Introduction

‘On the Culture of Blame’ concludes my recent series of posts on the NHS Complaints Procedure and the medical litigation culture. In those posts, I explored how clinicians rarely handle medical errors with candour, because of a defensive culture that exists within the medical landscape. I discussed how clinicians often cover for their errors, rather than own their failings and learn from their mistakes. This post attempts to understand the reason for this lack of accountability in medicine, which is the culture of blame.

The single greatest impediment to error prevention is that we punish people for making mistakes. 

Dr Lucian Leape

In Culture of blame in National Health Service; Consequences and Solutions, S Radhakrishna explores how the health industry handles human errors. ‘The culture is to blame the individual for the error, rather than to try to understand the processes in the system that lead to the error.’[1] Her article discusses the medical and the legal paradigms, which Radhakrishna believes, are responsible for the culture of blame in healthcare.

‘The medical paradigm demands that the practitioner practises to perfection. It maintains that error is an ethical failure that constitutes an unprofessional act, which should be punished. Given that errors are not treated as human, errors may not be reported for fear of professional or legal reprisals. The legal paradigm’s approach to ensuring safe medical care is by rules of malpractice, which has been made more attractive with the no win-no fee banners.’[2] S Radhakrishna argues that medical and legal paradigms make individuals feel victimized, and because they are fearful of being blamed, they will not report errors. This inhibits frank discussions about errors and systems weakness.

Medical and legal paradigms put shackles on the health-care industry, whereas the systems approach is the way forward, that should take us out of the dreaded culture of blame. 

S Radhakrishna

The Systems Paradigm

The systems paradigm is based on the principle that humans are fallible and that human errors are likely to occur in the best organizations. Errors are the result of a series of failures in the system and therefore are the consequences and not the causes. ‘The systems paradigm looks at the error as a cause of failures at several levels. It does not believe in ‘name and shame’ approach of the legal and medical paradigms. When an event occurs, it is not about who committed the error but, why the defences in the various layers failed.’[3] Radhakrishna argues that staff in such a set-up are more likely to report an error without fear, which will allow for real lessons to be learnt.

The NHS has an urgent need to implement the systems approach. A robust incident reporting system is the key to improving patient safety. A system that encourages data input, analysis and feedback without fear of punishment is likely to grow stronger.

My Case

My case is without doubt, a systemic failing. ‘The defences in the various levels’ have definitely failed. There is a complete systemic shut down of my case. Over 18 NHS bodies have now closed my case. I see a domino effect happening. One NHS body shuts my case down, and then the next one does the same, shortly afterwards. Because the systemic response is now so large-scale, no one individual will dare speak up on my behalf.

The situation with my GP is an example of how strong the systemic current is. When I first met him, 2 years ago, he was wonderful. He referred me to different departments for my facial pain, and said; ‘I know there is something seriously wrong with the left side of your face.’ He also expressed how terrible it is that ‘no one will take ownership of the problem.’ As NHS trusts rejected his referrals, or discharged me with no action taken, he and the practice have pulled down the shutters. The GP, who said two years ago, ‘there is seriously something wrong,’ writes two years later in my notes; scan abnormal, to be expected, no further action.

GP Shutdown

 

In the last year, this GP practice; 1) locked me out of my System One online account, while they amended a note on my medical records. They did this 18 months after they made the initial entry, which documents them not acting on an abnormal scan. This incident was after I told a clinician from Mental Health services, that I had seen this comment on my records. The clinician told the GP, with speed, that I had seen the comment. 2) There have also been three extremely serious incidents since then, which I have not yet blogged about. These further incidents involve the GP Practice deleting one entry and falsifying two medical entries. I will be writing about this at a later date, but this is the systemic behaviour with my case- to ignore and cover-up.

As Radhakrishna explains, individuals are afraid to speak up and report error because of the culture of blame and fear of reprisal. If someone within the system would vocalise what has gone wrong with my case, in an open and frank way, it could be put right. I would get the medical help that I need, and genuine lessons could be learnt. The systemic error is unlikely to flourish again.

The Code of Silence

In response to Radhakrishna’s article, a final year medical Student, Adam Shuttleworth, comments that ‘the reluctance to accept fallibility has led to the reporting of adverse events, which is labelled as “whistleblowing.” With this, there is an association with the placing of blame and “breaking silence.” He adds that a “code of silence” exists within medicine, in an effort to maintain a façade of perfection. Shuttleworth concludes that the ‘medical profession is yet to fully appreciate the safety in numbers.’ [4]

I see the ‘safety in numbers’ psychology with the clinicians and NHS bodies, involved my case, and it is chilling. They are complacent that it is safe to turn a blind eye to my medical problem. So many clinicians have done it too. Clinicians discharge me from clinics, when they know that there is a clinical issue. They also know that I cannot do anything to challenge them, so they are ‘safe.’

In Follow the Leader, I explain that it is like an endemic game of Chinese Whispers. When one NHS body is not transparent about clinical findings, or closes my case, it sends a signal to the next one. They then do the same. It is safer for these bodies to stay silent, rather than “blow a whistle.” I cannot find the words to convey how frightening it is to be on the receiving end of this behaviour. The unequal leverage of power is criminally unjust.

Respect and Curiosity

Rammya Mathew argues that clinicians have difficulty managing the conflict between avoiding humiliation for themselves, and honestly examining behaviour that does not meet expectations for which they might be responsible. ‘People do not need to be blamed in order to take responsibility and do better. We must make changes to improve care without needing to find someone to blame. This starts from a place of curiosity and respect.’[5] This is the crux of where the turning point is –  replacing blame with curiosity and respect.

For healthcare, moving from a blame culture to one of rapid learning is critical to facilitate continuous improvement and innovation. A robust incident-reporting system, which seeks to identify root causes of incidents at a system level in order to prevent mistakes being repeated is key to enable this transition.[6]

Patient Safety

Patient Safety Learning uses the results of an NHS Staff Survey from 2020 on the safety culture, to explore the implications to patient safety within the persistent culture of blame in the NHS. The survey asked questions regarding action taken on reported errors and patient safety incidents. ‘More than 150,000 felt that they could not respond with confidence that their organisation takes action to ensure reported errors or incidents do not happen again.’[7] The survey also showed that the NHS does not act on concerns, that patients raise about patient safety.

Speaking Up

 

When an NHS worker speaks up, they are making a vital contribution to the quality and safety of patient care.

Sir Robert Francis, QC, 2015

The survey asked how safe staff feel about speaking up about errors, and patient safety incidents. Nearly a third of respondents said they do not feel safe to speak up. The survey also asked staff whether their organisation would treat staff involved in a patient safety incident fairly. 230,00 said this was not the case. In response to this, Henrietta Hughes, OBE states that; ‘there needs to be a more consistent approach from senior leadership throughout the health system to ensure that all workers are thanked, supported and listened to whenever they speak up.’[8]

Improving Safety Culture

 

To improve patient safety, it is important to move towards a just culture which considers wider systemic issues where things go wrong, enabling professionals to learn without fear of retribution, and to address incidents of unsafe care with empathy, respect and rigour.[9]

Patient Safety Learning, (PSL) argues that to ensure that patient safety incidents are reported and acted on, staff need to feel safe speaking up. They advocate for an “organisational culture that supports this.” They believe that the NHS should take the following actions, to improve the patient safety culture within the NHS;

• Ensure organisations measure and report on their progress in an open and transparent way.
• Enable organisations to share good practice for wide dissemination and implementation.
• Provide resources, guidance, support, and direction for organisations wanting to encourage staff speaking up.
• Proactively share examples where improvements have been made to speaking up cultures so lessons learnt can be shared widely and best practice implemented.
• Identify poorly performing organisations and intervene to make improvements.
• Report publicly on the progress and the impact that speaking up has had on patient safety and staff safety. [10]

Conclusion

As all of the summarised articles explain, we need to move away from a culture of blame. We need to move towards a culture where clinicians can report incidents without fear of reprisals. Incident reporting should not be used to apportion blame, but to drive systemic changes that improve patient care. Moving towards dealing with the systemic failing, instead of blaming individuals, is key to facilitate real learning in healthcare. Awareness of cases like mine have the potential to improve patient safety measures. They also highlight the urgent need for greater accountability and candour in healthcare. However, if we stay locked in a culture of blame and fear, and keep our heads buried in the sand, many more patients, like me, will continue to be harmed.

We need to get away from the culture of blame, and the fear that it generates, to one which celebrates openness and commitment to safety and improvement. The risks to patients’ lives and well-being will be reduced, and confidence in the NHS protected.[11]

Foot Notes

[1]  Radhakrishna, S; Culture of Blame in The National Health Service; Consequences and Solutions, British Journal of Anaesthesia, Volume 115, Issue 5, ©Oxford University Press, November, 2015.

[2] Radhakrishna, S; Culture of Blame in The National Health Service; Consequences and Solutions, British Journal of Anaesthesia, Volume 115, Issue 5, ©Oxford University Press, November, 2015.

[3] Same source as footnotes 1&2.

[4] Shuttleworth, A J; Safety in Numbers- To Err is Human, September, 2015. (A Shuttleworth was a Final Year Medical Student at St George’s, University of London.)

[5] Mathew R; Lucy Letby and the Limits of a No Blame Culture, BMJ 2023; 382: p 1966

[6]Why a Culture of Rapid Learning in Healthcare is Vital  www.improvewell.com

[7]Tackling the Blame Culture? NHS Staff Survey Results 2020  www.patientsafetylearning.org

[8] Hughes H, OBE; The National Guardian’s Response to the NHS Staff Survey Results, The National Guardian’s Office, March, 2021.

[9] Sir Norman Williams; Gross Negligence Manslaughter in Healthcare; The Report of a Rapid Policy Review, 3.4, P9, June, 2018.

[10] Tackling The Blame Culture? NHS Staff Survey Results 2020, www.patientsafetylearning.org

[11] Sir Robert Francis QC; Freedom to Speak Up; An Independent Review into Creating an Open and Honest Reporting Culture in the NHS, February, 2015.

Photo Credits; Sander Sammy, Designecologist, Tom Wilson, Jorge Flores, Brett Jordan, Mark Konig and Marco Bianchetti on Unsplash. Polina Kovalova on Pexels.