Speaking up as an IMG – what is it, why do it and how to do it?

It is important to speak up if you have concerns about patient care in your workplace, but doctors don’t always know where to start. Dr Henrietta Hughes OBE FRCGP SFFMLM provides advice on when and how to speak out.

What is speaking up?

Speaking up is about anything that gets in the way of delivering great care. When something isn’t right with our patients we find a confidential space where we can listen to their concerns, investigate what might be the underlying causes and then make a plan to improve things, following up to see if it has worked or whether any more steps need to be taken. So far, so simple.  We also have a professional duty, under Good medical practice (paragraph 25), to raise concerns about anything that impacts patient safety or could impact patient safety. But if you see something that’s not right at work, is it straightforward to speak up?

There are lots of barriers that we face to speaking up, and barriers that managers and leaders face to listening and following up.  Barriers to speaking up include hierarchy, conflicts of interest, knowledge, skills and fear about retribution. Leaders and managers also face barriers, their power silences truth and it’s difficult to create a psychologically safe environment; there are links to TED talks which go into more detail. Some groups of staff face even greater barriers.  For international medical graduates you might face differences in culture and unwritten rules, feel vulnerable about your employment situation and words may have a different meaning than you expect.  All of these can make it harder for you to speak up and be heard. 

This article helps to demystify some of these barriers and help signpost you to places where you can receive support and thanks for raising matters that can improve patients’ and colleagues’ safety and wellbeing, including your own.

Why Speak Up?

In 2013 an independent inquiry report was published which examined the causes of the failings in care at Mid Staffordshire NHS Foundation Trust, where hundreds of patients died needlessly between 2005 and 2009. The report identified that staff had tried to raise matters, but had experienced bullying and victimisation as a result.  A further review, Freedom to Speak Up, was published in 2015 and made a recommendation that every NHS Trust in England should have a Freedom to Speak Up Guardian and a National Guardian to lead that network, a role I held from 2016-2021.

In that time, more than 700 Freedom to Speak Up Guardians were appointed across England in Trusts, independent sector providers and national bodies so that people had an alternative channel if, for whatever reason, they did not want to speak to their line manager or supervisor.  Over 50,000 cases were raised to guardians, about patient safety concerns, staff safety, bullying and harassment and other concerns.  You can read about case studies relating to international medical graduates on the National Guardian Office website and access free training in speaking up, listening up and following up.

How to Speak Up?

Most people speak up to their line manager or supervisor, but there are also times when you might not want to do this, or have already tried this route without success. You can find your own guardian using the search tool on the National Guardian Office website (link: The National Guardian's Office - Freedom to Speak Up) and through your organisation’s intranet where you can also find the Freedom to Speak Up policy.  Ideally you should have already met your Freedom to Speak Up Guardian at your induction or at team meetings or events. Your Freedom to Speak Up Guardian will thank you, listen to you, offer support and escalate with you or on your behalf if you prefer. There is no barrier to speaking to them, they can usually maintain your confidentiality and will keep you updated on the actions that have been taken. 

In your organisation’s Speaking Up Policy there are other routes for speaking up, including an executive and Non Executive lead, the Chief Executive Officer (CEO) and Chair. But if you don’t want to speak up internally, there are a range of other organisations that you can approach, and receive the same legal protection as if you speak up in your workplace.

Medical Protection – You can contact the helpline for medicolegal advice if you have concerns about unethical behaviour or quality of care

Care Quality Commission – This is the health regulator and they conduct inspections of healthcare providers. The leaders of your organisation are held to account for the speaking up culture through the CQC Well Led inspections. They hold focus groups for staff and you can also contact them with concerns about care.  This is described on their website as Whistleblowing and Reporting a Concern.

General Medical Council – There is a speaking up hub on the GMC website with information and practical steps on how to speak up and signposting to organisations. 

Protect – This is the whistleblowing charity. As a legal advice service they offer free expert and confidential advice on how best to raise your concern and your protection as a whistleblower.

British Medical Association – The BMA website has information on raising concerns and a flow chart to help you decide who to approach.

Summary

Speaking up, listening up and following up are all relational activities and you may need to do all of these at different stages in your career.  If you need to speak up, there are people to help you, you will be thanked, your concerns will be heard and the right actions will be taken.  If you need to listen up or follow up, remember when you were at an early stage in your career and how intimidating your seniors were – now remember that’s you!  Think about how you will foster a psychologically safe environment where speaking up is business as usual.

Finally, if you’re interested in some further information below are links to some further reading, a couple of relevant TED talks and details of follow up training offered by the National Guardian’s office.

Freedom to Speak Up training - National Guardian's Office

An International Medical Doctor’s experience - National Guardian's Office

Safety and quality - GMC

VIDEO: How your power silences truth by Megan Reitz @ TEDx

VIDEO: Building a psychologically safe workplace by Amy Edmondson @ TEDx

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