Locking down and speaking up

Doctors must be allowed to expose injustices at work without fear of recrimination during the COVID-19 crisis, write University of Birmingham Freedom to Speak Up guardian Julian Bion and head of inclusion Byron Batten

Location: UK
Published: Wednesday 13 May 2020
Depiction of molecular virus

In her two recent addresses to the nation, the Queen has drawn parallels between the coronavirus crisis and our response to adversity in the Second World War.

The analogy is apt. We have come together to defeat a common enemy. We have massively expanded intensive care capacity. Staff have volunteered to redeploy to acute and critical care areas despite the risks to their own health. Leave has been cancelled – who needs a holiday when we can’t travel? Our armed forces have built new Nightingale hospitals in days. We have ‘made do and mended’.

Vacuum cleaner and motor manufacturers have reconfigured their production lines to create ventilators; cottage industries, schools and haute couture firms have evoked the Dunkirk spirit in producing masks and visors for local services. Whole communities have come together on Thursday evenings to applaud the commitment of NHS and care staff, and others who maintain vital services.

However, the uncertain and inadequate supply of PPE (personal protective equipment), and changing instructions on its use, have caused considerable moral distress among staff, and raise difficult issues about balancing a duty of care to one’s patients against the need for self-preservation. Regrettably, there have been reports of staff being reprimanded for raising concerns about PPE; the BMA has provided guidance on this matter.

What is clear is that this crisis offers a potential opportunity. For example, led by our Inclusion and Health and Wellbeing Team, our trust has implemented telephone staff support incorporating our Freedom To Speak Up service, backed up by clinical psychology and psychiatry: preliminary experience suggests this has been very helpful. 

Staff who have concerns about redeployment or exposure to risk, or indeed any other matter which may adversely affect working relationships and patient care, should discuss them first with their line managers.

In the event that this conventional route is problematic, there is also another pathway for speaking up confidentially, and in a manner that can promote organisational reflective learning: the Freedom to Speak up guardian.

The Freedom To Speak Up network was established at the recommendation of Sir Robert Francis QC, in a report arising from the Mid-Staffordshire inquiry.

Every NHS trust in England now has a guardian, part of a national network led by the national guardian, Henrietta Hughes. Protection of the right to speak up is associated with organisational excellence (see the national guardian’s annual report), but some staff still fear that doing so may either compromise their career prospects (a concern particularly prevalent among junior doctors), or expose them to micro-aggressive behaviours from co-workers or seniors.

Freedom to Speak Up guardians, supported by a number of local champions or confidential contacts, enable staff to speak up about patient care or about experiences in the workplace, without suffering detriment.

These matters can then be taken to the appropriate line manager with authority for investigation or action. The identity of the individual who has spoken up is protected unless they are willing to have this made known.

Between April 2017 and March 2019, 19,331 concerns were raised with trust guardians, most frequently relating to allegations of disrespect, bullying, discrimination, and compromised patient safety.

Since ‘lockdown’ was implemented on 23 March, in my experience and in informal discussions with colleagues, the typology of concerns seems to have changed, focusing on PPE and exposure of self or family to risk, and lack of access to SARS-CoV-2 testing. Whether this change represents displacement by more pressing concerns, or an improvement in collaborative behaviours in response to a common threat, will become clearer when the pandemic subsides.

I would hypothesise that those trusts whose leaders are creative, collaborative and reflective will be better equipped to deal with the economic consequences of this pandemic than those who have suppressed or ignored expressions of concern. This is not just a matter for chief executives; it needs to be practised by all of us. Take time to be kind. Take time to listen. Lock down the virus but liberate the voice. 

Julian Bion is the Freedom To Speak Up guardian for University Hospitals Birmingham and professor of intensive care medicine at the University of Birmingham and Byron Batten is head of inclusion-improvement, communications and engagement at University Hospitals Birmingham. The views expressed in this article are those of the authors