Hilary Thomas on clinical governance and values

Hilary Thomas

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An old friend has just been in touch, having found one of my HSJ columns through Google.

We met more than a decade ago after exchanging houses. She lives in a remote, civilised North American city. We have moved several times since.

She is a journalist who has recently morphed from radio host to newspaper columnist – a gentle, cerebral, aesthete who has enriched my family's lives by staying with us on trips to or through the UK. She is one of those people who radiate values and can appreciate life and hold on to what really matters.

Since we last met, she has experienced tragedy in her life and it was news of my life-threatening diagnosis that prompted her to get in touch. Her letter led to some mid-life reflection on meaning.

Life lessons

I'm sure all of you remember parental aphorisms. The one that comes back to me most is my mother's "truth will out". My mum is an atheist. I wasn't christened, a fact that bothered a handful of pious friends, to whom I would retort it was more important to have a fundamental understanding of the difference between good and evil than to be subject to a ceremony in which you were no more than a passive participant.

Similar axioms resonated for me as a medical student. I often recall one that made a deep impression on a naive clinical student - that errors in medicine are more often of omission than commission. The wise source is now an eminent cardiologist at a London teaching hospital.

Another gem is the call to work within the limits of your competence, part of the code of conduct of the Nursing and Midwifery Council and Duties of a Doctor, published by the General Medical Council. How often are these two principles applied when things go wrong?

Realising you need to ask for help and pointing out when you are out of your depth are both signs of that quintessential characteristic of good leaders: self-awareness. I can think of numerous examples where making the wrong decision less frequently results in an adverse outcome than failing to make a decision at all. Or where failing to put in place a safe system or process can result in adverse outcomes under a series of different circumstances.

The intrathecal administration of vinca alkaloids, which has resulted in death or serious harm to children and young adults on too many occasions, was potentially simple to fix but it required a concerted will to define a suitable process.

Core principles

Just as you can distil a person down to their core values, it is possible to refine the principles of clinical governance into similar core elements. An appreciation of avoiding omissions, self-awareness, openness, transparency and no blame will get any healthcare professional or manager a long way on an individual or collective basis.

Such shared understanding and ownership will also enable the system - be it a ward, a service or an entire organisation - to work and flourish.

Groucho Marx famously said: "I have principles, if you don't like them I have another set." But perhaps the appropriate response is encapsulated by the more profound thoughts of mathematician and biologist Jacob Bronowski: "The values by which we are to survive are not rules for just and unjust conduct, but are those deeper illuminations in whose light justice and injustice, good and evil, means and ends are seen in fearful sharpness of outline."