Witness Statement from Dr Phil Hammond

I have been both a general practitioner and journalist for twenty years, breaking the story of the Bristol Heart Scandal in Private Eye in 1992 and giving evidence to the eventual Public Inquiry seven years later. Much of my journalistic work involves supporting and protecting NHS whistleblowers, while allowing their concerns to be made public in a way that could help protect patients from avoidable harm. One of the saddest elements about the high rates of death and brain damage for babies undergoing complex heart surgery in Bristol was that the problems were well known within the heart surgery community and regulatory authorities, and yet no-one – save for whistleblower Stephen Bolsin – saw fit to act.

Despite legislation to protect those who blow the whistle in good faith, I am not convinced that the lot of the NHS whistleblower has improved much over 20 years, nor that we have got any better at stepping in to protect patients from harm when concerns are raised. This is well documented in the recent Private Eye supplement, Shoot the Messenger. The Francis Inquiry may well find that NHS staff are now even less likely to blow the whistle, rather than more.

Staff that do blow the whistle are frequently marginalised, counter-smeared and suspended, and many subsequently agree to a modest pay off with a gagging clause to protect themselves from personal and professional ruin. The gagging clause is counter to DH guidance and technically not enforceable under PIDA, but few whistleblowers have the strength and legal resources to risk breaching it, and so their legitimate safety concerns are never made public and there is no evidence that they have been addressed.

Gagging clauses seem to occur in all walks of life for all sorts of reasons, and it may be that some are used by staff themselves to hide their own failings when they move jobs. However, the wider point remains that public money should never be used to suppress information that may be in the public interest. Gagging clauses provide management with a powerful tool to suppress stories of medical harm and cover up management wrongdoing (particularly the failure to act swiftly and appropriately when concerns are first raised).

I believe that many doctors who have previously been silenced would welcome the opportunity of openness and it might ensure action is taken on long standing safety problems. To maintain trust in the NHS, we need to explain why and how public money has been used to silence doctors. It would not harm the profession for this information to be released, and it may even improve it. In future, I would hope the CQC will assess the culture of the NHS by asking hospitals to provide evidence of how they responded to whistleblowers’ concerns, and whether the whistleblowers  were happy with that response, rather than unable to comment.

Signed……………….

Dated………………..

18th June 2014

Rt Hon Jeremy Hunt MP
Secretary of State for Health
Richmond House
Whitehall
London

Dear Secretary of State

Thank you for meeting with us today to hear from whistleblowers across the NHS.

We were heartened to hear your praise for our courage, and how you saw us as being at the ‘vanguard’ in showing how the NHS culture is still intolerant of whistleblowing.

We are looking to help you achieve the cultural change that is overdue, in order that NHS staff feel safe to report their concerns about harm to patients.

At present, we have the opposite of a witness protection program, where staying silent is rewarded by payoffs and relocation, whereas speaking up gets you ‘buried in the woods’. Until this changes, and NHS staff can see for themselves clear examples of restorative justice, NHS workers can never feel safe to raise the most serious concerns about patient care.

Our position is that a public inquiry is now required to reveal the whistleblower’s journey in full and show how the ‘middle’ – that complex interaction of Boards, Unions, Colleges and Legal gaming of PIDA (PIDA avoidance) – puts patients and staff in harm’s way.

The call for a public inquiry already has wide expert support from a number of leading figures, ranging from Sir Brian Jarman to the President of the Royal College of Physicians.

Without a substantive inquiry, the top of the NHS will again fail to get to grips with the powerful culture of the ‘middle’, while the sharp end of the NHS will continue to suffer.

Inquiries can take time and may be expensive. But the 13-year Mattu case shows how the NHS can spend £20M on a single whistleblower, over a clear and neglected matter of patient safety. And patient harm is very expensive in every sense.

‘Plebgate’ revealed the police union culture – now courageously critiqued by Theresa May. Similarly, an inquiry is needed to reveal how health unions and others, help to suppress concerns and manage whistleblowers out of their posts. Please bear in mind that the latter experience was shared without hesitation by every whistleblower in the room today. Roger Kline has worked for eight unions and he too agreed. Only a public inquiry will have the powers to ensure that these organisations that operate in the midst of the NHS are held accountable, and required to reform.

Without this inquiry, the best intentions at the top of the NHS will be frustrated. Having an ombudsman for whistleblowers is supportable, but we know from Clywd-Hart it is not sufficient. Reform to professional codes will not help if culture does not change. After all, Raj Mattu is a whistleblower and yet one of the doctors most investigated by the GMC. In contrast, Harold Shipman was investigated once, but the GMC missed his lethal intent.

We appreciate that your consideration of these matters may take time. Therefore, in the near term, we wish to engage with your teams via working groups, to flesh out interim proposals required urgently to protect staff and patients at risk now.

Finally, we also wish to work again within the NHS to support the culture change and to protect patients. This would be the most positive form of restorative justice being urged by Ann Clywd.

Yours sincerely

Ms Loo Blackburn
Ms Sharmila Chowdhury
Dr David Drew
Ms Jennie Feccit
Dr Edwin Jesudason
Professor Narinder Kapur

cc Mr Simon Stevens, CEO NHS England

Ms Fiona Bell, Cure the NHS North East
Dr Kim Holt, Chair, Patients First
Mr Roger Kline, Director, Patients First
Dr Raj Mattu, formerly Consultant Cardiologistwe

Urgent Investment Needed in Young People’s Mental Health Services

The British Medical Journal’s erroneous over-egging the risks of side effects of statins lead to former heart surgeon Sir Magdi Yacoub pronouncing that everyone over 40 should be on a statin to lower their cholesterol. Whilst statins can be life saving for those at high risk of heart disease and stroke, there is no evidence that the mass medicalisation of those at low risk and with no symptoms, would do any good. Making everyone pill-dependant, anxious and ‘at risk’ at the age of 40 is hardly a recipe for happiness, and the money would be much better spent on mental health services which are failing badly in the NHS.

A report by NHS England leaked to the Observer has found that only a quarter of children with mental health conditions receive the treatment they need, but this is hardly news. Multiple previous reviews have found the same problems, but the current budget cuts and increasing demand is tipping the service into crisis. Only 6% of spending on mental health goes on services aimed at children and young people, yet 50% of lifetime mental illness starts by the age of 14. MD’s own experience of trying to access mental health services for young patients it that they have to be very severely ill before they will be seen in many parts of the country. So young people with moderately severe anxiety and depression are left to deteriorate with no specialist care until they get bad enough to warrant it, often by self-harming or suicide attempts. NHS England  found that whilst 35% of adults with anxiety or diagnosable depression are not in contact with mental health services,  this rises to 76% for those aged five to 15.

There has also  been a sharp rise in the number of young people needing assessment for complex conditions such as attention deficit hyperactivity disorder (ADHD) and autism, and many face severe delays or are not seen at all. The report echoed MD’s experience that many services were unable to offer early intervention and we’re becoming ‘urgent only.’ In England there is only one mental health specialist per 30,000 young people under 20, compared with one per 5,300 in Switzerland, 6,000 in Finland and 7,500 in France.

A recent survey by YoungMinds, a mental health charity, found that two-thirds of local authorities had cut their budgets for young people’s mental health. Sarah Brennan, chief executive of YoungMinds, told the Observer: “It is verging on inhumane for children and young people to end up, as they do now, being shipped hundred of miles across the country for the nearest bed, held in police cells or placed on unsuitable adult wards. We should be ashamed of the paltry support and care we assign to the mental health of children and young people in this country.”

The government is investing a modest £17.4m to try to improve earlier intervention, diagnosis and treatment of mental health problems in under-18s, and the hope is that technology in the form of ‘e-Therapies and computer based-applications’ will work for the prevention and treatment of less every mental health problems and substance misuse in this group, to take the strain off frontline services. A recent systematic review of these services by the  National Collaborating Centre for  Mental Health found that the evidence of their effectiveness was limited. ‘When considering  e-Therapies collectively, the treatment delivered shows promise and may be beneficial for improving the mental health of some  children and young people.’ It also stressed that ‘e-Therapies are not a replacement for face-to-face therapy and, if used, should form part of a child or young person’s overall therapeutic plan.’

Clearly more research is needed, as is current data on the numbers of children and young people with mental health problems. The last national study was done 10 years ago and so commissioners are either ignoring the problem or ‘buying blind’ which is unlikely to result in a rational, cost-effective service. There is good information for young people with mental ill health and their carers, such as the MindEd website launched by the Royal College of Psychiatrists in March. It helps parents identify mental illnesses in their children at an early stage when early intervention could stop it progressing. GPs manage most mental health problems, often very effectively, but if referral to a specialist service is needed, it’s a long wait to get the right care. Mental health services are  much less sexy than, say, those for cancer and heart disease, but those with mental illness are at far higher risk of physical illness too and the impact on the whole family is huge. And the later the illness is picked up, the more damaging and costly it is. To deny proper care is a false economy as well as inhumane.

No Jerks, we’re British

Most of the debate about the proposed merger between Pfizer and Astra Zeneca focused on whether Pfizer would asset strip and make thousands of UK employees redundant. But what’s it like working for Pfizer? An employee has sent MD details of an ‘excruciating’ No Jerks staff development program where everyone was given a ‘No Jerks’ self refection survey, ‘Straight Talk Tools’ and the ‘Let’s Discuss Behaviours’ coin.

Pfizer is a global company and presumably aware that jerking has a number of off-message meanings. ‘Often jerk like behaviour is subtle and nuanced but equally as destructive as the more overt bullying and belittling behaviours we often think of.’ Pfizer asks its employees to identify such behaviours in themselves. ‘Is your focus always on your own goals, rather than Pfizer’s? Do you think nothing of belittling others for affect or sport? Do you indulge in whisper campaigns, trade on position power and threats, over-react emotionally and take credit for the work of others while being negative and subversive in the face of change?’ If you were foolish enough to answer ‘yes’ to any of these, you may no longer be working for Pfizer.

The No Jerks Survey was apparently adapted from ‘The No Arsehole Rule’ by Robert Sutton PhD. The idea behind ‘Let’s Discuss Behaviour’ coin is to ‘facilitate a challenging conversation’ by placing the coin on the table to discuss errant behaviour or give ‘targeted one-on-one feedback’ Does such a controlling approach to staff behaviour suppress those trying to express legitimate concerns about product safety or mis-selling? In 2009, Pfizer paid $2.3 billion (including a criminal fine of $1.2 billion) to settle fraud claims about four drugs (Bextra, Geodon, Zyvox and Lyrica.) Not enough to sink a company that turns over $67 billion, but a shocking embarrassment none the less and a reminder of the importance of whistle blowers on the staff. Would staff who expose such practices be considered as jerks and non-team players who follow their own or the patients’ agenda rather than that of Pfizer?

Pfizer has at least started down the route of more openness and transparency about what it does. GlaxoSmithKline, which has also been fined heavily for mis-selling and is currently under investigation in China, was first to sign up to the All Trials campaign, which commits a drug company to publicly sharing all results, on all trials, of all uses, of all their medicines currently being prescribed. At present, the best evidence suggests that between a third and a half of all clinical trials conducted have not been published. And trials with positive results are twice as likely to be published as those with negative results. So researchers are being kept in the dark and doctors and patients are lulled into believing drugs work better than they actually do, and with fewer side effects.

Pfizer has yet to sign up but it has launched a portal through which ‘qualified researchers can request access to anonymised patient data from completed trials of approved (or discontinued) medicines and indications. And it’s pledged to publish synopses of clinical study reports CSRs) on its website for trials dating back to September 2007’. However, this will exclude “off-label” studies, even though such uses are commonplace and very profitable, and it was the unethical promotion of off-label usage that lead to Pfizer’s extremely large fines. It’s imperative that this trial data is not kept secret.

Pfizer must also publish results of older trials, which relate to many of the drugs that are most commonly used now, and publish its CSRs in full, not just as summaries. Important information on results and methodological flaws are only available in full CSRs. The corporate rap sheet for Pfizer does not make pretty reading, and its biggest wrongdoings have only come to light thanks to whistle blowers who have exposed the company for making claims about its products that can’t be substantiated by the evidence. The safest way forward is not to rely solely on whistle blowers but for all companies to sign up to All Trials and to put all the evidence on all their drugs in the public domain. Pfizer and AstraZeneca should be obliged to do this prior to any merger. www.alltrials.net