to create an improved culture where professionals are empowered to speak up and blow the whistle.

Concerns ignored

But whistleblowing is not just about healthcare workers speaking up, it is also requires management and regulators to be willing to act. A senior nurse at the Winterbourne View private hospital in Hambrook, South Gloucestershire, tried to alert managers at Castlebeck — which subsequently went into administration — and the Care Quality Commission (CQC) about the abuse of residents. After being ignored, he contacted the BBC who sent in an undercover journalist to film at the care home for its current affairs documentary programme Panorama in 2011.

Finally, there are the deaths of five elderly residents at Orchid View Nursing Home in Copthorne, West Sussex, run by the now defunct Southern Cross. A coroner’s inquest in 2013 showed the deaths had been caused by neglect. What is particularly important about this case is that a serious case review found that a community pharmacist working for Boots had visited the home in October 2011. The conditions were so bad that she was physically sick after leaving. She did raise her concerns with a senior staff nurse, but did not report them elsewhere because she knew the CQC had rated the home as failing, so believed that they would already be aware of the problems.

Whistleblowing procedures are a symptom that an organisation has failed to listen to the concerns of its staff

Since Mid Staffs, the number of people contacting the CQC with concerns has risen dramatically. In 2013–2014, there were 9,473 contacts — a 10% rise^[2]
on the 8,634 received in 2012–2013 — and between 2011–2012 and 2012–2013, the number more than doubled^[3]
. In the vast majority of cases, concerns related to social care.

But while on the surface the increasing number of whistleblowers contacting the CQC seems positive, its chief executive David Behan is clear that problems need to be dealt with before this stage. “Whistleblowing procedures are a symptom that an organisation has failed to listen to the concerns of its staff,” he said in July 2014 when giving evidence to the Common’s Health Committee’s ongoing inquiry into complaints and raising concerns.

Regulator’s requirements

Community pharmacies offer NHS services within a retail environment, and this can sometimes create tension between a pharmacist’s professional duty to provide the best care for patients and the public, and expectations commercially.

Under standards of conduct, ethics and performance set by the UK pharmacy regulator the General Pharmaceutical Council (GPhC), pharmacists and pharmacy technicians have a duty to raise any concerns about individuals, actions or circumstances that could result in risks to patient and public safety^[4]
. This includes raising and reporting concerns about behaviours, competency and the working environment, involving other pharmacists, pharmacy technicians, pharmacy owners, managers and employers, other healthcare professionals or people responsible for the care of a patient, such as carers, care home staff or key workers.

In 2012, the GPhC issued guidance outlining how to do this^[5]
, with a specific section for employers on creating policies and “an open working environment” where employees “feel comfortable raising concerns”. It says that employers should have “fair and robust policies and procedures” to manage concerns raised and that these should be accessible to all staff. Any concerns raised should be taken seriously, properly investigated, treated in confidence, and the whistleblower supported and not victimised.

Furthermore, the GPhC’s standards for registered pharmacies^[6]
, which all pharmacy owners and pharmacy superintendents must abide by, state that they must make sure that “staff can comply with their own professional and legal obligations, ” and that “incentives or targets do not compromise” this. They add that staff need to be “empowered to provide feedback and raise concerns”, and that this requires there to be “a culture of openness, honesty and learning”.

These standards are assessed by the GPhC in inspections: to be rated satisfactory, a pharmacy must have a whistleblowing policy in place; to be rated good, there needs to be “a culture within the pharmacy that means staff are confident to raise concerns” and views of staff must be sought actively and regularly^[7]
.

Employer policies

Mark Pitt, assistant general secretary at the Pharmacists’ Defence Association (PDA) Union, a certified independent trade union with a membership in excess of 22,000, says that while the Francis report has shone a light on things that can go wrong in the NHS, the situation is very different for employed and locum pharmacists working for some community pharmacy employers.

Pitt says the PDA Union deals with hundreds of whistleblowing cases each year and is contacted on an almost daily basis by pharmacists who have concerns that directly impact on patient safety. He has dealt with many cases where pharmacists have raised concerns with their line manager and then found themselves downgraded at their performance review or their capability to do the job is questioned.

Concerns raised have included that there are too few staff to provide a safe service, not being prepared to sign off healthcare staff as being competent when they are not ready, and being pressured to hit targets for medicines use reviews which would mean conducting reviews for patients who do not need them.

Of the major community pharmacy chains contacted by The Pharmaceutical Journal, only the Co-operative Group was willing to share its whistleblowing policy. “As a professional services business recognised for its commitment to delivering very high levels of customer service and outcomes, it is essential that we have an open culture where colleagues feel truly empowered to have a voice, that will be listened to and acted upon,” a Co-operative Group spokesperson says.

As well as its whistleblowing policy, the Co-operative Group has a section on its intranet highlighting how to raise concerns, and all new starters are briefed on what to do as part of their induction. “This is an approach which is regularly reviewed to ensure that we constantly have the right cultural environment to meet the needs of all our stakeholders,” the spokesperson adds.

LloydsPharmacy did not provide a copy of its policy, but was willing to provide details of how it has responded to the Francis report. A spokesperson for its parent company Celesio UK says that it encourages its employees to speak about their concerns openly and directly. “All employees are called upon to report any circumstances that suggest that there has been a violation of the law, the code of conduct, standard operating procedures or other internal guidelines,” says the spokesperson, adding that all reports are treated confidentially and that the person making a report is protected.

In response to the Francis report, LloydsPharmacy launched a safer care programme in 2013. “Each pharmacy team across the UK conducts internal weekly check-up meetings, as well as monthly briefing sessions where any concerns are raised and best practice learned during the month is discussed,” the spokeswoman explains. “Each pharmacy has a dedicated safer care champion, as well as an area champion who can be utilised as a peer-level support contact.”

Steve Banks, professional standards director and superintendent pharmacist at Boots UK, says that helping to create a professional culture of trust and openness is a priority for him. “We have a number of different routes to enable pharmacists and pharmacy teams to raise concerns, including anonymous options and organisations like the BPA [The Boots Pharmacists’ Association].”

The serious case review into Orchid View, published in June 2014, noted that it was reassuring to see that Boots has used the experience of the poor standards of hygiene and haphazard medication management as a case study in the January 2014 issue of its in-house newsletter, intended to improve awareness and professional standards throughout the company. Boots declined to share the article.

Stephen Thomas, NHS contract and policy manager at Rowlands, explains that the company’s superintendent’s office and pharmacy operations department meet monthly and, if whistleblowing issues are raised, they are discussed and resolved through this group.

“Rowlands Pharmacy has always had a flat and approachable management structure,” says Thomas. “We believe that this means that the escalation of concerns is simple and straightforward for all employees.”

Thomas adds that Rowlands has recently formed a pharmacist representative group, which consists of 11 pharmacists elected from within the workforce, and concerns about working practices can be raised at their meetings.

Actions, not words

Drafting policies and revising them regularly is pointless if the words are not followed-up with the right actions.

“[Some community pharmacy employers] may have a glossy policy that covers whistleblowing but the reality is that it can just be for show,” says Pitt. “They don’t create the environment and the culture necessary to make staff comfortable in raising patient safety concerns. In fact, some pharmacies have policies and procedures in place that can suppress genuine concerns being raised.”

“Employers need to do much more than merely having a whistleblowing or speak up policy in order to overcome the sense that to speak up is a risky business,” says James. She explains that whether a policy works in practice will depend on a number of factors, including staff trust and confidence in the arrangements, what other reporting mechanisms there are in place within the organisation, and what work is undertaken to review the process.

Employers need to do much more than merely having a whistleblowing or speak up policy in order to overcome the sense that to speak up is a risky business

Not everyone blows the whistle and then gets dismissed. It is more likely to result in being put at a disadvantage or suffering a detriment that falls short of losing your job, such as lack of promotion, being seen as awkward, not getting a pay rise and being moved out of the store.

“Proving a link between whistleblowing and any disadvantage suffered as a consequence can be problematic, which can make seeking justice through an employment tribunal quite difficult,” says Pitt.

Widespread problem

The fate of whistleblowers in pharmacy is not dissimilar to the outcome for those across the NHS and other healthcare sectors.

In September 2014, Patients First, which campaigns for better rights for whistleblowers, submitted a dossier of 70 cases to a review on the reporting culture in the NHS being conducted by Francis and due to report in November 2014. Nearly half the cases are ongoing, and all the whistleblowers have reported some adverse effects — professional, personal, or financial — from raising a concern.

In 2013, a more formal analysis of 1,000 cases from across all sectors where the whistleblower had contacted the charity Public Concern at Work found that in three quarters of cases (74%), nothing was done about the concern raised, and a total of 60% of whistleblowers received no response whatsoever^[8]
. When there was a response, it was most likely to be disciplinary action or demotion (19%). Junior staff were more likely to be ignored than senior staff, who were more likely to be dismissed. Seven out of ten whistleblowers said their position at work worsened each time they raised a concern, and each time they did, their risk of dismissal was also found to increase (see graphs).

A number of things need to happen within the pharmacy sector to ensure that the lessons from Mid Staffs and other key incidents are taken on board and staff feel able to raise concerns with their employer, according to Pitt.

“The GPhC needs to take a firmer approach with pharmacy employers to embed it into the culture of organisations that they should not be operating policies and procedures that actually stifle raising concerns,” he says. “The right management culture is just as important as any whistleblowing policy.”