To the Editor: I compliment Dunbar and colleagues on their analysis of the systematic problems underlying whistleblowing “scandals” at four Australian hospitals.1

I disagree totally, however, with their major conclusion. I refer to their endorsing the recommendation from the President of the General Medical Council of the United Kingdom that “... if there’s a risk to patients ... we expect people to pipe up, but pipe up locally”. Attempting to put this recommendation into practice is itself the root cause of the problem.

The many and varied obstacles to locally notifying one’s concerns about a colleague’s performance are almost insurmountable; any permutation or combination might apply in a particular location. On the part of the whistleblower, obstacles might include fear of their confidence being breached, being suspected of professional envy or of being a troublemaker, a concern for job security or about failure to be promoted, a reluctance to rock the boat in their own working environment, or fear of being victimised at work. On the part of the chief executive officer or equivalent local person to whom the report is made, obstacles might include their potential affront at a slight on their responsibility for overall management or for having appointed the person to whom the notification refers, personal friendships and even family relationships (especially in smaller centres), reluctance to have to inquire into a senior staff member’s work, or financial implications (as in the case of Bundaberg Hospital1).

I suggest that, instead of trying to overcome such awkward and off-putting obstacles locally, performance concerns should be taken directly to a statutory body with responsibility for overall standards of health care and with absolutely no “conflicts of interest” in specific local situations.

In New South Wales, at least, and specifically in relation to doctors, Section 86E of the Medical Practice Act 1992 provides that persons may notify the medical board of professional performance matters, namely “any matter that the person thinks indicates that the professional performance of a registered medical practitioner is unsatisfactory”.

This avenue avoids all the pitfalls involved in attempting to resolve the matter locally, affords the potential whistleblower a recognised means of having their concerns given serious consideration, and reassures the whistleblower that the matter is in the hands of a responsible body with statutory authority and with tried and tested methods of dispassionately assessing the situation.

The whistleblower would then have no need to “go public”, with the devastating results so well described by the authors.

In reply: Dr Arnold raises the difficulties involved in bringing poorly performing colleagues to notice and proposes that reporting doctors to a medical board is the best option.

There are difficulties in relying solely on medical boards. First, doctors have a very high threshold for referral to a medical board, so poor performance may not be reported. Even serious cases of poor performance can go unreported for many years.1 Second, there are many cases of remediable poor performance2 that require a different approach. In the United Kingdom, local procedures are managed by medical directors as part of their contract. The Good Medical Practice guidelines issued by the General Medical Council make it clear that all doctors have a responsibility to report poorly performing colleagues.3 If the medical director then fails to act, the hospital’s insurance could be invalidated and the medical director would appear before the General Medical Council.

A number of Australian jurisdictions, including the Australian Capital Territory, New South Wales and Queensland,4,5 have made substantial progress in developing local procedures that offer the best opportunity for remediation of doctors where possible, and for discipline by the medical board where not. With these procedures, we can assure patients of safety while maintaining as many doctors as possible in the workforce.