‘Whistle-blowing’ is common shorthand for a situation where a staff member exposes information or activity in the work-place that is deemed illegal, unethical, or otherwise likely to cause harm. The Mid Staffordshire Public Inquiry revealed a catalogue of preventable physical and psychological harm, including deaths, of patients in a National Health Service (NHS) general hospital, and triggered concerns about how whistle-blowing is managed. Various factors affect whistle-blowing, such as expectations of staff loyalty and assumptions that the NHS is the ‘best health service in the world.’
Whistle-blowing is not an easy option. People like to be accepted by those around them, and tend to conform to group norms and accept instructions from those in authority, even when their actions may harm others. Metaphorically stepping outside one’s own work group to criticise it and its leaders is psychologically challenging. The Francis Report identified that staff were scared to speak out, and when they did, senior staff were hostile towards them and defended sub-standard practices. Whistle-blowing requires special consideration during periods of austerity, as in the NHS at present, when staff are working under increased pressure and the risks of standards falling are greater.
Looking back to influential whistle-blowers of the past elucidates problems still faced today within the NHS. The 1960s saw particular controversy around long-stay institutions. Although the 1960s was not a time of NHS austerity, resources were unevenly distributed. In particular, psychiatric hospitals. from which most of the reports stemmed, were consistently less well funded than general hospitals, and within them, long-stay wards were the least well resourced. Although the Hospital Plan (1962) aimed to expand general hospitals and community care, implementation was slow. Psychiatric hospitals, often designated for closure, received little attention, adding to their Cinderella status. Some of the challenges they faced provide insights relevant to the NHS today.
In 1965, Barbara Robb, a psychotherapist outside the NHS, visited Amy Gibbs, a 73-year-old acquaintance, then an in-patient on a long-stay ward at Friern Hospital, London. Robb was appalled by the inhumane care patients received including: slapping; degrading bathing arrangements; appalling food; lack of dentures, spectacles and hearing aids, which discouraged independence; and lack of activities, personal clothes and privacy, which undermined dignity and self-esteem.
Robb took her concerns to Kenneth Robinson who was Gibbs’ constituency MP, as well as Minister of Health. Robinson did not investigate the issues as Robb requested. Meanwhile, Robb obtained reliable information that similar conditions were widespread. She therefore founded AEGIS, Aid for the Elderly in Government Institutions. AEGIS, a small, elite pressure group, aimed to improve standards of care. It comprised Robb and a few committed, unpaid advisors including Brian Abel-Smith, Professor of Social Administration at London School of Economics, and pioneering psychiatrist Russell Barton. AEGIS built strong links with the national press which publicised its cause, informed the public and exerted pressure on the Ministry to make improvements.
In 1967, Robb compiled the book Sans Everything: a case to answer. It included eye-witness reports sent to her, from six whistle-blower nurses, one social work student, and two visitors to elderly patients, describing practices similar to those she encountered at Friern. Sans Everything proposed remedies, including: community and rehabilitation-focussed psychiatric services specifically for older people; ways to generate income to pay for new services and facilities; raising and monitoring standards through effective NHS complaints management, an independent health service ombudsman, and hospital inspections.
The Regional Hospital Boards (RHBs) which managed the hospitals established committees of inquiry into the Sans Everything allegations. At St Lawrence’s Hospital, Bodmin, allegations by nursing assistant Joyce Daniel included: staff swearing at, hitting and roughly handling elderly patients; communal bathrooms where 44 dependent patients were hurriedly bathed in a single morning; and staff making crude remarks about patients in their hearing. The transcript of the St Lawrence’s inquiry indicates that the committee expected to find the whistle-blower’s evidence false (e.g. ‘quite frankly I anticipate that some of the allegations in the book may very well not be quite so impressive after cross examination’). It also criticized the whistle-blower (e.g. ‘sentimental and sloppy and perhaps soft’) rather than properly evaluating her complaints. The committee used leading questions (‘You have never seen anything like that at all, have you?’) and out-dated clinical knowledge (e.g. that depression in older people was ‘normal’). Other inquiries were flawed: for example at Friern, the committee did not interview Robb or the other witnesses; it used stereotypical, negative views of older people (e.g. being in bed by 7 p.m. was acceptable as ‘owing to their age many would wish to do so’) and justified harsh, undignified care (e.g. if staff were stressed or overworked) and it was acceptable to slap old people to get them out of bed in the morning if there were ‘legitimate reasons for this, provided of course that the slap was not too severe.’ The committees condoned low standards of care for older people. Biases led to conclusions that Sans Everything exaggerated and that standards of care, as at St Lawrence’s, ‘might well be emulated by the rest of the country’. In addition, archives reveal that RHBs in charge of both Friern and St Lawrence’s hospitals censored the reports before submitting them to the Ministry.
The press and public, including the whistle-blowers who were denigrated by their colleagues and by the committees of inquiry, consistently backed Robb. Numerous supportive articles appeared in national newspapers, such as the Sunday Times (e.g. Hugo Young, 4 June 1967). NHS authorities attacked Robb, including Robinson who announced in 1968 that the inquiries’ findings ‘should discourage anyone from making … ill-founded and irresponsible allegations in future’. Robb had extraordinary determination, personal resilience and emotional energy to persist in the face of repeated denial of ill-treatment and her public discrediting.
Robb’s work triggered similar allegations elsewhere, notably from Ely Hospital, Cardiff. In contrast to the Sans Everything inquiries, the Ely Inquiry, chaired by Geoffrey Howe, upheld most of the allegations. By the time the Ely Report was available, the Ministry of Health was the Department of Health and Social Security (DHSS) and Richard Crossman had replaced Robinson. Crossman knew that Robb worked closely with senior DHSS advisor Abel-Smith, and that Abel-Smith was a friend of Howe. Crossman regarded Howe’s report as ‘explosive’ and feared that Howe would go to the media about the report being suppressed if it was not published in full. Crossman had criticised Robinson for his handling of Sans Everything and feared detrimental effects on his own career unless he published the Ely Report and proposed remedies (Crossman archive, Warwick University). Crossman also feared Robb’s press connections: his diary described her as a ‘terrible danger’ to the government. Ely became known as the turning point for policy changes, although behind the scenes, Robb contributed significantly to the process and continued to fight for policy changes. Her reputation meant that whistle-blowers at other hospitals, such as South Ockendon, sought her advice. Following the South Ockendon Inquiry, Secretary of State Barbara Castle acknowledged in 1974 Robb’s influence. The outcomes of these (and other) inquiries contributed to NHS policy changes about psychiatric services, monitoring standards and complaint management, closely linked to the proposals in Sans Everything.
In the 1960s, long-stay psychiatric hospital wards were often overcrowded, to the extent of having no space for lockers for patients to keep personal possessions. They were also understaffed (there was one trained member and three untrained members of staff for 84 ‘ambulant geriatric’ patients on one ward at Friern Hospital), contributing to low standards of care.
Fifty years later, overcrowding has transmuted from visible ‘spatial overcrowding’ of too many beds on a ward, into ‘temporal overcrowding’, with beds fully occupied, intense pressure to admit and rapid throughput of patients. Both sorts of overcrowding are associated with a heavy nursing workload which risks rushing tasks and compromising care. From my recent experience as a hospital doctor, pressures from ‘temporal overcrowding’ are invisible, but among NHS managers may generate a sense of complacency or achievement that care and treatment are good because of speedy discharge. As in the 1960s, staff levels and the ratio of qualified to unqualified staff may be insufficient to meet patients’ needs, and shoddy care can become accepted as standard. Hospital managers today request ward leaders to inform them when staff levels are too low for safe and humane care. However, a 2015 study on staffing levels by the trade union Unison reported that the authorities may fail to respond to these requests for more staff, and when the situation recurs, it passes unreported as ward leaders lack confidence in the process and outcome. Empty-handed responses from managers also discourage ward staff from discussing other risks.
In Robb’s time, nurses were expected to obey instructions from their superiors automatically. Hierarchical, rigid, top-down management discouraged front-line staff from asking questions. According to Tommy Dickinson’s study Curing Queers (see further reading), staff were disciplined for querying instructions, even if attempting to improve care. Demeaning clinical practices passed unchallenged and became the norm.
In the twenty-first century, expectations of obedience manifest as the use of rigid clinical protocols and ‘care pathways’, monitored by management to ensure that ‘targets’ are met rather than best care provided. Protocols and pathways assumed to be created by experts and therefore best for patients may not be, as they are not tailored to the complexities of individual patient needs. Rigidity and monitoring give staff little scope for questioning, innovating, or improving patient care. The Francis Report cited Andy Burnham (Secretary of State for Health, 2009-10): ‘the NHS is not good at giving its front-line staff a sense of empowerment. People with good ideas do not feel that they can easily put them into action.’ Top-down, non-participatory management inhibits open discussion about how poor practice can be remedied, before it fuels whistle-blowing. This management pattern is uncomfortably similar to psychiatric hospital organisation in the 1960s. This contrasts with the 1970s and ‘80s when many hospital authorities encouraged bottom-up innovation by clinical teams, which contributed to improving services especially in unpopular and under-resourced specialties, such as psychiatry for older or learning disabled people.
Government rhetoric about the ‘best health service in the world’ was widely believed in the 1950s and 1960s but was unsupported by data. Comparative health outcomes were in their infancy, and leading economists such as Abel-Smith sought comparative economic data. ‘‘Best’ was a political rather than medical or economic term. Robinson, in his response to Sans Everything, stated: ‘I am absolutely sure, that the care of our old people in our geriatric and psychiatric hospitals is as good as anything in the world.’ Similarly, the response in times of limited resources, that one is ‘doing one’s best under the circumstances’, was (and is) a relative rather than absolute ‘best’. These expressions acknowledged deficits, but engender complacency towards low standards.
‘Best’ was part of a rhetoric used in response to Robb which was associated with an impenetrable wall of secrecy, defensiveness and denial about poor clinical practice. Maurice Hackett, chairman of the RHB which managed Friern Hospital, wrote in the Times in 1965 that the RHBs aimed to ‘guard and protect the interest and care of patients’. On television in 1967 he stated: ‘we are on the side of the patient. That is what we are there for.’ The undignified care of patients under his watch contradicted his assertion.
Reports today also make ‘best health service’ claims. The widely quoted study 2014 Mirror, Mirror on the Wall identified the NHS as top of 11 Western countries for quality care, access and efficiency. However, the NHS was almost bottom (10/11) on the crucial criterion ‘healthy lives’, the measure of clinical effectiveness: the study weighted ‘healthy lives’ equally with measures of service organisation, rather than as the main objective. The report indicates that political motives can contribute to determining ‘best’. ‘Best in the world’ statements support complacency to criticism and rejecting whistle-blowers as unreasonable.
In Sans Everything, the main whistle-blowers were ward nurses. Most were new to their hospital, idealistic about the well-being of their patients, and over half were ‘auxiliary nurses’ who lacked formal nursing qualifications. Sans Everything inspired nurses and nursing students in other hospitals to blow the whistle. Those further up the hierarchy had usually achieved their rank by conforming to organisational pressures. Many enforced pragmatic, but often harsh and outdated methods, reluctant to deviate from established practices or to seek better. At Whittingham, St Augustine’s and Farleigh Hospitals, which all had scandals investigated in the 1970s, senior staff had snubbed earlier alarms raised by inexperienced workers about degrading or dangerous practices.
In 1967, Minister of Health Kenneth Robinson was asked if he would protect staff who voiced concerns. He replied ‘Yes, certainly’, but gave no clues as to how he would achieve it. The Ministry nebulously advised the Regional Hospital Boards to try to ‘dispel such apprehensions.’ Two years later the Nursing Mirror commented that when nurses speak out, ‘the painful truth is that, invariably, their own discredit is the only result of their efforts.’
Since then, attempts have been made to improve NHS complaints procedures, but have typically focussed on the patients’ right to a fair hearing rather than on whistle-blowing. The 2015 Lampard Report into allegations of abuse carried out by Jimmy Savile highlighted the need to empower staff to feel able to raise concerns: ‘People do not feel comfortable challenging those they see as in positions of authority and hierarchies within hospitals are a barrier to staff raising concerns.’ NHS guidance, Freedom to Speak Up issued in 2016 takes a constructive approach to raising concerns and reassures potential whistle-blowers: ‘We will look into what you say and you will always have access to the support you need.’ It is less clear about how it will achieve its goal of not tolerating ‘harassment or victimisation of anyone raising a concern.’ In large NHS Trusts directions to the top of the hierarchy may not translate to the treatment of an individual whistle-blower or to attitudes and behaviours within their work-group. Reprisals, feared by whistle blowers, may be subtle, un-pleasant and lingering: a change in NHS culture is needed to prevent them.
As in the 1960s, today new staff and students are the least likely to be asked their views about practice, despite evidence that a ‘new pair of eyes’ can be constructive. It would be valuable to routinely seek feedback from them, preferably face to face, if necessary by a member of staff in a different department, taking into account ongoing insecurities about whistle-blowing. Doing this, alongside training students and staff in the art and ethics of raising and responding to concerns, not just in the technicalities, would contribute to shifting NHS culture towards accepting constructive criticism. Ethics, beyond the traditional principles of justice, beneficence, non-maleficence and respect for autonomy as they relate to individual patients, need to be taught in relationship to the workings of NHS organisation and management. This might give staff at all levels a greater understanding of their duties and loyalties. This is not included in Freedom to Speak Up.
The Francis Report deplored the finding that loyalty to the team can take precedence over loyalty to the patient. Sans Everything also illustrated this conflict. Colleagues were hostile to Joyce Daniel at St Lawrence’s after she complained, saying that her comments created an unpleasant work atmosphere and that nurses should be loyal and unified. She resigned. Also in the 1960s, staff were dismissed on grounds of transgressing the loyalty etiquette. One outspoken nurse received a letter from her matron: ‘I feel that your disloyalty towards your colleagues and the fact that you are not happy with conditions […], leaves me with no alternative but to ask you to accept one week’s notice.’ Archives do not indicate if the reasons underlying her discontent were remedied. Barton wrote in Sans Everything of the ‘misplaced loyalty of one staff member to another’ and that ‘Victimisation of anyone who is critical, whether justifiably or not, may be automatic.’ Overcoming these tendencies within the NHS remains a challenge.
Unsafe, damaging or disrespectful patient care continues. It is linked to institutional and personal factors, some of which are uncomfortably similar to those at work in the 1960s. Compromised patient care due to under-resourcing, overcrowding and understaffing has changed, but has not disappeared. Unacceptable practices, reassuringly justified as ‘best under the circumstances’, if left unchallenged, can become the new accepted standards. The rigid hierarchical style of management in the 1960s, where staff dared not criticise, is similar to today’s culture of NHS managers monitoring obedience to inflexible pathways and protocols which preclude patient-focussed questioning, innovation and adaptation. Not providing opportunities for clinical staff to question and reflect to improve standards in a timely manner may lead to ‘crisis whistle-blowing’. Managers need to value a ‘new pair of eyes’, regardless of formal status within the organisation. If coupled with a less hierarchical management culture, this could help ensure that constructive criticism becomes part of all staff’s practice.
Changing institutional culture and human behaviour is a slow process. Changing behaviours does not follow automatically from telling people what to do. A whistle-blowing policy needs to include attention to the ethics of responsibilities and psychology of relationships between the whistle-blower, their work colleagues, and the person criticised. Training in how to whistle-blow and how to respond to criticism is required, not just the technicalities, but in communication skills and ethical and emotional understanding around honesty, patient care, loyalty, criticising and being criticised. Robb wrote that harmful practices in the NHS were ‘an indictment of every one of us who knew these things were happening and did nothing about it.’ Her comment stands today.
Dickinson, Tommy. ‘Curing Queers’: Mental nurses and their patients, 1935-1974. Manchester: Manchester University Press, 2015.
Robb, Barbara. Sans Everything: a case to answer. London: Nelson, 1967.
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H&P is based at the Institute of Historical Research, Senate House, University of London.