Speaking up in Health Care: The Canary in the Mine?

The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of the University of Birmingham

“As the NHS increasingly seeks collaborations with other sectors as ways of responding to the challenges of an ageing population, external staff and other stakeholders are increasingly exposed to, and in a position to speak up about, poor quality care.”  


When health care professionals see deficient or unsafe care it is important that they speak up so that care can be improved. Sometimes, speaking up is informal and managed within the care organisation. At other times, speaking out happens by alerting outside authorities (whistleblowing).

There is, however, compelling evidence from recent reports and official inquiries as well as data gathered over many years as part of the annual to suggest that, in many part of the NHS, staff may feel unable to speak up, and that even when they do voice concerns, their organisation may respond inappropriately.  

Against this background, our National Institute for Health Research funded study draws on a rich stream of theoretical research, empirical evidence, legal analysis and stakeholder work, with the aim of sharpening thinking around speaking up and whistleblowing in health care.

Raising concerns: a complex and contested issue

Individuals voicing concerns may be perceived as heroes by some but as villains by others.  This ambiguity is reflected in media portrayals of them either as ‘courageous employees’ who act at great personal cost or ‘disloyal malcontents’ who pursue their own interests regardless of the dysfunctional consequences for individuals and organisations.

Similarly, not all issues raised as concerns by frontline staff can neatly be categorised as either conducive or detrimental to safe and high-quality care.

Personal and cultural factors in raising concerns

There is mixed evidence on the role and impact of personal factors in raising concerns. For example, in terms of length and security of tenure, some studies have found that the more embedded and socialised into particular culture staff are, the less likely they are to spot poor practice and report it. Similarly, the evidence is mixed over whether health professionals who over time become more socialised and integrated members of the organisation are less likely (through desensitisation) or more likely (through better organisational knowledge and developed networks) to detect and report poor care. 

Silence or voice?

Policy prescriptions have tended to conceive the issue of raising concerns about unsafe or poor-quality care as a simple (individual) choice between deciding to speak up or remaining silent. Our research suggests that such simple dichotomies are unhelpful: for example, healthcare professionals may raise concerns internally within the organisation in more informal ways before (or instead of) voicing concerns through formal processes. Considering how to listen to, record and respond to this informal feedback is essential for any NHS organisation if they wish to learn from poor-quality care.

The ‘deaf effect’

Effective voicing of concerns is but the first stage in reshaping better safer healthcare: those with influence have to hear, and they have to act.  This is associated with the ‘deaf effect’, a concept that has been used in the management literature to describe the reluctance of senior managers to hear, accept and act on concerns by those raised by employees. 

 In some cases, it is clear that senior managers seek to ostracise individuals by undermining their concerns. In extreme cases, healthcare professionals have been disciplined, suspended or reported for misconduct to professional bodies on pretexts derived from a very partisan reading of events. In an intensely hierarchical organisation such as the NHS, entrenched status and power differences between professional groups can harm the development of open reporting cultures. Any attempt to address speaking up in the NHS must deal with the challenging organisational dynamic of resistance to bad news.

Whistleblowing or bell ringing?

Whistleblowing usually describes staff members raising concerns to those who can take action. However, ‘bell-ringing’: the reporting of care failings by those other than employees (for example, relatives, or professionals from other agencies, such as social workers) is potentially a more significant issue for healthcare than for any other sector. As the NHS increasingly seeks collaborations with other sectors  as ways of responding to the challenges of an ageing population, external staff and other stakeholders are increasingly exposed to, and in a position to speak up about, poor quality care. 

All quiet on the frontline?

Frontline staff are often best placed to identify substandard care and alert colleagues and managers if patients are at risk - they are the ‘canaries in the mine.’ Yet staff are often fearful of raising legitimate concerns and have sometimes been bullied and victimised for doing so.  Managers on their part need to redouble efforts to create the right organisational environments where frontline voices can be aired and responded to appropriately. Finding ways to encourage this will be a key challenge for management education and leadership training.

Read the full report. Mannion R, Blenkinsopp J, Powell M, McHale J, Millar R, Snowden N & Davies H.  Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews. Health Serv Deliv Res 2018;6(30)