I have never understood why hospital managers don't crawl, on bended knee, from one end of their trust to the other, begging staff to tell them what's going on, what's wrong and what needs fixing. Why do senior managers insulate themselves from the frontline?

Instead they have policies, procedures, guidance and toolkits. The bureaucracy that stifles speaking up is fruitlessly employed in the task of encouraging speaking out.

To understand the plight of the whistleblower working with 7,000 or more colleagues, is to understand the loneliness, the dilemma, and the fear and the courage it takes for a junior doctor to denounce a careless, crass and cack-handed consultant; the guts needed for a young nurse to take on the might of management and say, "the nurse-patient ratios where I work are dangerous"; the bottle required for a line manager to denounce the budget pairing that endangers life and limb.

To blow the whistle inevitably means suspension, which means isolation and the forensic scrutiny of personal practice and motives. It means seclusion, suspicion and colleagues put under huge pressure to take sides. The evidence shows that most whistleblowers lose their jobs.

The management bugle is louder than the whistle. Trust management must decide if this is a complainant or a campaign, an axe grinder or someone with a real point, a grudge bearer or standard bearer for issues that must not be ignored. But when an investigation is carried out, it is by trusts themselves – judge and jury in their own court.

Ministers make fruitless laws about candour and honesty. They misunderstand the corrosive climate of fear surrounding NHS staff who have seen how other whistleblowers have been pilloried and denounced.

Internal complaints procedures first go through the line manager, someone likely to be part of the problem. Escalating concerns, to a director, is daunting. An executive open-door policy does not make it easy for staff to walk off the frontline and through the door on the fifth floor.

Serious allegations need forensic evidence that whistleblowers may not have. Trade unions struggle to have their voices heard and MPs are off the horizon. The Parliamentary and Health Service Ombudsman, the Mental Health Act commissioner and Public Concern at Work add to the complexity and even the best employers are mired in Nursing and Midwifery Council, General Medical Council procedures, guidance, and employment law.

Staff acting in good faith, with reasonable evidence that a concern is true, and who have no personal gain to make from complaining should be encouraged to speak out. Why aren't they?

I'll tell you. The success of the NHS is linked to the political fortunes of whoever is in power. It's called "managing up". Passing good news up the line; better no news than bad news, which is never passed up the line. To manage up, you also have to manage down and choke off failure, bad practice and complaints. Hence a corrosive culture of bullying and fear becomes part of an organisation.

There are four things we could do:

1 No trust should investigate its own whistleblowing complaints. Neutral, outside trusts should do it.

2 Safe havens for whistleblowers; hosted in neutral trusts, so that they may carry on working while investigations are undertaken.

3 Recognition that a mention of whistleblowing policies, during the induction process, is not enough.

4 Senior managers should be a permanent fixture on the shop floor, asking staff "how are we doing?" and "what do I need to know today?".

And a national Whistleblowing Day might create a climate of collective courage and action.

The chief executive at Watford NHS trust, Sam Jones, hosts a daily staff walk-in open forum she calls Onion to "peel back the layers", early morning sessions where scores of staff turn up and talk about problems and successes.

Managers, like Jones, understand laws, guidance and policies will not change the perils of whistleblowing. It takes organisations with courage to hold up a mirror, look at themselves and reflect on what they are missing if they don't ask.

Roy Lilley will be talking at the Speaking Out Summit on the subject of speaking up and whistleblowing on Thursday 8 May.

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