Dr Stephanie Jordan is a Care of the Elderly registrar training in the South West and one of six Clinical Fellows who worked with us this year. Dr Chris Brooks worked as a Policy Officer in the Education and Standards Directorate. He’s now returning to his role as a Junior Medical Officer in Australia. Here they reflect on being part of the team developing materials on speaking up, the conversations they’ve had this year, and the learning points from our ‘Speak up, speak out’ workshop that they co-led at our conference in April.
Stephanie
Another morning, wedged against the doors of the London underground, jutted by an elbow, rucksack between my feet like a huddling penguin. As a Clinical Fellow at the GMC earlier this year, I am a new and transient Londoner; it’s been a huge change from the West Country. Then the familiar words come across the tannoy, “See it, say it, sorted”.
Powerful rhetoric. Simple! Except of course, it’s not.
Speaking up
When I was first invited to be part of the Speaking up working group, I was fresh out of the medical registrar on call rota. I’d always known I had a professional duty to raise concerns about patient safety. I knew the processes I should follow. I knew the titles of the people I should involve. I understood documenting and had the need to escalate drilled into me from medical school. I’d even raised concerns myself and as I became a more senior trainee, had concerns raised to me.
I always tried to be an advocate for my patients – I want to keep them and my colleagues safe. But I’d previously viewed raising concerns as a series of steps to take, a chain of events and a need to ‘do the right thing’. I’d never before viewed it as a philosophy. I do now.
Here are some of the things I’ve learnt this year that have shifted my perspective.
Giving permission
Speaking up is often talked about with a lot of focus on individual bravery – but really it is relational. As Megan Reitz, Professor of Leadership and Dialogue at Ashridge Hult International Business School says, it’s about the perceptions of power. I’ve heard leaders use phrases which can help give permission. This can ensure your metaphorical door is always open.
“Tell me the uncomfortable truth.”
“What do I not know, that you all know, that I really need to know?”
There is also something about setting the scene for the tone of the conversation or meeting to follow.
“I just want this to work best for patients, tell me how we can do this?”
At a chief executive panel at NHS Confed 2019, there was discussion about the importance of being a vulnerable leader in a way that still inspires confidence. I know the leaders I most respect are those who are prepared to show their own learning and insights, and I’d be happiest speaking up to them.
Recognising titles
It is not just chief executives and national leaders who need to recognise their role in encouraging a speaking up culture – it is everyone’s responsibility.
I’ve reflected on Megan Reitz’s powerful challenges to look at your own ‘titles’ and how scary you can appear to others. As a trainee I’d never really seen myself as carrying a title, but when she really made me look at myself I can see I do; Doctor, Trainee, Medical Registrar, Clinical Fellow at the GMC, British, Female, Young(ish) as a starting point. This is the lens that others see me through and this may affect their choices of whether or how to speak to me.
What are your titles? By being self-aware you can start to understand why your ‘open door policy’ may not be as effective as you thought.
Unconscious habits
I’ve also learnt about the importance of being mindful of conversational habits. A habit I now know I’m guilty of is mitigated language. I was introduced to this concept by Dr Clare Holt, former air traffic controller, at a joint GMC and Scottish Government event. Mitigated language is where you downplay or sugarcoat the meaning[1] of what you are saying, often through deferential or indirect speech. It’s common when there is a perceived power differential.
I can now see how the impact of my message can be lost simply by the way I frame it and inadvertently understate its importance. What are people more likely to listen to: “I wonder if maybe the drug dose needs to be adjusted slightly?” or “Stop. That is the wrong drug dose”.
Can you spot your automatic conversational habits at the moment they happen?
Saying thank you
From our conversations with Dr Henrietta Hughes, National Freedom to Speak Up Guardian, I’ve learnt the importance of saying “thank you” if someone shares a concern with me. Information is a gift, and it’s likely taken courage to give. Saying thank you recognises that, and hopefully means the person will be more willing to speak up again in future.
Re-framing
One of the most powerful stories I’ve heard this year is from Dr Chris Turner, Emergency Medicine Consultant and co-founder of Civility Saves Lives. He tells a story of how a doctor had noticed an unprofessional behaviour in a colleague, but didn’t see it as their role to address it at the time. Twenty years later, that doctor, now in a leadership role, had a concern raised to them about the same colleague displaying the same unprofessional behaviour. When approached, the colleague had no insight into this and was distraught that others had perceived them in this way all these years.
This story really struck me; it helped me re-frame how speaking up about even subtle “non-serious” behaviours can be a very positive thing and help the person in front of you. Ultimately, this will benefit patients and colleagues. It’s time we changed the narrative.
Chris
Speak up, speak out
“See it, say it, sorted”. As Stephanie says, it seems simple, but it’s not. Co-hosting the Speak up, speak out workshop with Dr Henrietta Hughes gave me the opportunity to explore what it really means to raise concerns, and how we can encourage a speaking up culture.
Key to the session’s success was the range of attendees who joined. Not only did we have doctors but also educators, medical students, royal colleges and policy makers. The broad mix of professionals led to great discussion, especially on what was to be a prominent theme, the importance of listening well.
This resonated with me as I know how difficult it can be to raise issues with those above you, particularly when you’re a doctor in training and already unsure of yourself. Stephanie alluded to this earlier when she discussed leaders giving permission for people to speak up and the importance of recognising your role in making people feel safe to share their concerns.
In light of this, we asked attendees what they would do when they go back to their organisations to encourage a speaking up culture. I was amazed at the breadth and honesty of some of the responses. They covered things including personal improvement, actively seeking feedback, empowering others, and facilitating organisational change.
- “Get better at ‘listening up’. Leave my phone in my pocket more”
- “Vocalise that others can speak to me”
- “Build capacity in junior members of the team to feel able to speak up and be listened to”
- “Being open to challenge and reinforcing the benefit to patients and the organisation whenever speaking up is mentioned”
These commitments emphasised the importance of cultural change in enabling people to speak up. As doctors we have a duty to raise concerns where patient safety, dignity or comfort is compromised. However, everybody needs to work together to create a culture that ensures we speak up and are listened to. And I left the workshop thinking that we’re on the right track.
What are we doing?
Both Steph and I want to deliver the best possible care for our patients, and we believe speaking up should be business as usual, forming a part of everyday conversations.
Our team is using what we’ve all learnt this year to create a set of speaking up resources that will be released soon. They will accompany our professional guidance, Raising and acting on concerns and include a quick guide to help you speak up in your organisation. There will also be case studies, practical tools and first hand accounts from the front line to help us to speak up and be heard.
Knowing how to raise a concern isn’t only relevant when you become a doctor though. That is why the GMC is currently running a competition for medical students, asking them to design a peer-to-peer teaching session on speaking up. If you’re a medical student we’d love you to take part before it closes on 29 September 2019.
What can you do?
This year we’ve learnt how others speak up and listen well, and enable those around them to do the same. As we return to clinical practice, we’ll be taking this with us.
Will you consider making a personal commitment to look at yourself, your team and your organisation and think about the practical things you could do to help everyone feel safe and confident to talk?
[1] Gladwell, Malcolm: Outliers: The Story of Success, Penguin (2008)
Improving medical education and practice across the UK 
When I was Medical Director of Wrightinton, Wigan and Leigh FT (2010-2016) the Trust reduced harm to patients by 90% over 8 years. The patient safety work had started 2007.
We empowered and engaged staff and patients to speak up and we implemented good governance and fair and open culture and accountability culture.
Fairness, truth, justice is important. Value based leaders do not compromise core human values and unite everyone for a common purpose. Our purpose in our patients and our staff.
70 staff raised concerns with me and executive Directors. We dismissed few bad doctors and some bullying leaders and managers to protect patients and hard working staff.
In a culture of bullying and blame staff do not speak up.
Happy to help GMC even now. In a kind, caring compassionate culture staff speak up and organisation learns lesson. Bad staff must be held to account.
There is a real difficulty here with the GMC. No amount of GMC “competition(s) for medical students” on speaking up, cosy “workshops” where folk tell each other how well they are doing or talk about changing “the narrative” is going to address this.
Progress in bringing integrity requires “good” scandals – and a demonstration from the GMC that it can make the most of these.
There needs to be some attempt to make sure that the “solutions” proffered in the “workshops”, “competitions” and “narrative” shifts actually address these real-world problems, that the solutions actually match the scandals, and that the systems proposed will actually make any headway at all in preventing them.
The problem is that the GMC has completely failed to address problems which have arisen historically, and has often supported and excused very serious wrongdoing. The GMC needs to invite speakers to these little workshops that are critics of the GMC, not cosy supporters of the dreadful status quo and of apologists for fraud and misconduct.
I and I am sure many others would be delighted to discuss with the GMC the details of how they have behaved, and to seek plausible explanations for those behaviours so that they can be corrected.
Hiding behind workshops, consultations, and some nice stories, is not going to help anyone — least of all our patients. Hard questions need addressing with some honesty. Perhaps one day the GMC will invite the appropriate individuals to address its procedures and attitudes.
The GMC is so intoxicated with its own rhetoric it steams ahead with self congratulation, listening to nobody who has anything of substance to inform itself.
Come on GMC – do something brave, and hold workshops with those who actually know about some of the things you have done which have damaged our patients and profession – and be prepared to answer or learn.
Thank you for your comment Dr Blumsohn. We’re working to encourage a speak up culture across our health services. We regularly speak to doctors of all grades, types and specialities, along with those involved in medical education and practice across the UK. This includes those who have a range of contrasting views about our role, responsibilities and work programme.
We know there is more we can do but here are a few examples of the way we support doctors to speak up; and how we listen to the profession:
• We provide a confidential helpline for doctors who want to raise a concern but don’t feel able to do so at a local level (0161 923 6399). Since launch in 2012 we’ve had 5,427 calls to the helpline.
• We’ve introduced greater safeguards to our fitness to practise (https://bit.ly/2n2N7r6) and revalidation (https://bit.ly/2mQrvBi) processes to make sure referrals and recommendations are made fairly.
• We encourage reporting through our annual national training survey (https://bit.ly/2liQcWB) and follow up on every patient safety concern raised.
• Our liaison services (https://bit.ly/2mjfjJ9) engage with doctors on a daily basis across all four countries of the UK. They regularly advise those who are considering speaking up on how they can do this and who can support them.
• Doctors who have experience of whistleblowing, have shared their story with colleagues across the GMC, through workshops and presentations.
• We’ve rolled out mandatory whistleblowing training to all GMC fitness to practice staff and decision makers; and provided detailed guidance on handling cases involving public interest concerns.
• We’ve introduced a new professional behaviours and patient safety training programme (https://bit.ly/2kqjp1u) to equip doctors with the skills to speak up, with a focus on leadership and just culture.
In addition, later this year we will release practical advice, developed with doctors, to help tackle some of the barriers we know exist. It will provide advice and learning from those who have spoken up or supported others to do so.
If you have any specific concerns you’d like to raise, please do get in touch gmc@gmc-uk.org
Your comments are totally correct Dr Blumsohn. Thank you for your contribution. I have my doubts the the GMC will listen or that they will contact you to “hold workshops with those who actually know about some of the things you have done”.
It is a shame that they don’t listen. It is also a shame that they contribute to the abuse of those who ask questions (and hold meetings such as this one that ignores those people and the facts).
There is no evidence base for the government’s Freedom To Speak Up project.
It was built on politics & was an exercise in political theatre that did not transfer any power to the NHS frontline. Weasel words and loopholes, made worse during implementation, meant that there is no additional protection for NHS workers who speak up.
Not all speaking up ends in disaster but serious cases all too often do.
NHS discplinary processes are still unfairly stacked against staff, and successive governments have failed to act on recommendations for improvement and quality assurance:
Over 10,000 NHS staff have been sacked because they were unwanted, under the slippery ‘Some Other Substantial Reason’ route, not because they were incapable or had misconducted themselves:
I urge anyone thinking of speaking up to research and apprise themselves of the facts, and not to rely on government propaganda by the DHSC, its arms length bodies, regulators or the National Guardian’s Office, which is basically a subcommittee of the Care Quality Commission, and is jointly funded by CQC, NHS Improvement and NHS England.
These are the condensed facts:
Dr Minh Alexander
NHS whistleblower and former consultant psychiatrist
The author first describes raising concerns, quite rightly, as a doctor’s duty, but then says it is not simply a ‘need to do the right thing’ but a ‘philosophy’. Regrettably the contradiction here is not apparent to the author.