Dr Peter Brambleby and the N&N PFI Flagship

Dr Peter Brambleby is a public health doctor.  When he started looking into the lack of delivery of negative pressure beds (used for pandemic flu and respiratory illnesses) at the NHS flagship PFI hospital, he was threatened with “ending up in the woods like David Kelly”.  This is a fuller story.

A National Stealth Service

Norfolk’s new hospital was supposed to be the flagship for NHS hospital building under PFI, and then one of four new Foundation Trusts.  Yet it came to be called “the unacceptable face of capitalism in the NHS” by the Tory chair of the Public Accounts Committee, and despite all its technical and economic advantages it failed to meet basic criteria for Foundation status in the first wave and slumped into the slow stream.  Where did it all go wrong?  Evidence points to aggressive personalities fixated on narrow personal and organisational objectives, weak challenge from commissioning and scrutinising bodies, an avaricious private sector looking at easy pickings from a bloated public service, and a gradual drift away from the NHS core values of care and compassion, and away from the Nolan Principles of conduct of public affairs.

Many unanswered questions remain about the leadership of the Trust and the wider NHS climate in which it operated and was rewarded.  The experience of a local public health doctor, later turned whistleblower, illustrates a wider malaise and lessons that still haven’t been learned.

The Norfolk PFI initiative had its origins in the previous Tory administration but was enthusiastically embraced by New Labour project, especially under Alan Milburn when Secretary of State for Health.  It ticked all the right boxes: ambitious, modern, private partnership, American connections – and all off balance sheet.

Negotiating PFI contracts and steering such projects was new for the NHS and the Department of Health but, curiously, it was not seen as a priority to capture the learning for all those who followed.  Commercial interests dominated.  Secrecy became a defining feature.

Much of the credit for the project, but so too much of the blame, has to rest with the charismatic and controversial chief executive of the hospital trust who steered it through the design, build and opening phases – Malcolm Stamp.

Concerns about lack of openness surfaced at the Parliamentary Health Select Committee on 20 May 1999 where puzzled MPs asked Stamp:“We cannot possibly make a judgement on whether it is value for money if vital information which enables one to make that comparison is denied the Committee.”  When asked who decided it should be kept from them, Stamp said it had been taken out of his hands and: “We are part of a wider NHS family and we had to liaise with the NHS Executive as well as lawyers and the private sector in bringing this to a conclusion.” But he went on to reassure MPs: “If there are problems in construction and it does not pass the independent certifier we do not occupy it and we have not paid anything out.  Because it is Octagon’s building and they have it for 60 years, if there is some inherent problem in the construction then that is a problem for them and they will need to rectify it.  That is a risk that has been transferred.”

A BBC TV documentary on PFI entitled “The only game in town” was shown in 2000, featuring an interview with Stamp.  The producer, John Mair, wrote up his curious experience in the Health Service Journal of 7 December 2000, under the heading “Stealing the show: secrecy seems to go with the PFI territory”.

The “Pirate” Finance Initiative

Later, a study published in Public Administration, Vol 85, no 3, 2007, by Greenaway, Salter and Hart, entitled “How policy networks can damage democratic health: a case study in the government of governance” made the following observations.  “In the mid 1990s, under Stamp, the Trust was able to play a pivotal role in structuring the power relations rather than simply operating within existing power structures. … To be successful, such entrepreneurship depended on closing down of opportunities for others, the exclusion of rivals, and the tight control of information flows within and between networks … What it did not need, and could not countenance, was open democratic consultation and debate.”  The authors quoted senior interviewees’ opinion of Stamp’s style, including “very bright”, “a man with a mission”, “a clever tactician”, “a bully” and “a buccaneer”.

So there it was – a buccaneer on the bridge of the flagship.  This had become a Pirate Finance Initiative.  Or more correctly a Privateer Finance Initiative, since the pirate was state-sponsored.

The Curious Case of the Toothless Watchdogs that Didn’t Bark in the Night

Stamp had close friends in high places and was well rewarded.  He had then, and continued to have, a track record of delivering high profile projects, though closer inspection shows a pattern of overspent local health economies in his wake: Liverpool, Norfolk, Cambridge, Waikato (New Zealand), London, and Coventry.  In 2010, according to the Daily Telegraph’s rich list of NHS managers, Stamp came 23rd, on £217,500 per year, more than the chief executive of the NHS (£212,500) and Chief Medical Officer (£207,500).

Stamp’s social partner during the latter period in Norfolk was Professor Shirley Pearce, a rising star of the University of East Anglia who successfully steered through a bid for a new medical school at what became the “university” hospital.  She was a non-executive member of the Strategic Health Authority (SHA) and the Healthcare Commission – two critical supervisory bodies for standards at the new hospital.

So well-connected was Stamp that even when, in 1999 he crashed his car while drunk, acquiring an 18-month ban and hefty fine – he still was left in charge of the hospital and its project.  Would an ambulance driver or bus driver be given that kind of latitude?

The SHA gave Stamp’s project every assistance, especially financial bail-outs and “smoothing payments” as costs began to escalate and the political and contractual stakes grew too high for it to fail. Those stakes included the whole multi-billion NHS PFI pipeline and many political careers.

But where was the local Norfolk Health Authority in all this?  Marginalised.  Emasculated.  Just as much in thrall to the SHA as the Hospital Trust.  Led by a donnish ex-Cambridge economist called David Walker, the Health Authority grew weary of rebuffs from Stamp’s Trust and gradually stopped asking questions – for example on design specifications or hidden clauses about rent increases – and settled into a sulk of frustrated helplessness.

And so the flagship disappeared into the fog.  A few design details were lodged at the local library but heavily redacted under “commercial in confidence”, and photocopying prohibited.  Even the clinicians, who were initially consulted on their requirements, were left out of later specifications changes.

Some Not Very Public Health

In 1996, a year after Stamp’s arrival, the local Norfolk Health Authority recruited a public health consultant, Dr Peter Brambleby, to assist in commissioning health care from the hospital.  His clinical background was in child health but he was recruited largely for his interest in a health economics approach called “programme budgeting”. This is simply a way of relating costs to outcomes grouped by health programmes such as heart health, bone health, mental health and so on, rather than the traditional breakdown by hospitals, GPs and community services.  He admits to being naïve about PFI and market forces at that time, being much more interested in the interdependent relationship between all parts of health and social care.  His interest was in how to deploy a given budget to best effect with maximum involvement from all sides (including the patients, and including prevention).  He argued that no hospital could be successful on its own without a network of GPs, community hospitals and social services.  But in the embryonic “NHS internal market” these ideas were old hat.  Hospital activity, not health improvement, was the dominant objective.

In a letter to Brambleby dated 21 January 1997 Stamp made “an emphatic rebuttal of programme budgeting.”   The hospital trust also declined to sign up to a 10-point summary of perceived problems and proposed solutions, aimed at improving commissioning dialogue, that Brambleby submitted in June 1998.  This had included a proposal to adopt an “open book attitude on costs, activity and outcome.”  Instead, Brambleby was summoned to a private meeting in Stamp’s office to be warned off.

As time passed, Brambleby continue to ask questions at commissioning meetings.  For example, if the hospital was planning electronic records, how should the GPs be trained and equipped to facilitate this …by e-mail referrals for consultations perhaps, and electronic links to pathology results?  And if the hospital was getting state of the art digital x-rays (the sort that are viewed on a computer, not as a film on a light box), then how would this work in the community hospitals and hospices after discharge … shouldn’t matching investment be made across the local health network?  How was it that the cervical screening laboratory was declared unfit for purpose as soon as it was opened and had to be rebuilt?  Why were the locker facilities for staff abandoned along with the idea of all clinical staff wearing scrubs?  And why, in Europe’s newest hospital, were the infection control team relegated to a semi-permanent Portacabin in the car park?

No answers.  This was not seen as commissioners’ business.  Information technology was the domain of the now infamous McKesson contract (see Eyes passim “McCock-up”, October 2004).  This was an American system so patently unsuited to the British NHS that it fell over not long after the hospital opened and its employees had to be brought in-house.  Ironically a number of its bemused analysts found themselves NHS employees with anomalous private health care entitlements.

Stamp was rewarded with a CBE and promotion to lead Addenbrooke’s hospital in Cambridge.

By late 2003 and early 2004 Brambleby started getting approaches from senior clinical staff, now installed in the new building, expressing fears about safety and build quality, and claiming lack of management action.  Two were infection control sisters who had resigned over what they called a culture of bullying and marginalisation.  Another informant was a former matron who to this day has asked to remain anonymous, though Brambleby did persuade her to talk by phone to an inquiry team.  The fear was palpable.  One informant reported a confrontation with Stamp who told her “a bed is a bed and I will determine how it is used”.  Another had struck up a personal relationship with an engineer on the building project who lifted ceiling tiles and showed her the unconnected ventilation ducts.  Photos were taken and later shown to an internal inquiry, but these images were not used in its report.

Three consultant physicians were amongst Brambleby’s informants.  One had written to trust management expressing concern about clinical risks from air-borne infection.  Another had expressed disquiet about ventilation and overcrowding in neonatal intensive care and the standards of electrical fittings.  A third shared with Brambleby a copy of a document from the trust’s estates department to the PFI building consortium that detailed eight specifications for respiratory isolation rooms that had not been delivered.  The first of these informants changed his risk assessment under pressure, before taking 3 months off sick.  The second resigned and found a job in another hospital.  The third took early retirement.  Collateral damage was considerable.

In January 2004 Brambleby, by then Director of Public Health for the new Norwich Primary Care Trust, took the ventilation issue as a test case and sent a probing letter to the hospital estates manager, copied to the hospital’s chief executive (now a successor to Stamp called Stephen Day) and to his own PCT chief executive (Dr Chris Price).  He wanted a definitive position statement on number of rooms that were fit for their intended purposes.  This was at the height of the SARS scare.  It took three months to get an answer.

That answer was so unsatisfactory that Brambleby passed his concerns on to Sir John Bourn, Comptroller General of the National Audit Office on 31 March 2004 (see PE, Medicine Balls, Sept 2010).  His primary concern was the failure to follow the Nolan principles for conduct in public life, namely: selflessness, integrity, objectivity, accountability, openness, honesty and leadership.  The breakdown in commissioning dialogue, systematic secrecy and failure to learn were putting patients at risk as well as failing to deliver the promised value for money.  The dangerously non-functional respiratory isolation was a particularly florid example, but just one example, of the consequences of these failures.

Incidentally, both Milburn and his special adviser Simon Stevens, major authors of the NHS Plan of 2000 and advocates of greater private sector involvement in health care, had gone on to lucrative associations with private healthcare.  In 2004, for example, Milburn had given a seminar to the bankers who re-mortgaged Norfolk’s PFI hospital, for a fee and at a swish south of France hotel.

In a carefully worded statement to the NAO, shared in advance with his chief executive (for information but not for permission) Brambleby included the following statements:  “The allegation they [three nurse informants] make is that the contractors of the PFI for Norwich never built the specified positive/negative air flow ventilation, and that this was either with the full approval of the Trust as or cost-cutting exercise, or without approval, ie fraudulently…. My concerns are these: … the lack of openness … the needless exposure to risk from respiratory disease of the staff, patients and visitors to the hospital, due to a combination of poor build, poor project management, misinformation and delay … So much was cloaked in secrecy what assurance have we that other corners were not cut … We need a credible, third party inspection of the building … I have not shared [this letter] with Malcolm Stamp or Peter Houghton [chief executive of the SHA], since there may need to an investigation into their handling of the PFI project, but they should be given the opportunity to comment on the facts as I have understood and related them … If there is evidence of wrongdoing I hope you will root it out, if there are ways of mitigating costs to the public purse I hope you will ensure the private sector picks up its share, and if there are implications for further PFI schemes I hope you will give the wider lessons due publicity.”

It is worth pointing out that the job description of all England’s directors of public health includes the requirement to produce “an independent report on the health of the population”.  Furthermore, for DsPH who are medically qualified, there is a requirement from the General Medical Council that, as for any doctor in a management role, they should insist their concerns are documented and that if they truly believe patients are at risk they must escalate it, and even make it public if all else fails and they have taken professional advice.  Brambleby wrote to the Chief Medical Officer and Regional Director of Public Health, offering to submit to an audit of everything he had written and done, as a test case of the role and independence of the DPH, but this was declined.

The response of the NAO was to refer the matters straight back to the hospital and SHA to investigate!  The NHS-DH axis instantly swung into damage limitation mode in a well-rehearsed set of moves which are listed below.

How to Tackle a Whistle-Blowing Incident – the NHS Guide

1.  The service under complaint must instantly assure the higher tiers in the chain of command, including ministers, that this disclosure is a lone aberration and will be swiftly closed down without further embarrassment.  Ministers did not want to know the truth – they wanted it sorted.

2.  Accept the bare inescapable facts and play them down.  Ignore the rest and ascribe accountability to the lowest tier possible.  Better still hold no-one accountable because to finger someone for blame might set off a chain of questions of accountability that could get embarrassing.

3.  Issue a statement that the matter will be thoroughly investigated.  Offer to set up an inquiry, before someone truly independent imposes one, and make sure its terms of reference steer well clear of the true problem. Choose its members with care.  In the N&NUH debacle, despite being named as witness, SHA chief executive Peter Houghton was quick off the mark to set up his own inquiry, steering its remit well clear of any exploration of systemic problems or Nolan principles and focussing chiefly on the ventilation issue.  He appointed a non-executive board member of the Norfolk and Norwich Trust itself, David Wright, as chair, and all the other members from within his purview in the region – no outsiders.  As a safety net, the secretary to the inquiry, though not a formal inquiry member and therefore absolved from declaring interests, was Anna Dugdale – Malcolm Stamp’s director of finance.  Brambleby protested in writing about this perceived clash of interest, but was ignored.  This was an internal inquiry masquerading as an independent inquiry.

4.  Make sure the chair is tactfully steered away from anything contentious.  In fact, David Wright deserves credit for unearthing significant new evidence, and it is unfortunate that neither he nor his inquiry members followed through.

His first contribution was to commission Silcock Dawson, building services consulting engineers, to look into the chain of specifications and changes.  Their June 2004 report was revealing and damning but they were taken off the case before following up all the leads.  They found, for example, “The review has shown that there has been a change from the first set of the Trust’s Requirements to that which has been provided and handed over.  It is not possible to say how these changes were arrived at from the information reviewed to date….From a review of the site the Isolation Rooms as originally constructed are not capable of consistently maintaining a pressure regime.” They went into considerable technical detail about the changes and why the supposed isolation rooms were not fit for purpose.  Most telling of all, they found “The Independent Certifier’s commission … states: “Familiarise itself with the Project documents and Design Documents and any Variations issued from time to time …” On 28 July 2000 the Project Company wrote to the Trust with a Schedule … of design documents … the letter requests confirmation that the trust considered these schedules as correct … but these have not yet been found … It would appear therefore that the Independent Certifier was not reviewing the Trust’s requirements, and confirming these being met but only the installation was in accordance with the drawings.  It can only be assumed that the Trust’s other advisers should have ensured the design had been developed to meet the Trusts Requirements as part of the Design Approval Request procedure”.

The second contribution was look into Brambleby’s assertion of a less than open and honest management culture.  He called in external auditors Bentley Jennison to look into adherence with Trust policy on declarations of interest.  They reported on 8 November 2005 that: “60% of staff who responded were not aware of the policy; hospitality in the form of lunches, evening meals, accommodation, transport and trips are readily accepted by staff from companies that they deal with; only 20% detailed that hospitality was recorded in a register as the policy requires; 9.5% of staff who indicated they were involved with contracts were not aware that companies invited to tender should receive a warning of the consequences of engaging in corrupt practices involving employees of public bodies; 91% of staff who responded have not signed statements subscribing to the Code of Conduct for NHS Managers.; only 40% of the staff who responded confirmed that the policy on declarations of hospitality and potential conflicts of interest had been brought to their attention at some point during their employment with the Trust; 43% of the staff who responded detailed that they had been offered hospitality … some hospitality could be deemed to be outside of what the policy details as normal and reasonable, for example a company with whom the Trust does business taking two thirds of a department out to lunch twice a year.”  Even more worrying was that only 2 out 24 clinical directors bothered to fill in the audit, and only 24 out of 243 consultants!  With such a tiny participation who knows what the real situation was.  Such was the culture that Stamp ran, encouraged and led by example. This aspect of the inquiry was suppressed until obtained by MP Norman Lamb and put in the public domain.

5.  Marginalise the whistleblower.  This is easiest if it is an ex-employee because she or he can be portrayed as a bit of misfit harbouring a grudge.  If they are awkward and remain in post, as Brambleby did, then isolate them from further disclosure by offering them “special leave at this stressful time” (he declined), suggest a referral to occupational health (he had pre-empted this by self-referral and clean bill of health) and then issue a gagging letter signed by the chief executive of the employing organisation and copied to the chief executive of the SHA for emphasis.  Brambleby got his gagging letter on 6 May 2004, six weeks after writing to the NAO.  He politely acknowledged it, accepted full personal responsibility for actions, and pressed on.

6.  Denigrate the whistleblower.  Say he or she has exaggerated, was stressed, had a grudge, or just plain lied.  An accusation of potential libel works a treat.  This is sufficiently vague as not to need substantiation but implies lack of honesty and integrity on the part of the whistle blower and the reverse on the part of the astonished and wounded accused party.  It also means all their evidence can conveniently be suppressed “while we take advice”.  Stamp, when shown the correspondence accused Brambleby of libel, and his employers too because Brambleby had written on PCT notepaper and in his capacity as their DPH.  Cleverly, this was not done directly, but via his successor at the hospital, the unfortunate Stephen Day who soon afterwards left his job with less than a day’s notice.  Wright’s final report to his hospital’s board on 7 September 2004 opened with the statement: “Our legal advice is that in part some could be considered defamatory.  For this reason we have been unable to place the correspondence from Dr Brambleby in the public arena.”  This was not only a gratuitous slur, unsupported by any evidence, but a massive cop-out and smoke screen.  The report stayed on the Trust’s website for months until removed on the insistence of lawyers acting for Brambleby, but no retraction or apology was ever made.

7.  Be economical with the truth or just lie.  The Wright report is a catalogue of inaccuracies that they must have known to be untrue, or they were hopelessly negligent in checking their assertions.  Take three main findings as examples:

  • “The absence of functioning negative pressure rooms has resulted in no additional material risk to safety of patients, staff or visitors.” This is rubbish – the fact that they found no harm didn’t mean there was no risk – why else have ask for the rooms at all, or spend a reported £80,000 at NHS expense to fix them later?  Brambleby hadn’t been allowed to attend the risk assessment, and when he later pointed out errors in their epidemiological report his corrections were not added.  And away from the respiratory unit, the trust did get an outbreak of Clostridium dificile (with four deaths) and 19 cases of PVL staphylococcus on the neonatal unit with one death.
  • “The failure to provide negative pressure rooms resulted largely from a lack of clarity of what was required.” In my opinion, rubbish – there were detailed specifications in existence, based on their own experience with their own burns unit, technical guidance from elsewhere such as the USA.  And they admitted losing key design documents, but inexplicably failed to ask the builders to lend their copies.
  • “That there is no evidence of fraud, corruption or negligence.”  In my opinion, rubbish – although they called in the NHS counter-fraud squad (itself accountable to the NHS/DH axis) they just stopped looking as soon as they encountered resistance, and didn’t bother to interview Stamp himself since no evidence from him is reported.  Or did they?  The absence of any testimony from Stamp or Houghton, named as key witnesses in Brambleby’s disclosure letter, was so stark it prompted Lamb to write to the Trust under the Freedom of Information Act, asking why this was so.  On 8 August 2006 Anna Dugdale replied that “Malcolm Stamp and Peter Houghton did not submit any written evidence to the inquiry.”  This is not true.  Amongst a separate set of papers released years later to Brambleby at the insistence of the Information Commissioner, is an e-mail from Stamp dated 17 May 2004, to Stephen Day, directing the inquiry to a former member of his staff who would have relevant information and stressing the role of the Independent Certifier.

Wright’s report steers scrupulously clear of allocating any personal accountability to any individual for any of the failings despite admitting that failures did occur.  It was a whitewash and a cover-up.  After receiving this report at the September 2004 Hospital Board meeting, not a single board member contacted Brambleby for his reaction or to fill in the gaping gaps.  Sir John Bourn of the NAO accepted the report in full and declined to respond to a critique of it that Brambleby sent him a few days later.

8.  Threaten the whistleblower.  The SHA press officer, Peter Davies, warned Brambleby to reflect on the fate of the late Dr David Kelly who was found dead in the woods with his wrists slashed – a comment he later repeated, claimed was appropriate and said he was acting under orders.  Brambleby’s chief executive, Dr Chris Price, formally complained to Houghton about this (see eyes passim, Sept 2010) – and resigned straight afterwards.  Meanwhile, Jewell summoned Brambleby to a quasi-disciplinary hearing attended by the Regional DPH (Dr Gina Radford) and recorded by the SHA personnel department.  The status of that meeting and where its records were shared were never disclosed, but in documents later released under FOI it was evident they were discussed at DH level and underwent at least one significant rewrite accordingly, for example deleting reference to the David Kelly threat.  The purpose of this meeting was to assure the top of the office that Brambleby had been dealt with.  (Dr Price’s complaint was eventually investigated and upheld, but Davies never apologised, and the SHA only apologised to Brambleby when prompted by a solicitor’s letter).  Mentor had become tormentor.  Jewell set up two risk assessments – one of the hospital’s respiratory isolation and the other of all the Region’s hospitals isolation facilities.  He barred Brambleby from attending both.  The look-back exercise showed the hospital’s respiratory ward had indeed nursed high risk infectious respiratory patients though there was no evidence of onward spread.  It is impossible to track all possible contacts and be certain no-one later came to harm or died, and many contacts were vulnerable cancer patients or otherwise immune-suppressed. Fingers crossed.

9.  Silence the whistleblower.  Political damage-limitation was imperative.  The Lib-Dem MP for North Norfolk, Norman Lamb, was asking awkward questions.  Dr Tony Jewell, SHA Medical Director, wrote to Brambleby on 17 October 2005 saying “Hope you are still keeping away from PFI/briefing local MPs – since you mention the fact that N&NUH [Norfolk and Norwich University Hospital] is PFI which is not strictly relevant”.  The clear inference was that NHS business was no matter for local democratically-elected representatives.  Private means private in PFI.

10. Confuse the lines of accountability in a maze of overlapping regulators.  Then it is nobody’s fault (or everybody’s) and no-one is accountable.  Simple.  Brilliant.  In an exchange of e-mails bordering on the farcical, Jewell asked Brambleby why he hadn’t followed “normal expected channels”.  Brambleby’s exasperated response on 24 May 2004 included the following paragraph: “I had to choose between the Health Protection Agency (which I used first), Norfolk and Norwich University Hospital (which I used next), Norwich PCT (which I copied in), Strategic Health Authority and Regional Office (who I believed already knew and were part of the problem), Norfolk Overview and Scrutiny Committee (on whose expert panel I serve), Health and Safety Executive (who had previously prosecuted the hospital), Healthcare Commission (clinical governance), Commission for Patient and Public Involvement in Health (patient interest), Emergency Planners (unknown readiness for biological incident), Ombudsman (unsatisfactory answers to letters), Audit Commission (possible financial irregularities), Chief Medical Officer (he is now briefed), General Medical Council (potentially underperforming doctors at various levels), local members of parliament (I copied two MPs into the NAO declaration), etc, etc.”   Jewell did have the grace to admit there was no written escalation policy.

11.  Ignore, delay and deny.  From the outset Brambleby appealed for openness.  He made repeated attempts to check the accuracy of briefings about him to ministers and others, to be met with outright refusal.  He has seen evidence, albeit with date and author redacted, of a highly inaccurate briefing from the SHA to John Reid, then Secretary of State for Health, including the reference to libel, but far too late to correct it.  It was only on the intervention of the Information Commissioner years later that other details were released, either to Brambleby or to Lamb, though these too were heavily redacted.  The DH and NHS do not do openness.  They cannot handle truth.  The SHA had even written to Brambleby denying that any such personal references existed, which was clearly untrue.

Dr Brambleby’s Survival Tips for Whistleblowers

  1. Be sure of your facts and don’t overstate your case.
  2. You do not have to have concrete proof to raise concern about possible risk to patients and staff, of management failures or outright fraud. In fact, arguably, you are on dodgy ground if you do have serious concern and don’t act.
  3. If you are attacked you are almost certainly on the right lines – take it as an encouraging sign and press on.
  4. Take legal advice early on. In retrospect, Brambleby admits he was under-trained and inexperienced for a challenge of this magnitude. He should have built pre-emptive support from a wider constituency of colleagues, lawyers, professional bodies and friends before writing to the NAO, but naively believed a simple letter to an approved regulator would set the necessary wheels in motion and ensure fair play.
  5. Keep meticulous records, and make hard copies of e-mails. Store them safely, preferably a duplicate set, and away from work. Brambleby was glad he had received this advice from a colleague who had been through something similar. On two occasions papers were removed from his office overnight. These were investigated but no culprit found. His laptop was stolen (but not the smaller and more valuable projector to which it was connected, nor and other laptops in the room) while at a regional public health conference. Police investigated, but without success.
  6. Don’t expect thanks or rewards. Or apologies.
  7. Learn to distinguish between shame and guilt. Others may try to shame you – but you and your detractors will know that there is no guilt. But mud sticks, so expect snide remarks about corporate loyalty ever afterwards, or awkward questions at subsequent job interviews. Concentrate on doing the day job well, keep a high profile by speaking at conferences and publishing academic papers and generally consolidate your professional credentials. This is invaluable protection.
  8. Don’t expect that everyone will obey the rules, or even observe their own standards. A classic example is long delays. Authorities frequently fail to reply within their own specified periods. They will use delay to wear you down. Be persistent. On one occasion Brambleby found the SHA had sent a post-dated letter to his chief executive days before he got his own copy, purporting to be confidential, and apologising for the delay!
  9. Expect to receive demands for long reports at short notice, and don’t be surprised if such requests are received the day before you are due to go on leave.
  10. Be persistent and assertive, but not aggressive. Keep the moral high ground. Challenge early and keep the pressure up, because once an inquiry has reported it carries great weight and other regulators will not want to overturn it or re-open the case.
  11. Keep physically and mentally fit, drawing on expert support for the latter before the inevitable sleeplessness, anxiety, weariness and depression set in. Prepare for a long haul. Take breaks and holidays. Keep up your hobbies.
  12. Draw on a support network of friends. Hang onto written messages of support, and read them to yourself in the darker moments.
  13. Remember that there are always alternative power structures to tap into, such as MPs, the Information Commissioners Office and the press. Use them. Brambleby now regrets not being more proactive with press briefings – he was too trusting of institutional hierarchies – and admits having become institutionalised himself to a degree. Break out of the NHS power structure. Nothing panics civil servants like loss of control.
  14. Be prepared to risk everything. The stakes for your opponents may be much higher than for you and they will defend themselves with vigour. Cushion your family and dependents where you can, but they will have to cope with your obsession, distraction and sometimes outright clinical depression. You may be pressured into resigning and relocating, with all that means for family, housing, schools, support networks and finances. Brambleby says he regrets failing to admit that he had gradually become clinically depressed after years of relentless obstruction and attrition, and only recently accepted a course of medication and counselling. He believes he is now stronger for the experience, but it is never easy for doctors to admit weakness or seek help. Be humble. Be sensible.
  15. If you have to resign or retire then do so – it may not be worth the sacrifice to stay. Many whistleblowers do eventually leave. But if you quit it will probably weaken your negotiating position and diminish the likelihood of achieving change, so hang on if you can.
  16. Expect collateral damage. You cannot expect others to be brave or make sacrifices just because you have opted to make a stand, and you cannot always protect others from vindictive retaliation.
  17. Be true to your values. Two aphorisms that Brambleby found helpful were, “It is better to light a candle than curse the darkness”, “For evil to triumph it is enough for good men and women to stay silent”.
  18. Openness is your best and most powerful weapon. It scares the hell out those with anything to hide. Sunshine is a powerful antiseptic.
  19. Be creative, cunning and try to triangulate responses. It is often possible to trap detractors or liars into mistakes. Get a colleague (MP, etc) to ask the same question of several people and catch them out in their inconsistent answers. Brambleby claims he got most of his information, especially from redacted sources, in this way.
  20. Closure is your call. Remember that you started this and it is therefore your say, not anyone else’s, to declare when it is over. That is power, so use it. Keep asking questions until you are satisfied with the answers. And that may mean insisting the lessons are shared and learned.

Unanswered Questions

Who authorised changes to the design and build of the Norfolk PFI hospital – was it the building consortium or the hospital trust?

 

Why didn’t the Independent Certifier check the changes to specifications?

 

Why was so much conducted in secret, especially for a trailblazer project of this scale?

 

Why did David Wright’s inquiry  fail to publish significant elements of the evidence he collected, including that of Brambleby, Stamp and Silcock Dawson, and why did Dugdale hide from Norman Lamb that there had been evidence from Malcolm Stamp?

 

Why has no-one accepted personal responsibility for any of the lapses?

 

Why did ministers and senior civil servants try so hard to prevent Brambleby checking the briefings they were receiving about him?  Did they have a problem with the truth?  Did they have something to hide?

 

Bullying is rife in the NHS, from the very top down, and should be taken much more seriously.  It inhibits challenge and innovation, and it destroys the NHS’s most precious asset which is the motivation of its staff.  Bullies are always insecure.  Where is this insecurity coming from?   Do the political and management leaders of the NHS have so little self-confidence that they cannot tolerate, let alone encourage, questions and dissent?

 

When will the NHS adopt a culture where raising concern will be an obligation, not an offence?

 

 

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