A just culture for the NHS: Cicely Cunningham writes...

 Since starting this campaign, I have often been asked the question: “What would success look like for Learn Not Blame?”


To start with, I struggled to answer this question. There seemed to be many answers which applied in different situations. A world where front line staff who make mistakes are not thrown under a bus by their colleagues and organisations. A world where patients and families are heard, their questions answered, their desire for learning met. A world where doctors could go to work and know that their care was getting safer, because there was a commitment to listening to staff, acting on concerns and not repeating the mistakes of the past.


But this can all be summed up in one phrase – a “just culture”.


“Just culture” is a phrase that seems to be in the ascendancy at the moment in debates about healthcare. It’s often described as the “opposite of a blame culture”, but describing it this way suggests that it only applies when things go wrong. To me, a “just culture” should be the prevailing way of working and thinking. Quite simply, to me, it means a culture that values and cares for every individual as a human being.


It follows then that this applies equally to those for whom the NHS cares, and those within the NHS doing the caring. 


I recently read with sadness – and a degree of recognition – the comments of a doctor in a British Medical Journal article: “It [the NHS] just doesn’t care. It chews people up, spits them out, and then gets another well meaning chump to replace them.” The feeling that you are just another cog that enables the machine to keep turning, that you are dispensable, that your own life counts for nothing compared to the requirement of the service. I know innumerable stories of colleagues refused leave for their own weddings, let alone anyone else’s. Chastised when they went out of their way to help a patient, because things weren’t done in the “right way”. Refused compassionate leave for a funeral because the family member who died didn’t meet a bureaucratic definition of “close family”.


This pales into insignificance when compared to the treatment that many harmed patients and families face from the NHS: a closing down to enquiry, denial of problems, dismissal of concerns and then defence. Often, legal teams brought in to initial meetings – where families just want to discuss how the organisation can learn from what happened and make sure it doesn’t happen again. At our Learn Not Blame launch event, Scott Morrish, dad to 3 year old Sam who died avoidably of sepsis, spoke of how he felt after the death of his child. Having to fight to get the answers he needed about Sam’s care, he described a profound loss of trust in the NHS, an institution that he felt should having caring at its heart, yet which treated him with coldness and a lack of concern.


While the constant small slights felt by staff in their working lives do not compare to the experience of those who have lost children avoidably or suffered harm themselves , the remedy is the same. A just culture seeks to redress the hurt that people feel, by asking “who is hurt? What do they need? And whose responsibility is it to meet that need?” If we ask these questions every day, we can see a change in the world. 

The blame game: why do we play it? Cicely Cunningham writes...

“Learning from error, rather than seeking someone to blame, must be the priority in order to improve safety and quality.”


Not the words of the current Secretary of State (although he did speak about the need to Learn Not Blame, in various speeches at the end of last year), nor of the reports emerging from the mid-Staffs scandal (although Don Berwick did urge the NHS to “abandon blame as a tool”).


These words are from the recommendations of the report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995.


Blame in the NHS has been around a long time. Each of us will be familiar with everyday instances of blame being apportioned for things going wrong, near misses, and even when everything goes to plan but someone just doesn’t like the way it was done.


But why do we do it? And why has so little changed since 2001, when these words were written?


I recently took part in a BBC World Service programme, called “The Why Factor”, on blame. If you haven’t listened to it yet, you can catch up with it here. The other contributors to the programme shared some fascinating insights into blame, which are very directly applicable to the NHS.


Blame is a visceral defensive response, a “shield” that deflects pressure off when we are feeling attacked over something that has gone wrong. But it can also be a tool of attack by those in positions of power, and that has serious ramifications for the culture of an organisation, degrading it to a poisonous and toxic atmosphere. 


But the blaming process does not take place in isolation. Publicly blaming others has actually been shown in studies to be socially contagious. When blame is modelled in a workplace, it spreads.


I have a very personal reason for caring about this. When I was an FY1, I was involved in the care of someone whose gentamicin levels were not adequately monitored. When I say involved, I prescribed at least one of the doses that shouldn’t have been given. It was an absolute “swiss cheese” scenario where all the holes lined up so that human error was not mitigated. The patient suffered organ failure and subsequently died.


But in my case, despite the family rightly making a complaint about the care their relative had received, I was not blamed individually. Instead, my consultant took responsibility, met the family, and found out what they wanted and needed – which was to understand how things had happened and how to ensure it didn’t happen again. So, at their request, the whole team involved in the patient’s care sat down with the family and went through everything. It was painful at the time – I’m sure more painful for the family – but I believe it led to some closure and it certainly led to changes within the hospital. 


What I didn’t realise at the time – and have only come to realise in the last year – is that how I was treated, which was fairly, justly and without blame, is so rare within the NHS. I learnt from that awful tragedy, and it has shaped me as a doctor.


We must do better. So what can we do? By signing up to the Learn Not Blame campaign, you are already an advocate for change. But modelling the behaviours we want to see throughout the system is more powerful than we think. So the next time you find yourself slipping into the blame game, take a step back and think – can I break the chain of infection here? Can I find a different way to frame this? Instead, Sidney Dekker’s 3 questions are useful: who is hurt? What do they need? Whose responsibility is it to meet that need?

Me? I'm just an ordinary doctor... Cicely Cunningham writes

It’s been a year now since my personal campaigning journey began – from a generally opinionated clinical oncology trainee to passionate advocate for a just culture in the NHS. The story began on 25th January 2018, when I was doing what many of us do of a normal evening – scrolling through social media on my phone. But instead of the usual fluffy animal pictures, something was afoot. All the doctors I knew on social media were up in arms about a court case where the General Medical Council (GMC) had pursued a paediatric trainee to seek her erasure from the medical register – Dr Hadiza Bawa-Garba. 


The more I read, the angrier I became at the injustice of it. The more I read, the more I felt that this could have been me. This hadbeen me, as I too had been involved in a situation where care was sub-optimal due to the disastrous interplay of personal error and systems failures. I couldn’t sleep that night, and after several hours of tossing and turning, I got up and phoned Radio 4’s Today programme office.


A confused night shift producer answered the phone. “You’re a doctor and you’re phoning… why?” I pieced together the story as I’d understood it and I could hear the producer losing interest as I spoke. But when I mentioned that Jeremy Hunt was tweeting about this earlier that day, the producer’s ears pricked up again. It turned out they had Jeremy Hunt on the Today programme the following morning, and as a result of my phone call, he did in fact get asked about Hadiza.


After that my involvement snowballed. Joining a demonstration in Glasgow introduced me to some wonderful doctors in Scotland, passionate about changing the NHS for the better. Answering a call on social media for interested doctors to come together to work for change led to the creation of The Doctors’ Association UK (DAUK). During 2018, I produced submissions to government consultations, wrote letters to the GMC, the Secretary of State for Health, and the media. When the judgement on Hadiza’s appeal was announced in August, I headed to London to do media interviews along with other DAUK Committee members. Later in the year, I formally launched the Learn Not Blame campaign in Parliament, which was attended by Matt Hancock and Nick Ross amongst others. The DAUK has established an ongoing dialogue with the GMC and will be going back to them for further talks later this month.


I guess my point in telling you all this is to show that we can achieve things as ordinary doctors. The Learn Not Blame campaign is an opportunity for everyone who believes in a just culture in the NHS to come together to advocate for change, with doctors leading the call. It’s easy to feel helpless and hopeless within the sprawling, powerful NHS organisations we work for, but the small things matter. Just wearing your lanyard or badge, and engaging colleagues in conversation if they ask about it can make a difference. Just letting people know you are part of a different mindset, a supportive colleague, someone prepared to try and understand why things happened, can change how people feel at work. 


And if you are feeling small, insignificant and powerless, I just leave you with this thought from the Dalai Lama: “If you think you are too small to make a difference, try sleeping with a mosquito”.


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What next for Learn Not Blame in 2019? Cicely Cunningham writes...

2018 was the beginning of the Learn Not Blame campaign and what a year it was! From a phrase coined by the inimicable David Nicholl to a wave of nationwide outrage at the injustice of criminalisation of healthcare professionals for honest mistakes.


Along with this outrage was the understanding that fear, blame and criminalisation of honest error – especially when made when working in a system under pressure – does nothing for patient safety. Yet too many NHS organisations are perpetuating a culture which allows this toxic mix to thrive, and patients are put at risk. The figures for avoidable harm in the NHS are staggering. And yet the pattern repeats. Too often reputation is put above truth-seeking, families are battered by the process of trying to get answers, and doctors and other healthcare professionals are too fearful of victimisation and blame to put their head above the parapet.


The Learn Not Blame campaign offers a chance to bring together a collective voice about this. To say – enough. The blame culture has to end. We owe it to our patients. We need to create a place where all voices are heard, and all – staff and patients – are cared for. We took this message to Parliament in November, and made our voice heard with the Secretary of State for Health and Social Care, Matt Hancock.


But the Learn Not Blame campaign offers more than that. It’s a chance for each of us to demonstrate how change can happen. To create change within our own sphere of influence. Whether we like it or not, doctors are seen as leaders in the NHS. We all have some influence and how we behave has knock-on effects. And the little things have ripple effects. Take the #hellomynameis campaign – so simple, yet makes such a difference, not just to patients, but to colleagues. But also noticing and thanking someone for their work when they go the extra mile. Asking colleagues if they’re OK when it’s been a tough shift, or talking someone through to debrief. Making sure people know that you want to Learn, Not Blame.


This campaign is all about people. And the people who will make the difference are you. There is much to do, but if we all do it together, we will make progress. 


I’m looking forward to what 2019 will bring. In this blog, Jenny Vaughan and I will bring you our thoughts and views on the campaign, along with guest blogs from the many and varied individuals who are supporting us. Follow us on social media, and get in touch by email, facebook or twitter. We want to hear from you. How are YOU making Learn Not Blame a reality?

Sign up to the Learn Not Blame campaign to get your free campaign pack at dauk.org/learnnotblame.


"What has the GMC learnt?" DAUK asks Charlie Massey

"What has the GMC learnt?" DAUK asks Charlie Massey

The Doctors’ Association UK committee met with Charlie Massey, Chief Executive and Registrar of the GMC and Dr Colin Melville, Medical Director and Director of Education and Standards last week. We were clear to convey the anger and distrust the profession feel towards the GMC. During the meeting we covered a variety of subjects including issues raised by the Bawa-Garba case, continued appeal of MPTS decisions, weaponisation of GMC referrals, accountability of NHS managers, and mental health and wellbeing of doctors under investigation.

"What is stopping you doing something that is patently sensible?" says Rosie Cooper MP to Charlie Massey: Jenny Vaughan reports on the HSC inquiry.

"What is stopping you doing something that is patently sensible?" says Rosie Cooper MP to Charlie Massey: Jenny Vaughan reports on the HSC inquiry.

After month of campaigning by DAUK, the Health and Social Care Committee held an inquiry into gross negligence manslaughter. Dr Jenny Vaughan attended on behalf of DAUK. Read her report here: