If we truly believe in a just culture and the benefits this can bring for patient safety, it has to give equal importance to being fair to patients and families as well as to staff. By James Titcombe, Peter Walsh and Cicely Cunningham
The lexicon of a “just culture” in the NHS has become popular over recent months, notably in the publication of Being Fair: Supporting a just and learning culture for staff and patients following incidents in the NHS by NHS Resolution.
We are taught that to create this culture, when things have gone wrong, we need to focus on three questions (Dekker 2017): Who is hurt? What are their needs? And whose responsibility is it to meet those needs?
There is much to celebrate in the increased focus on “just culture”– not least that this has become accepted parlance within the NHS mainstream and more widely in the regulatory community. The phrase can be found in the National Patient Safety Strategy from NHS England/NHS Improvement.
It is advocated in the General Medical Council-commissioned review on gross negligence manslaughter and culpable homicide. There is A just culture guide, from NHS Improvement, which “encourages managers to treat staff involved in a patient safety incident in a consistent, constructive and fair way”.
Yet from the perspective of patients and families, the narrative to date can seem somewhat one sided. In our view, a “just culture” has to give equal importance to being fair to staff and patients.
In the aftermath of a patient safety event resulting in serious patient harm or death, the response of the organisation to the patient or family is crucial. Yet too often, rather than the restorative approach Dekker calls for, harmed patients and bereaved families experience a response that in many cases significantly exacerbates their grief, trauma and distress.
Given the notion of justice encompasses concepts of fairness and equity, the pursuit of a just culture must also ensure further harm to patients and families is avoided.
At recent events hosted by AvMA and The Doctors’ Association UK, harmed patients and families sat side by side with clinicians and researchers. It was moving and heartening to hear the empathy felt by both “sides” expressed for all affected by the fallout from patient safety incidents.
The needs of harmed patients and families are for acknowledgement, apology, honest and full explanation, genuine reflection and also accountability.
However, blame and accountability are intertwined in many people’s minds – not least because some have felt that NHS organisations have professed a “no blame” culture in order to avoid accountability.
There must also be a collective accountability to build healthcare systems that support staff to deliver safe care in the first place.
The Being Fair publication states that there is “… very rarely intent by staff to provide care that did not go as expected or planned”. However, patients rightly expect more from their healthcare than the absence of deliberate “intent” to cause harm.
They expect the organisation to have put in place reasonable steps to minimise risks to their safety and for systems, processes and the prevalent culture to support safe care and continuous learning and improvement.
A truly “just culture” for patients and staff must also encompass meaningful and proportionate accountability – especially with regard to organisations and management.
The model Just and learning culture charter from the NHS Resolution describes accountability as “sharing what happened, working out why it happened, and learning and being responsible for making changes for the future safety of staff and patients”.
These of course are vital components, but there must also be a collective accountability to build healthcare systems that support staff to deliver safe care in the first place.
This should certainly include ensuring staff feel empowered and supported to raise concerns prior to patient harm, processes to address such concerns and systems in place to learn from good practice as well as what goes wrong.
Patients also deserve a frank and honest dialogue with their healthcare provider about the prevalence of avoidable harm and the known common causes.
Ensuring that staff involved in patient safety events are treated consistently and fairly is crucial to creating a just culture in healthcare, but there must also be a clearer framework of accountability that unpins the reasonable actions all healthcare providers should undertake to ensure their systems, processes and culture support their staff to deliver safe care.
Most importantly of all, the healthcare system needs to ensure that harmed patients and their families are properly cared for with compassion and empathy and not subject to further harm caused by the organisational and system response.
From the perspective of those affected, the current system of variable quality local investigations, inquests, litigation, complaints and interactions with a host of other regulatory bodies and organisations can feel designed in such a way that ensures further harm is inevitable.
If we truly believe in a just culture for everyone and the benefits that can bring for patient safety, it has to give equal importance to being fair to patients and families as well as to staff, and inform practice and policy at every level.