NHS: Changing culture (from B to A from blame to accountability)

2 October 2013

Good management is doing things right, good leadership is doing the right thing. I was therefore heartened by Lesley Curwen’s two Radio 4 programmes NHS: Changing Culture spotlighting the leadership needed to turn culture around in the NHS.

Another recent news report tells us that successful hospital trusts are being asked to deliver up their managers to help failing Trusts. This seems sensible, however, it is quite an interventionist approach and I wonder if it will deliver. As a clinical negligence lawyer I have a different take. Perhaps it is because what I see is the “failure” end of the story. Also, as someone who has led and managed a team of lawyers for the last 10 years, I know that the challenge of leadership lies far more in dealing with failures (and how they are handled) than success. In a complex environment such as the NHS mistakes will happen: Targets will be missed, waiting times over-reached and, tragically, lives lost. But if those failures are seen as a collective responsibility, that needs to be addressed collectively, then the culture that will evolve is one of mutual support and commitment to improvement. Improvements that, when they come, can engender collective pride and save some of those lives. 

In the opening few minutes of the first Radio 4 programme, the dreaded “B” word was used; “who do you blame?” “Blame” distances the blameless from the problem and therefore dilutes a collective responsibility to be part of the solution. I prefer the word “Accountability”. It has a different spin. Accountability suggests that you are expected to explain and justify an action or outcome that is perceived to be surprising or undesirable. In an environment that was “forged in the furnace of politics”, like the NHS, it is inevitable that an adversarial approach (one that is far more often associated with lawyers) has grown up. The programmes described “two tribes – managers and doctors”. It also highlighted that the managers were brought in to sort out the failures and perception of fiefdoms of the doctors, when there was simply not enough money to service the ever growing demands upon the NHS in the 1980s. The profession felt pushed out of decision making we are told, with a new emphasis on value for money. Doctors and nurses felt their skills to be devalued, resulting in a demoralised and demotivated front line workforce. 

The programme then traced the arrival of “targets and terror” with the Blair Government which in turn engendered, apparently, the culture of bullying and fear. Sir Peter Dixon attributes this culture to money. Robert Francis QC says that people were in fear of losing their job if they put their head above the parapet and said the service could not deliver. 

Professor West, in the second programme, called for NHS staff to be treated with dignity, courtesy and compassion as a starting point for culture change. I agree and would add that supporting staff through the self-doubt that can be thrown up by adverse incidents is all part of that package. 

There was a plea for staff to no longer be perceived as “costs on two legs” but, instead as “value on two legs”.

So where are we now and do we need a Tsunami of future reforms to change the culture?

As a professional who takes pride in serving the public, I work with doctors, nurses and healthcare professionals who have the same professional pride. The fabric is there because the professionals want to do the best possible job. I wonder if there is a relatively simple way to start culture change and it has at its centre the ability to look at failures, admit to them and take joint responsibility for them. 

To do this, any failing needs to be inspected and learned from by all the participants in the health service: the providers (doctors and nurses, the managers and health professionals), the “hold-to-accounters”(regulators, CQC, lawyers etc) and, above all else, the service recipients (i.e the patients/public at large). It is, after all, the public who will decide whether the NHS is delivering high quality compassionate care.

I am not suggesting that candour with the public about errors, mistakes and failures is the be all and end all to cultural change. I am very aware that there is much ink being spilled about the benefits or otherwise of a statutory duty of candour for institutions and about how any such duty should be worded. But I say give it a proper go. Also, please set the bar low for the trigger for the need for an honest conversation. Transparency could well be the beginning of a quiet revolution towards a system of comfortable collective responsibility for mistakes, moving towards accountability and away from blame. Openness should be part of a compassionate, caring and successful NHS that is committed to learning and adapting to meet the needs of the public.

A renegotiation of the relationship between the public and the NHS based on transparency could see ever better public engagement with health campaigns which otherwise risk being perceived as a patronising attempt to pass the blame and paper over the cracks of an inadequate service. It is worth remembering that successful public heath campaigns with high levels of public engagement can and do save the NHS millions.

My personal aspiration is that lawyers be perceived not as the villains of the piece, depriving the NHS of resources but as a necessary part of the process leading to improvement. Part of the process of healing trust in the NHS. The fact is that we see the failures. A speaker in the second episode said “Our patients are rightly intolerant of mistakes…where we let them down. So if we don’t provide the culture change that our staff need and our patients demand then I don’t think we will have an NHS to protect because people will look elsewhere.” This is a chilling prospect. I am interested in culture change, in delivering accountability, representation and patient voice when there are difficult issues to do with quality of care and standards to be adhered to, that need to be highlighted via the legal process and, sometimes, defined for the public. My hope is that, with strong leadership and a willingness to learn from mistakes and look at them in an open and transparent way, repeated, avoidable and obvious failures become a thing of the past. After all it is those mistakes that really shock the public and are, I believe, at least in part, the product of a fearful, secretive and embattled environment.

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