Speaking up: how to raise concerns in the pharmacy workplace — transcription

Katherine: Hello and welcome to another learning episode of The PJ Pod, brought to you by The Pharmaceutical Journal, the official journal of the Royal Pharmaceutical Society. 

I’m research and learning editor Katherine Sole and, in this episode, we’ll be talking about the importance of speaking up whenever anyone in the pharmacy team has a safety or wellbeing concern and how to go about it.  

Around 25,000 people report safety concerns regarding the NHS each year. The most common reports are of inappropriate behaviours and attitudes; worker safety and wellbeing issues; and bullying and harassment.

High-profile enquiries, like the Winterbourne View Hospital review and the Francis report of patient safety failings at Mid-Staffordshire NHS Foundation Trust, have resulted in significant reforms and structural changes to the way patient care is delivered. Both are examples of change coming after someone blew the whistle on their concerns. In both cases, the whistleblowers felt they needed to speak up publicly and the media played a central role.

One of the recommendations in the Francis report was that a new national system be established to make speaking up about a safety concern easier and embed it into healthcare’s organisational culture. The National Guardian’s Office was set up in 2016 to give people working in healthcare a way to speak up if they don’t feel they can within their organisation. Every NHS trust, and many other organisations, now have a ‘Freedom to speak up’ guardian.

Within healthcare, we’re moving away from the term ‘whistleblowing’. Traditionally, whistleblowing can be thought of as when someone speaks out about serious wrongdoing that can harm patients, colleagues or organisations. But this term has some negative connotations and it’s now preferred to use the broader term of ‘speaking up’. Having said that, the term whistleblowing is still widely used and will be referred to in this podcast.

So for this episode, we spoke to some experts in the field to find out what someone in a pharmacy team should know if they’re thinking about speaking up.

Beth Carter is the interim director of operations and strategy at the National Guardian’s Office. I asked Beth what sort of problems should pharmacists report if they see them.

Beth: So, it could be absolutely anything. It could be a very specific patient safety incident. So if we’re thinking about pharmacies — maybe they’re seeing some repeated drug errors or issues with medication storage, you know, anything around that. But it could also be anything, like inappropriate behaviours from other colleagues — whether directly in their department or elsewhere — that they’re seeing. It could be bullying, harassment, discrimination; it could be consistently low staffing levels, you know — anything at all that they feel is impacting on them performing their role to the best of their ability.

Katherine: Mark Pitt is a pharmacist and the director of defence services at the Pharmacists’ Defence Association, an independent UK trade union with over 40,000 members. He gave some more examples of what pharmacists should be reporting.

Mark: For example, an employer is neglecting their duty of care towards patients, their customers or staff. Another area that can be reported is a miscarriage of justice for somebody being dismissed for something that actually wasn’t their fault, it was an error from another system. Another quite common one is somebody’s health and safety being put in danger. Examples of those that are pharmacy specific — supplying out of date medicines, reusing patient returns, counterfeit medicines, unsafe storage conditions for medicines, you know, fridge not working properly — and other examples, things like asbestos being in the building which is being worked upon. So those are some more pharmacy-specific examples. 

And finally there’s damage to the environment. An employer, for example, is disposing of returned or out-of-date medicines inappropriately. Or occasionally you get pharmacies who find in the cellar some old historic stock of poisons, arsenic or mercury-containing products and there are very strict regulations about how those are disposed of, and if that’s done inappropriately — you know, just flushed down the toilet — that can cause environmental damage. So those are the principle areas and, also, overarching all of those is if there’s any attempt to cover up any of those types of qualifying disclosures.

Katherine: So there are clearly lots of reasons that you might want to speak up. But I wanted to know whether pharmacists have an actual obligation to report problems. Here’s Beth again.

Beth: The General Pharmaceutical Council has different standards for pharmacists, nine different standards, that they need to comply by. One of those standards is to speak up about concerns, so it is part of their professional responsibilities to speak up about concerns. But I think also it’s a moral obligation, you know, if you see something that’s not right, thinking about the impact it might have on other workers or patient safety, etc. It’s really important that the pharmacist does find somebody to speak up to. 

Katherine: These standards apply to all pharmacy professionals, including pharmacy technicians, who are registered in their own right. I asked what could happen if you don’t report a problem.

Beth: You know, worst-case scenario could be absolutely catastrophic. With failings that we’ve seen across healthcare sector in NHS, you know, the very extreme is someone who doesn’t speak up and raise concerns that could lead to patient harm, potentially fatal in some instances. But also if it is something to do with behaviours, inappropriate behaviours, bullying or something, if somebody doesn’t speak up about that, that could have a real detrimental impact to the person that’s on the receiving end of that bullying, whether that’s the pharmacist themselves or somebody else there witnessing it, so that can have an impact on the wider morale of a team if it’s witnessed by more people, etc. So the impact of not speaking up can be minor but it can also be really significant. 

But also some day, you know, if a pharmacist witnesses something and doesn’t speak up, that’s potentially going to have that impact on themselves as well, holding onto that information you know, ‘Oh gosh, I’ve seen this, I’ve heard this, I’ve not done anything with it, because of X Y and Z’, and then if something does happen wider that can have a real impact on the person that’s witnessed that and hasn’t been able to speak up as well.

Katherine: Mark says there could even be professional or legal repercussions as well.

Mark: But I think as well, and we see this quite often, is if the regulator becomes involved in a complaint or, you know, through its own investigations, they become aware that a pharmacist was either complicit in the problem or condoned what was going on. They could themselves face fitness-to-practise allegations for in breach of the standards. If there’s a criminal investigation or inquest or fatal accident inquiry, that the pharmacist risks being subject to criticism about their inaction in preventing or reducing the risk of harm

Katherine: OK, so reporting problems when you see them is important. But what should your strategy be? If a pharmacist or member of the pharmacy team sees a problem and wants to do something about it, the advice is to start by reporting it within your own organisation.

Mark: It’s always advisable to start at the lowest level first, through the company’s own internal policies. The big organisations tend to have good ones. And the organisation has a responsibility to create the culture, an environment where, you know, whistleblowing is effective and dealt with appropriately. It’s only if those don’t work that you’ve got other routes to follow. So the other thing I think, and pharmacists are very good at this because of their nature of documenting things, is to keep a record of what was said. If it, you know, if they are concerned about things, keeping a diary, a log, chronology, that’s always very helpful if, you know, as a sort of a safety net, if things don’t work out.

Beth: So, wherever possible, we say to workers, you know, if you can speak up in your organisation — even if you’re at the lowest level yet — if you can go to your line manager, you might not be able to do that if you’re line manager is the problem for example. You know, if you can find somebody else to speak to in the organisation, whether it’s a another peer or supervisor, a guardian — try and do that first, because if we can resolve things at that lowest level before it becomes this whistleblowing procedure, then that’s what we need to do because by solving it or at least attempting to resolve it first at a local level, you know, that’s a better outcome for the people involved. That’s a better outcome for the organisation. Obviously, it’s financially better. But that’s not always possible for some people, sometimes there is no other option than to go externally.  

So before a pharmacist decides to go external to the organisation to raise a concern, to speak up, to whistleblow. I would say, first of all, take a moment to step back — have they tried to resolve it internally first? If not, why not? And do they think they could approach somebody internally to raise that concern? If they have tried to raise it internally and it hasn’t been resolved, are they clear about why that hasn’t been resolved? You know, maybe they didn’t go to the right person. But you know, if after all those reflections they think ‘no, I absolutely need to take this externally’, then that’s their decision to make.

Katherine: But sometimes, if speaking up internally doesn’t seem to have had an effect, it might be time to go outside the organisation. So what people or organisations can pharmacists go to? Here’s Mark again.

Mark: There’s a whole list of what’s called prescribed external organisations, that pharmacists and anybody else can whistleblow. There a huge list, you know there’s things like, you know, in the financial interest, Financial Conduct Authority, but the sort of pharmacy it’s usually regulators, the MHRA, the CQC, the Health and Safety Executive. You know, within the NHS there’s the National Guardian’s Office, and the ‘Freedom to speak up’ network. So there’s those type of organisations they can go to externally that fall within the framework of organisations that can be whistleblown to. So, it’s important that, if the internal mechanisms don’t work and that doesn’t prove successful, that there are external ones that, that they can turn to, or they can go to in the first instance if they don’t think that what they’re doing is going to be effective or is going to put them in jeopardy. 

You know, I would always suggest that for pharmacists to best protect themselves in terms of making a whistleblowing complaint, that they get some advice first from a variety of sources, whether that’s a trade union, a legal adviser or a charity, such as Protect.

Katherine: Beth has advice for how to find a ‘Freedom to speak up’ guardian.

Beth: So if they are in a healthcare organisation that has a ‘Freedom to speak up’ guardian, depending on what organisation you’re in, depends on how you get in touch with the guardian. It’s generally through an email direct to the guardian. Some organisations have sort of electronic platforms where you get in touch with them in different things, but that should all be available, the information within the organisation so they could contact the ‘Freedom to speak up’ guardian. 

The guardian acts as an impartial person and the guardian can then either raise the concern on the person’s behalf, they could link the person in with the relevant people and support them to then have those conversations. If a pharmacist is in an organisation and they’re not sure if there’s a guardian or not, they can go on the National Guardian’s Office website, and then there’s an area on the website that’s called ‘Find My Guardian’. So they can put in the organisation, or they could just put in the area, and then it will list the guardians and what organisations they are in and give contact details. And, if there isn’t, then we can say, ‘actually there isn’t a guardian in your area or your workplace, but we can signpost, you know, these are people to contact’, so they can always do that as well.

Katherine: Pharmacists and other members of the pharmacy team could have legal rights and protections after speaking up, depending on what has been reported. The Public Interest Disclosure Act protects staff from detriment if they make what is called a qualifying or protected disclosure to a prescribed person or organisation. But there are several criteria that must be met for that.

Beth: So that very much depends on what it is they’re speaking up about. But for it to fall under the Public Interest Disclosure Act [PIDA], it would need to be a criminal offence, a breach of a legal obligation, miscarriage of justice, danger to the health and safety of any individual, damage to the environment, or deliberate concealment of any of those listed. So, yes, if it falls under PIDA, then they would be protected from dismissal and detriment.

Mark: It’s quite specific in terms of how the concern is, what category it falls into. On whether it qualifies as a qualifying disclosure, which is why I’m always suggesting that people take advice from somewhere if that’s what they want to do, because you’ve got to make sure it fits in the category of a qualified disclosure and you’ve got to have a sort of a reasonable belief in what it is you’re raising, and it has to be in the public interest. So it’s not a personal issue — it’s a public interest. And that means it has to also affect others — other workers, patients, general public. Something that’s personal to you is unlikely to be counting in the public interest.

You know, we had a member who was a long-term locum in a particularly large company, who had raised concerns about what was going on in the pharmacy on patient safety aspects and had her bookings terminated. So that was the detriment. She raised it and that went through to a tribunal, found in favour of the pharmacist. It was demonstrated that, because of the disclosure that she’d made, that resulted in the bookings being cancelled and were successful in that case and was awarded compensation.

If you are dismissed, you can get some very swift action, and it’s called an interim relief application. And again, to bring it to life, I’ll give you an example:

We were supporting a pharmacist who, after taking advice from ourselves, flagged up concern to the owner of an online pharmacy that was employing pharmacists whose clinical practice was not great, and that was causing concern for our member working there as a pharmacist. He raised his concerns to the owner, who promptly dismissed him. It was a very dramatic moment, really. You know, we called into a meeting to discuss the concerns and was essentially told to pack his bags and leave the pharmacy. In those circumstances, an application can be made — and this is what happened — for an interim relief application. And that’s a very quick process that has to be made within seven days of the dismissal. And, what that does is it makes a decision based on what’s available on whether that person is likely to succeed in a claim later on because there isn’t enough time to get to the bottom of the full facts and that person can be reinstated back to the organisation. The tribunal can compel the organisation to re-employ that individual pending the hearing, to decide whether it’s a proper claim. 

Katherine: But even if there are some protections for people who speak up, the idea of doing so can obviously be intimidating. In small organisations especially, it can leave you feeling unprotected. I asked Beth if it’s possible to report a concern anonymously.

Beth: Yes, there absolutely is a place for anonymous reporting because some people are just too terrified to do it any other way. But there can be limitations with it and that’s really important to understand that before taking the step to anonymous reporting.

Some organisations use an electronic platform that allows for anonymous reporting. But there’ll still be a two-way conversation, but it is anonymous. So the person would register, send the email and it would go to the guardian. But the guardian doesn’t see any name or anything. It’s just got like this case number, but the guardian can actually respond to that and it will go back to that person and they can have dialogue.

The other way to report anonymously, if an organisation doesn’t have any kind of electronic way to do it, is back to basics, pen to paper, write your concern down, send it into the CEO or whoever, you know, the person wants to send it to with no name or where it’s coming from and raise the concern that way.

Put as much detail in as possible so that people, the organiser, whoever it goes to can try and follow up on that concern because there will be no option to come back to you, but also have the sense of recognising that if they do that anonymous concern, that they also won’t necessarily be able to get, they won’t be able to get any feedback on what actions were taken.

Katherine: Speaking up anonymously might feel safer, but it clearly has limitations. On the other hand, if your name is out there on a complaint, there can be consequences. 

Beth: Sadly, some people do face repercussions for speaking up, even if that is just internally. Whether that’s being overlooked for promotion, things like that, being treated differently, so they might suddenly sense that people are speaking to them differently or they’re been dismissed from conversations or meetings, that kind of thing. It could be that they face more severe detriment, so potentially some kind of dismissal or that kind of thing.

Katherine: It might sound unfair that someone speaking up about an important concern could be penalised like that. That’s why it’s important to get advice from a relevant organisation like the Pharmacists’ Defence Association or another trade union before you do anything. But of course, speaking up can be very positive.

Beth: Policies can be changed, processes can be changed. We can see improvements to worker experience. You know, if we see improvements to worker experience and the workers feel value, they feel that their voice heard and listened to, even if the changes aren’t always what they want. But there’s that feedback loop. So somebody speaks up — managers, whoever it is — listen and then acknowledge changes either happen or the explanation is given as to why the changes can’t happen. That person knows that they were heard and that ripple effect then goes through the organisation. Morale increases, morale increases, sickness reduces retention, you know, is better. You’ve got a better working environment. And when we’ve got a better working environment, an environment of workers that feel valued and empowered to speak, they provide the best care delivery that they can. And then the impact on the patient is, you know, is evident and it improves patient safety all round.

Katherine: As you can see, whether or not to speak up is not an easy decision to make. Navigating your choices can be difficult and stressful. But it’s important to know that support is available.

Beth: So, if they speak up through the guardian, the guardian is trained to be able to signpost to support. So whether that’s employee’s assistance support, occupational health support — it depends what it is, you know, that is happening to them. So there is support available, again it depends on the organisation and where they’re speaking up. You know, if a pharmacist is in a pharmacy in a village or small area that doesn’t have processes in place, then it’s going to be difficult for them to get support locally to them. But what I would say again is they need to feed into the NHS England ‘Speak up’ team and say ‘is there any support for me’ there and hopefully they can signpost them to relevant support. 

Certainly within larger organisations, the organisations where there are guardians, there’s that wellbeing support — the occupational health support, those kind of things — that they can be referred into.

Mark: You’ve got trade unions because they’re well used to supporting members. I talk from our own experience in that you know, we have dedicated and trained staff that help people through that journey. The PDA is a defence association and we’re also a trade union. So, we have 40,000 members, we’ve grown over the years and we provide a broad range of services as a defence association, as a trade union.

Katherine: Hopefully this has given you a good sense of when and how to raise concerns if you see something. But you might be the person someone is reporting an issue to. Beth has some advice on how to handle that situation.

Beth: If somebody comes to you with a concern, it’s really important that, first of all, you take the time to listen to their concern. So first and foremost, make the time and space. So if you can’t do it there and then, you know, let’s get time in our diary where we can focus on this and you know, we can talk it through. And then make sure you’re in, a room or an office, wherever it might be that you’re not going to be disturbed, so whether it’s your own office and you put some sort of ‘do not disturb’ sign on the outside, but you know you’re not going to be disturbed and you can give it your full attention. And then, you know, they’re going to share something with you. You don’t know what it’s going to be, so it’s really important to listen to understand. Listen to everything they’ve got to say — it’s their truth. It’s what they’re telling you. If it’s something about yourself, you know, maybe it’s something you’ve done as a manager, for example, don’t be defensive. You know, just listen, take that feedback. And then depending on what the concern is, it might be something that’s really easy to deal with and you can say to them, OK, you know, ‘thank you for sharing this, actually this isn’t something I’ve thought about or considered. And I’ll have the conversation with, you know, X, Y and Z. We’ll see if we can resolve this’.

If it’s something and you’re really not sure what to do with the information that they’re giving, you be honest with them. You know, tell them that you’re not sure about what to do and that you need to get guidance — from either a senior colleague or it might be HR — and then have the conversation with them about confidentiality. 

So, if you go say you’re going to go get guidance and you go get that guidance, that person tells you need to do X, Y and Z to resolve it. Don’t just go and do X, Y and Z and not tell the person that you’ve done X, Y and Z. Make sure you go back and feed back, because that’s really important.

It’s hard. It takes courage. You know, it’s the right thing to do. But getting to that point of actually being able to then share those concerns with somebody, that takes a lot of courage, that shouldn’t be underestimated. And when we do our training for our guardians, you know, we say to them, ‘if somebody comes to you to speak, so you need to thank them because it will have taken them a lot of courage to do that and to get to that point, to be able to speak up’.

Mark: It’s really important for organisations to have a proper whistleblowing culture so that people feel able to use the internal processes and have confidence in those and see that what they’re saying produces the results that they want to, because otherwise that they’ll just go externally and it means that the company doesn’t have an opportunity to put things right in the workplace. You know, and they’re dealing with an external investigation and rather than, dealing with matters internally, and properly, and making sure that, you know, it’s dealt with to the satisfaction of the individual raising the concerns. So, culture within organisations is paramount.

Katherine: I think that’s a good place to end. Speaking up is not small thing — as Beth says, it takes courage and can have consequences. But if a pharmacist or another member of the pharmacy team sees a problem at work that affects themselves, patients or colleagues, and could be considered public interest, they have an obligation to speak up about it. 

Most problems can be dealt with by reporting it to a manager within the organisation, so be sure to explore every avenue there first. 

If you think you need to speak up outside your organisation, seek advice from an independent external party, like a trade union or charity, then see if you have a ‘Freedom to speak up’ guardian or someone similar available to you. 

We’ll put links to these in the show notes, where you’ll also find links to relevant PJ articles and other resources. 

Our thanks to Beth Carter from the National Guardians’ Office, and Mark Pitt from the Pharmacists’ Defence Association, for their contributions. And thanks to you for listening. 

Until the next learning episode, it’s goodbye from us.