When is the right time to question a medical decision?
An article by Lawrence Dunhill in the Health Service Journal (HSJ) on the 18th January reported Mike Durkin (The national director of patient safety at NHS improvement) describing the health service as like a "rabbit in the headlights". He was describing the fact that in the maelstrom of all of the pressures on the NHS, from patient numbers to hospitals under pressure to deliver strict financial targets, safety is being compromised. Almost worse than this was his conclusion that the cause of the compromise is that there is a fear of raising the issue because they will not be listened to.
His proposition appears to be that because operational management is under pressure to just deliver a solution, patient safety is compromised. The reluctance to “down tools” and refuse to continue to treat in an unsafe way is creating problems. Mike Durkin called for a “responsible and grown-up debate” where people are not fearful of raising patient safety.
I was struck by the fact that Mike Durkin refers to the ethical responsibility of any individual in any decision-making process including the operational management. I was very interested by his proposition that ethical responsibility is the key to safe practice and agree.
Interesting also that, reported on the same page of the HSJ, was the news that more than 30 hospital trusts are yet to appoint whistleblower guardians. The same article cited that 56% of staff had confidence that their organisation would address concerns if they were raised. This leaves a rather large remaining percentage that did not have faith in their organisation to address their concerns.
The interplay between these two issues, failure to raise the issue of unsafe practice and a lack of whistleblower support, for me is pretty obvious. If you have no whistleblower guardians people are going to recognise that the priority given to concerns being raised is low. If other priorities such as meeting stringent financial targets are favoured the culture becomes one that ensures financial efficiency over safety.
So is there any way to start moving the rabbit out of the headlights? It has always seemed to me that there are three key elements that need to be in place to create a safe environment. First, people must be allowed to raise concerns about others without fear. Whistleblowers must be protected and guardians appointed. Second, the duty of candour requires that mistakes are discussed openly not stigmatised and that they must be learned from. Third, and an extension to the duty of candour, is that the patients are involved in the mature debate that Mike Durkin refers to. This is important because patient involvement engenders trust.
If this process (patient engagement) leads to an atmosphere of trust that, in turn, may mean patients listen more readily to advice about prevention, this will benefits everyone. Once trust has become a given, the public may engage better in the public health campaigns leading to responsible use of the health system and personal acceptance of responsibility for individual health. This could start to address the overwhelming demand on the NHS.
Patient engagement in the conversation about specific incidents and the general debate around patient safety could be the start of being able to achieve the holy grail of better preventative healthcare.
Unfortunately things will always go wrong, even in the best systems with the best clinical teams. However, not having the collective courage to speak about the problems or protect those who do speak can be (in my view correctly) characterised as unethical and counterproductive. If the public perceives this as an ethical gap, it is understandable that it pays little heed to sound public health advice and turns to lawyers to seek answers as well as redress.
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