It’s the culture, stupid

Culture, according to Henry ford, eats strategy for breakfast. No amount of regulation or reform can protect patients from harm if the culture remains sick. Healthcare staff, politicians, civil servants, regulators and the pharmaceutical industry have to want to be open and accountable, rather than ordered to be. Which means owning up to and learning from mistakes when they happen, not burying them for years and being retrospectively contrite when an inquiry finally pushes them out into the open.

GlaxoSmithKline (GSK) agreed to pay a fine of $3billion last week, the largest healthcare fraud fine in US history, but just the latest in a long line (Ely Lilly $1.42 billion, Pfizer $2.3 billion, Astra Zeneca $.52 billion, Merck $.95 billion, Abbot $1.5 billion). GSK was found guilty of mis-selling the antidepressant Paxil to children, making claims about a diabetes drug (Avandia) unsupported by evidence, failing to disclose safety data about Avandia and lavishing hospitality on doctors to influence their opinions and prescribing. The company claimed that these various frauds were a decade old and had been sorted. In 2003, they promised to make outcome and safety data from all their clinical trials freely available. But safety data on Avandia was still withheld up until 2007.

GSK is a UKfirm and the Medicines and Healthcare products Regulatory Agency (MHRA) spent four years investigating the criminal charges in the case of Paxil (Seroxat, paroxetine). But whistleblowers were central to the exposure and the fact that the cases were all judged in America, rather than the UK, is in no small part due to the fact that the US takes whistleblowing seriously, has its own National Whistleblower Centre offering advocacy and advice, and gives whistleblowers a share of the fine (in this case 20% of $3 billion). Why? Because there is good evidence that whistleblowing is more effective than the regulatory authorities and saves vast sums of public money and many lives. And theUK should follow suit (Shoot the Messenger, Eye…)

But it won’t. Last week, the Today programme ‘broke’ the story of the super-gag of whistleblower Gary Walker, the former chief executive of the United Lincolnshire Hospital Trust, a story comprehensively covered by the Eye in July and November last year (Shoot the Messenger and Eye 1303 The Gagging Wars). Walker blew the whistle about the danger to patients of being forced to hit simplistic targets to both NHS chief executive David Nicholson (also in the dock over the Mid Staffordshire scandal) and his director of commissioning (and former SHA chief executive) Dame Barbara Hakin.

Walker was sacked on the trumped up charge of swearing and –  without a job, effectively unemployable in the NHS and facing the loss of his home – accepted a settlement of over £300,000 that contained a gagging clause preventing him from making his safety concerns public, and warning his colleagues and supporters not too. The settlement and legal fees for the gag were paid for out of the public purse in the full knowledge of the Department of Health and the Treasury. Now some of his supporters have decided to breach the gag and release documents to the media (including the Eye) which need to be analysed in public in a way that protectsWalkerfrom further persecution. Such is the seriousness of the allegations against Hakin – a former GP – that the Eye has passed them onto the GMC. Nicholson – as with the Mid Staffs inquiry – is unlikely to be held to proper account.

On a brighter note, the (hopefully) safe reorganization of child heart surgery has now been completed, just 20 years after the Eye broke the story of theBristolheart scandal and Professor Steve Bolsin sacrificed his NHS career to blow the whistle. Professor Bolsin has never been officially thanked (now would be a good time) and the structural reorganization can only work if units grow up, put their institutional loyalties behind them and work together to ensure the outcomes, research and training are the best in the world. It’s doable, but the staff have got to want to do it, and the politicians, managers and media must let it happen.