• Professor Sidney Dekker says NHS leaders must create an environment for culture to change
  • NHS regulators should give chief executives space to develop new approaches to mistakes and learning
  • Families must be fully involved in processes following poor care as part of a “restorative justice”

NHS regulators must do more to enable trust leaders to try and improve culture in their organisations, a leading expert on system safety and “just culture” has said.

Professor Sidney Dekker, whose 2007 book Just Culture helped launch a movement to change organisational approaches to errors and harm, said short term thinking by NHS chief executives was inevitable if they feared losing their jobs.

Sidney Dekker

Professor Dekker: ‘Chief executives and leaders don’t aim to do a bad job’

He told HSJ regulators needed to “recognise that chief executives and leaders don’t aim to do a bad job. How can we expect more from CEOs if their horizon is only 700 days? That can only encourage short term thinking and actions designed to make them look good.”

Professor Dekker, director of the Safety Science Lab at Griffith University in Queensland, Australia, said a true “just culture” delivered for victims of harm, staff involved in incidents and the organisation. But he added that creating such a culture would not be easy for the NHS.

He said: “Whether the ultimate goal [of a just culture in the NHS] is doable I am not sure. There are a lot of factors that conspire against it given the complexity and the political nature and scrutiny under which a public system lives.

“If you’re a leader, it would be an illusion to think that you alone, or with your team, can somehow change an organisation’s culture. Culture change doesn’t happen within the tenure or lifetime of individual leaders. It takes longer and there are lots of influences and factors.

“But what you can do as a leader, and what is ethically incumbent on leaders in the NHS, is the commitment to create the conditions for particular cultural attributes to germinate and grow and flourish. If you don’t do that I don’t think you’re living up to the expectations of leadership that we have.”

Professor Dekker, who last week visited Mersey Care Foundation Trust, which is pursuing a just culture approach to incidents, said practical steps organisations could take included changing the name of incident investigations to “learning reviews” and looking at what happened and why, rather than who and what.

He added: “I am not saying just change some labels and culture will follow – that’s nonsense. You have to create other things, the most difficult of which is trust. None of this works without people having the trust and confidence in each other to do the right thing. Trust is a brittle commodity, really easy to break and really hard to fix. But that doesn’t mean there are things that you can’t do and shouldn’t do after a failure that harms patients or families.”

He said following an incident of poor care or harm, organisations must resist becoming “defensive and not talking”.

Talking was fundamental to a “restorative justice approach”, he said. “All the stakeholders are involved and get to tell their account of how it has affected them. This includes the care giver, the family and colleagues who were affected by the event. We know from research that families are not looking for retribution and compensation, they are looking first for being heard, they want to know that there is someone on the inside who listens to their grief, their story and their pain and takes that seriously for what it is. An organisation that is willing to confess and repent.

“Confession is about telling what happened and repentance is about connecting remorse to what happened. Don’t load that on the care giver, take responsibility as an organisation. Few things are as inauthentic in the eyes of families as an organisation who says ‘this wasn’t us, it was a bad apple’. Families immediately see through that and will accuse the organisation of trying to protect and distance itself from what happened.”

Professor Dekker, a former pilot and author of multiple research papers and books on system learning, said most families involved in healthcare incidents did not want staff to be “hung out to dry” but wanted organisations to show learning and collective responsibility for incidents. This included organisations involved but also professional regulators.

He said: “When you have a retributive response between the organisation and the individual or the individual and their regulator, the amount of involvement in the family is very limited. There is a dissatisfaction because they aren’t made a participant in the process of restoration and recovery, they are held outside. I have seen families be very dissatisfied with retributive processes precisely because it seems limited and to focus all the blame on the individual rather than a larger story around it, when most patients will be aware of systemic shortcomings around the event.

“That is what restorative justice tries to do. It finds out who is hurt, what their needs are and whose obligation it is to meet those needs and involve the community in all of this. It creates a very different conversation with core stakeholders. The outcome can be a restoration for trust and confidence in each other. It gives people the opportunity to hold their own account.”

Professor Dekker said the NHS was now taking more steps towards a better approach and he “wholeheartedly supported” the creation of the Healthcare Safety Investigation Branch, which focuses on system errors and learning.

Interview: Trust chiefs must be supported to change NHS culture