NHSSscotland Confidential Alert Line six month review: 1 February 2015 - 31 July 2015

NHSScotland Confidential Alert Line six month review (1 February 2015 - 31 July 2015)

2 November 2015

NHSScotland Confidential Alert Line
Six month review (1 February 2015 - 31 July 2015)

We are pleased to provide NHSScotland with this six month review as part of our contract to operate the NHSScotland Confidential Alert Line. As part of this evaluation we will also provide NHSScotland and NHS Scotland Health Boards with information on bullying cases that have been raised via the Alert Line.

As discussed at recent quarterly meetings, while this report looks back at the six month period ending 31 July 2015, it has been delayed for a three month period in order to gather feedback from those who have called the service. The outcome from this exercise is included below.

Advice line overview

In the above period we were contacted by 25 individuals who self-identified that they work for NHSScotland. 17 of these cases involved a public interest or whistleblowing concern, namely one in which the interests of others, colleagues, the public or the organisation itself were at risk. Eight cases related to private matters, namely where the issue involved an employment, HR issue or was a patient complaint about an issue affecting only the patient.

During the same time period we received 141 public interest cases from the health sector across the UK (including the above 17 cases from Scotland). It should be noted, however, that while Public Concern at Work (PCaW) is a whistleblowing charity providing a UK wide service to all whistleblowers, it does not provide a bespoke service for NHS workers from other parts of the UK.

Identification

When providing advice it is not a requirement that the caller provide the name of their employer to PCaW advice line staff. The starting point for our advisers will be what the concern is; to identify the risk; what may be preventing the individual from raising the concern; and, to assist or advise them in how best to raise the concern. The caller may not wish to provide the name of their employer. With this in mind when contacting us, staff may:

• Provide their name only
• Identify themselves as working for NHSScotland with or without their name
• Not provide any information as to their identity or their employer

During this period there has been an increase in the numbers of callers who were happy to leave their contact information. This is a positive trend we have seen continue from the initial pilot and the previous six month review. We believe this is due to the new service having time to embed and for NHS staff to become more familiar with the advice and support we can provide. This has in turn resulted in increased trust in the advice line and for callers to be willing for us to engage on an ongoing casework basis as opposed to one off calls to scope the service. However, as highlighted in the previous review, providing contact information is not a prerequisite for seeking advice from PCaW. As is the case on the PCaW advice line generally, in some cases an individual may contact us with a very specific query that we are able to deal with in the initial call. In these cases there is no case work element and so contact information may not be necessary. The individual is satisfied with the advice they have been given and is content to leave things there, but will always be informed of the name of their adviser and their ability to call back should they need further advice at a later date. As a result, it is clear that in these cases the fact that contact information was not left does not necessarily mean the individual was not content to leave information with us.

Of the 17 public interest cases, the identity of the caller was as follows:

Anonymous	3	18%
Unknown	1	6%
Name provided	13	76%
Total	17	100%

A correct number and/or email address was provided for re-contact in 11 (65%) cases.

Job position of the caller

In the majority of cases we were provided with enough information to identify the role of the caller.

Position	Count	Percentage
Unskilled	1	6%
Skilled	0	0%
Admin/Clerical	0	0%
Paramedic	0	0%
Management	0	0%
Executive	0	0%
Unknown	1	6%
Accountant	0	0%
Doctor	7	41%
Dentist	0	0%
GP	0	0%
Nurse	7	41%
Pharmacist	0	0%
Social Worker	0	0%
Non-Executive Director	0	0%
Board	0	0%
Other	1	6%
TOTAL	17	100%

Nurses and doctors were the largest groups to seek advice from the NCAL in the review period.

Type of suspected wrongdoing

We provide below an overview of the types of concerns that were raised during the stated period. Patient safety was the predominant concern during the review period which also reflects the predominant concern across all of our health calls over the same period. This is a common theme and patient safety has consistently featured in the top three concerns received to the advice line year after year.

Type of suspected wrongdoing	Count	Percentage
Ethical	1	6%
Financial malpractice	1	6%
Multiple	0	0%
Patient safety	13	76%
Public safety	0	0%
Unknown	0	0%
Work safety	1	6%
Other	1	6%
TOTAL	17	100%

Patient safety concerns have consistently comprised the majority of calls to the NCAL. Of these cases the concerns mainly involved the following:

• Reorganisation of services leading to understaffing and overworking impacting on patient care

Where callers raised concerns prior to contacting the Alert Line

Of the total 17 public cases, 16 callers had already raised their concern before contacting the Alert Line. This is in keeping with general trends we see on the advice line where the majority of callers are contacting us either because they have raised a concern and indicate they have been ignored and so are looking for other options, or, feel they have experienced victimisation as a result of raising an issue and so are seeking advice on their position in addition to receiving advice on an outstanding concern.

Of the callers who had already raised their concern before contacting the Alert Line, these were raised with:

Where raised the concern	Count	Percentage
Manager	10	62%
Senior Management/Executive	4	25%
Prescribed Regulator	0	0%
Media	0	0%
Other	0	0%
Multiple	2	13%
Unknown	0	0%
MP/MSP	0	0%
Police	0	0%
Total	16	100%

In the majority of cases where this information was shared, callers had already raised their concern internally to their local line management, prior to contacting the Alert Line. This is in line with trends we see more broadly on the advice line and it also the approach advocated in whistleblowing policies that follow the best practice model.

Response to concern at point of contact

The table below sets out the response the 16 callers indicated they received to their concern prior to contacting us.

Response to concern	Incident rate	Percentage
Admitted[1]	3	19%
Ignored	8	50%
Not known	2	12%
Under investigation	3	19%
Unknown	0	0%
TOTAL	16	100%

In 50% of cases callers felt their concerns had been ignored. This is a worrying trend and a more negative outcome than the previous review which found the most prevalent response was that the concern had been admitted. However, this response does reflect findings in our research into 1000 calls to the advice line, The Inside Story,^[2] which found that callers reported that their concern was ignored in 74% of cases. It is important to note however, that some of these responses may refer to a perception that the concerns were ignored either due to a poor or complete lack of feedback from the organisation. Incomplete or limited feedback is an issue we regularly deal with on the advice line. Even is a concern is investigated and resolved, if the individual does not receive adequate feedback they may feel that their concern has been ignored and this can reduce their confidence in the process and may deter staff from raising a concern in the future.

Advice from Public Concern at Work

We cannot provide further detail about the advice given as legal professional privilege applies. We can only provide non-identifying information where this does not breach confidentiality. Set out below is data on where we advised individuals to raise a matter.

During this period one referral was facilitated by PCaW to an external regulator (HIS) on the caller's behalf. In this case we obtained the relevant contact within the regulator and were able to pass this on to the caller so that they could liaise with the regulator directly. Where the individual is willing, this is a more effective way of referral as it allows the caller to discuss and explain their concern first hand rather than for us acting as a go between and communicating with the regulator on their behalf.

When the NCAL was first set up, PCaW agreed an information sharing protocol with HIS. Initially all whistleblowing concerns raised by staff out-with their Board were to be referred to HIS via PCaW. We agreed to set out the concern in writing (email) to assist HIS case workers to better understand the concern itself and to have a clear overview of the situation should the matter be passed to another person for investigation. This is particularly useful where the caller wishes to remain anonymous and the written note is the only information HIS have access to.

Our contact at HIS has advised us that the number of individuals approaching HIS directly to raise concerns (i.e. without first having contacted the NCAL) has increased as staff are now more aware of their status. It remains, however, where an individual wishes for PCaW to refer a case to HIS on their behalf, PCaW will continue to follow the protocol outlined previously, and provide a written summary. This will be recorded as a referral. If PCaW pass on contact details for HIS to a member of staff who has contacted NCAL who is happy to liaise with the regulator directly, this will also be logged as a referral. The Scottish Government should note that in the latter case there may be some discrepancy between the recorded number of referrals reported by PCaW and HIS as the individual may never actually follow up with HIS to report their concern.

The graph above reflects the various options provided to callers about where they might raise a concern. In some cases, depending upon the facts, we might provide advice on more than one option for the caller to consider and this is reflected in the graph. Moreover, we will often advise callers to raise the concern collectively if there are colleagues who share their concern. In cases where this is possible, callers are advised to consider this as an option as it provides safety in numbers so that the issue does not rest with one individual .Raising a concern collectively may also add weight to the concern (because there will be more than one witness to the issue being raised).

In 5 cases we did not provide advice for one of the following reasons:

• the individual had already raised the concern to the appropriate place
• the individual did not call back for advice and we were unable to contact them (i.e. because they did not provide a number or did not answer or return calls)
• the caller was looking for validation on the action they had taken so far as opposed to advice on where to raise/escalate the concern

Where we did advise, we advised the majority of callers to raise their concern with options in the 'Other' category. This included seeking guidance from their union and potentially with the police. There was an increase of callers who already had their union involved in the case. In these cases we will advise the individual that it is best for us to feed into the situation by speaking with their union representative directly on the whistleblowing elements of their case in order to avoid cutting across the union's advice on other private employment aspects of the case that may be present. We also advised individuals to raise their concern with a designated policy lead. The advice line team have access to all Health Board whistleblowing policies which has made it easier for us to offer this as a resource to an individual if they are seeking advice on raising a concern. In most cases this option is given in a situation where the individual has already raised the concern with the line manager and is looking for advice on where to escalate their concern if they have not received a response or are unhappy with the action taken so far.

Public Interest (Whistleblowing cases) in NHSScotland

We also provide information on the numbers of whistleblowing concerns raised in each Health Board where we have this information and the individual cannot be identified. It is not a requirement for an individual to provide the name of the Health Board they are employed by in order to obtain our advice and as such these figures should be seen as indicative only as we have received additional calls from individuals who do not identify their Health Board.

Of the 17 public cases from NHS Scotland, 9 of these identified the Health Board they worked for. Of those 9, there were 7 Health Boards identified. Due to the low numbers received for all of those Health Boards (between 1-3 calls), where the information could potentially identify a caller, we are unable to report cases from any individual Heath Board.

We will be shortly be sending each Health Board an individual report outlining data on both public and private calls received to the alert line.

The running totals of the number of public interest cases received to the advice line for NHSScotland during this 6 month period as shown in the following table.^[3]

NHSSCOTLAND PUBLIC INTEREST CASES	Feb-15	Mar-15	Apr-15	May-15	Jun-15	Jul-15	Running total
Patient Safety	1	7	1	0	3	1	13
Public Safety	0	0	0	0	0	0	0
Financial Malpractice	0	0	0	0	0	1	1
Multiple	0	0	0	0	0	0	0
Ethical concerns	1	0	0	0	0	0	1
Unknown	0	0	0	0	0	0	0
Other	0	0	0	0	1	0	1
Discrimination/harassment	0	0	0	0	0	0	0
Abuse in Care	0	0	0	0	0	0	0
Work Safety	0	0	0	1	0	0	1
Total Public Interest Cases	2	7	1	1	4	2	17
TOTAL UK PUBLIC INTEREST CASES (INCLUDING SCOTLAND)	29	33	10	15	28	26	141

Feedback

We were asked by the Scottish Government to include results on a feedback exercise of callers who contacted the Alert Line. We sought responses from callers over the period covering this and the last six month review (1 August 2014-31 July 2015). There were 32 public cases over this time period and of these we contacted those who had left contact details. Unfortunately this exercise resulted in a low response rate and we were able to obtain feedback from only 5 of the 32 callers in total. We provide a summary of the 5 responses below.

Feedback on advice from PCaW

Question	Response
Was the advice clear and easy to understand?	Y=5 N=0
Was the advice helpful?	Y=4 N=1
Did you follow the advice?	Y=4 N=1
Would you recommend the charity to someone who was unsure whether or how to raise a concern about malpractice?	Y=3 N=2
Did you ever raise your concern?	Y=4 N=1

Outcome for the caller and their concern

Of the respondents surveyed one said that they were victimised/disciplined by the organisation and one reported having been subjected to bullying by co-workers after having raised their concern. Two of the respondents reported that there was no detrimental outcome for them at all.

When asked about the outcome for the concern they had raised, one respondent said they were ignored, another stated that the concern was currently under investigation. Two of the respondents said they did not know what was happening with the concern they raised.

Private Cases (Contractual Matters)

We have included an updated table showing the private cases received by the Alert Line in the stated period.

NHSSCOTLAND PRIVATE CASES (i.e. Contractual Matters)	Feb-15	Mar-15	Apr-15	May-15	Jun-15	Jul-15	Running total
Bullying/Harassment	0	0	1	1	1	1	4
Other	1	0	1	0	1	1	4
TOTAL PRIVATE	1	0	2	1	2	2	8
Bullying/harassment as a second issue in a public case	2	0	0	0	1	1	4
TOTAL BULLYING/HARASSMENT COMPLAINTS	2	0	1	1	2	2	8

We also provide the number of cases where the individual has complained of bullying or harassment of another or themselves. Please note that this may occur in a private case as a single issue. It may also be identified as a second issue in a public case, if unrelated to the public concern. Please note that if bullying or harassment has led to a patient safety issue it will be classed as patient safety in the above public cases.

Bullying/Harassment reports to individual Health Boards

We provide data on bullying complaints from identified Health Boards both to the Health Boards directly and NHSScotland on a six monthly basis.

Due to the low rates of bullying complaints received we do not have substantive numbers to report on as reporting on low numbers from specified Health Boards may risk breaching confidentiality of callers. We have indicated this to each Health Board we have data for. It is important to note that PCaW do not substantively advise on workplace bullying as these are contractual (private) issues, but have agreed to pass on data received to the relevant Boards in order to help with a targeted focus on tackling bullying within NHSScotland.

NHSScotland Whistleblowing Champions Training

Following the success of the previous training delivered to representatives from each of the Health Boards on whistleblowing, PCaW delivered a set of training workshops aimed at the new Whistleblowing Champions. The aim of these sessions was to ensure that Whistleblowing Champions are familiar with policies and support mechanisms required for an effective whistleblowing culture and tools to promote and encourage good practice.

PCaW delivered 2 centrally based training sessions in November and December 2015 in Edinburgh and Glasgow which accommodated representatives from all 22 Health Boards.

The content of the sessions included:

• Introduction to whistleblowing- the history of developments in speak up policy and the creation of the Champion role, including a session considering responsibilities and what the position entails.
• Policy- interplay and integration of various existing policies and procedures. Consideration of key policy messages and best practice
• Reporting and review- a focused session exploring methods, ideas and suggestions on reporting and review. This included attendees working together to share existing methods and innovative new ideas
• Audit and review- exploring the Whistleblowing Champion's oversight role and providing assurance to Board.

The sessions were interactive and included consideration of a tailored case study, open discussion and group exercises.

We provide a summary of the key themes arising from the sessions below:

• It was clear from the discussions that a network of those holding the Champion role will be a useful forum for the post holders to share experience and learn from one another. Given that this is a new role and the subject matter it relates to, it was a common theme in both sessions that a peer to peer network would be a useful forum to develop and share best practice.
• Guidance around what is expected of the champion role, perhaps with a toolkit for ensuring consistency across boards.
• Review of NHSScotland PIN policy to include guidance generally for Boards - perhaps with training packages and training notes (including what is and what is not whistleblowing) generally seemed to be something most of the delegates would welcome.
• A sense of the structure of staff that could be involved in the ownership, operation and review of the whistleblowing process, taking into account the need for named contacts to provide support to staffand the varied demographics and size of health boards across Scotland. We noted that in some Health Boards there is a huge jump from the line manager (usually step one in terms of who to approach with a concern) to those designated as senior contacts in the policy.
• To consider a template flow diagram for Boards to use when updating policy.
• To consider template process for Board reporting.
• To explore how whistleblowing fits with adverse incident reporting and datix across NHS Scotland.

We received positive feedback from attendees for both sessions. Following the training, there is some important follow up work to be undertaken to ensure that the subtleties of the whistleblowing champion role are not lost. As a starting point we would recommend re-circulating the parameters of the role which was included in the delegate packs. It was clear from the sessions that despite the clarity in the role description, there is nevertheless some confusion and the role will take a while to embed.

We sent through a number of our standard documents to help with this work including a diagnostic tool to help managers assess the severity of a concern and whether there is a need to escalate, model training notes and a model whistleblowing survey.

Update on PCaW's work in the Health sector in England and Northern Ireland

As you are no doubt aware much work is being undertaken in the health sector in England following the Freedom to Speak Up report by Sir Robert Francis. We are involved in various aspects of the practical implementation of the recommendations in the review including advising NHS England and Public Health England on their policy roll out, advising on the national integrated policy recommended in the FTSU report and working with individual trusts to help them operationalise the reforms.

We were also successful in a tender issued by Health Education England in the creation of a national training curriculum following the FTSU report. This will include E-learning, train the trainer, face to face training and the development of a Freedom to Speak Up Guardian network and conference. We are keen to work with the new National whistleblowing officer soon to be appointed by the Care Quality Commission in order to ensure that the training options are integrated with any other initiatives arising as a result of the proposed reforms.

We are in the process of considering the development of guidance and supporting documents to help managers who undertake the training envisioned by the FTSU report. In particular help for managers to consider the formal and informal elements of an organisations whistleblowing arrangements, when to formalise a concern and when to escalate the issue as well as consideration of the formal reporting process which will feed into the Management Information collected by each organisation.

Additional matters to consider with the implementation of this work will be how the 'whistleblowing helpline' service in England is commissioned following the implementation of the FTSU reforms. We understand that the NCAL will also soon be considering the recommissioning process. We can envision additional elements to this service such as ADR and mediation as well as an independent investigation service. These are key elements of the FTSU report. We believe that the advice and support elements of the helpline should be considered in conjunction with all elements of the system and reforms currently being considered.

For information we are also in discussions with the regulator for Health and Social Care in Northern Ireland (RQIA) in relation to a review of the sector's whistleblowing arrangements being undertaken in the upcoming 5 months.

First 100 Campaign

In March 2013, PCaW set up an independent Whistleblowing Commission to examine the effectiveness of workplace whistleblowing. After an extensive public consultation, the final report which included a Code of Practice, was released in November 2013. Following the report, the charity launched 'The First 100' campaign which encouraged enlightened organisations to be become early signatories to the Code and show they are committed to best practice in this vital and ever-developing area. The campaign is proving to be a great success and we have already signed up a number of organisations from a variety of sectors and industries. You can view the full list of current signatories on our website. As a client who is driving a lot of change in this area in the health sector, the Scottish Government is perfectly placed to join the campaign. All that is required is an acknowledgement that the Code provides useful and workable guidance for organisations seeking to reach best practice standards on whistleblowing arrangements and culture.

We are hosted an event on Wednesday 18 November 2015; in conjunction with Howard Kennedy. The keynote speaker was Margaret Heffernan, an entrepreneur, CEO, writer, and leading authority on responsible leadership. As the recent Volkswagen scandal all too clearly demonstrates, trust in organisations has never been lower. Margaret discussed how trust in leadership is created so that these crises are avoided and confidence restored. Essential to this is the creation of an environment where it is safe to speak up.

The event provided an opportunity to hear how PCaW's First 100 signatories have implemented the Code of Practice, the challenges they encountered and what they do to ensure their whistleblowing arrangements continue to be effective.

We would be pleased to discuss this review with you and hope it is a useful overview of the Alert Line and how it works in practice.

Recommended workplans for NHSScotland in 2016

Training

• We would suggest exploring options for additional training for the NHS Health Boards. We successfully completed sessions with Health Board representatives and a session specific to the new Whistleblowing Champion role. The next phase of training might be best aimed at line managers. Our research into 1000 cases on our advice line, The Inside Story, found that the large majority of whistleblowers raise concerns at line management level. It is therefore important to ensure that individuals at this level also have confidence identifying and handling whistleblowing concerns. We have a number of options the Scottish government could consider in terms of providing this training:Train the trainer: we run a set of face to face sessions with local HR trainers providing them with the tools, knowledge and materials to deliver their own sessions to managers in house to cascade learning. This options benefits from organising fewer sessions as we will not be attempting to training managers directly but a targeted set of trainers from each locality.
• In house workshops: we run a set of face to face sessions directly with line managers with up to 15 delegates in each session. Participants will benefit from exploring the complex and sensitive issues that arise in handling a whistleblowing concern through case studies and sharing experience.

• E-learning: we can work with NHSScotland to develop an e-learning programme for managers that can include a general introduction to whistleblowing and why it is important, the role and responsibilities of a manager and assistance in handling a concern. The benefit of this option is that the training can be rolled out quickly and easily to a much larger pool of staff. You can also track understanding and completion rates.

Please do not hesitate to contact me should you wish to discuss any of the above.

Kind regards,

Cathy James
Chief Executive