What is Just Culture?

Just Culture is about creating a culture of fairness, openness and learning. In a Just Culture, people can raise concerns over risks, errors, and near misses without fear of blame and punishment. DAUK has been calling for a culture of learning through our Learn Not Blame campaign, NHS England adopted the standard nearly a decade ago. However, anecdotal information suggests it is barely present when it should be universal. Now we need your help to see where the NHS is and to guide our future work in seeking improvements. This is more important than ever with increasing demand and staff shortages leading to poorer outcomes.

Just Culture survey

Please take a few minutes to complete our anonymous and confidential survey. Your feedback is vital. The survey is in association pilots’ union BALPA, which wants to understand the challenges in the aviation industry. Our survey on NHS Just Culture can be accessed here and will run until 20 December. Thank you for taking the time to complete it. If you have any questions, please contact the DAUK project lead here. And please support our work by becoming a member or donating to our Go Fund Me.

Dr Kneale said safeguards needed to be put in place to protect whistleblowers which would lead to a safer NHS.

He was speaking after taking part in a key session at Westminster hosted by the All-Party Parliamentary Group (APPG) on Whistleblowing.

The roundtable titled Whistleblowing in Healthcare, a lesson in futility, was held at the House of Lords as part of Whistleblowing Awareness Week.

During the session, Dr Kneale focused on the need for independent scrutiny panels in NHS trusts, which have been proposed by, among others, Arun Baksi, founder director of Our NHS Our Concern.

He also emphasised the need to reduce unnecessary referrals by trusts to the regulator, advocating for a system that better supports and protects whistleblowers.

This was part of a wider discussion aimed at influencing the Government’s Whistleblowing Framework review and reinforcing the proposals in the Whistleblowing Bill, which was presented to Parliament last year.

Dr Kneale said: “As DAUK’s co-chair, my participation in the Whistleblowing Awareness Week was driven by our commitment for healthcare reform.

“I highlighted the urgent need for independent scrutiny panels in healthcare to safeguard whistleblowers and ensure their concerns are addressed fairly and transparently.

“I also backed the Whistleblowing Bill which will enshrine in law these protections that are sorely lacking.

“Our goal is to foster a Learn Not Blame culture where any healthcare professional can raise concerns without fear of retribution, ultimately leading to a safer NHS.”

He was joined on the panel by a number of prominent figures including BMA chair Professor Phil Banfield, Dr Chris Day, emergency medicine doctor, whistleblowers Martyn Pittman and Peter Duffy, along with Ravi Jayaram, one of the consultant whistleblowers in the Lucy Letby case.

Dr Kneale added: “Hopefully the comments and recommendations will significantly contribute to the ongoing efforts to reshape whistleblowing policies for the betterment of all professionals and the public, especially in healthcare.”

Each year we award The BMJ editors’ prize for “persistence and courage in speaking truth to power.” The list of previous winners reads like a roll of honour: Peter Wilmshurst, Clare Gerada, Martin McKee, Susan Bewley, Trish Greenhalgh, Robin Stott, Jenny Vaughan, and David Nicholl. These are people who have bravely called out wrongdoing or have paved a compelling path for doing right, often through their writings in The BMJ. At the end of last year the prize went to Allyson Pollock, who is interviewed this week.1

Why should we prize these people so highly? Because it takes determination, diligence, and skill to speak out effectively, to use data and judgment, to avoid the easy resort to polemic or personal attack, and to balance necessary criticism with constructive ideas. Because it means saying unpopular things that people in power don’t want to hear.

We know that these few prize winners represent many others, working across healthcare around the world, who have shown immense courage, sometimes quietly, sometimes alienating themselves from colleagues, sometimes risking their careers and even their lives.

Supporting them and the issues they champion is part of The BMJ’s role, and in this week’s print journal we have published articles that reflect just some of the many issues that need attention. With services at full stretch because of the surge in covid-19 cases, health professionals are speaking out.2 The vaccine rollout is faltering and patchy,3despite governments having had months to prepare.4 Hopes of global vaccine equity look slim,567 and more needs to be done to reach ethnic minority communities.8 Retired doctors wishing to volunteer as vaccinators have been mired in unnecessary bureaucracy.9

A decision in the UK to extend the gap between vaccine doses has led to confusion and accusations that the government and its advisers have abandoned science.1011 We have tried to answer the most pressing questions raised by this unexpected change.12 The implications for public trust and vaccine uptake remain to be seen.13 But let us at least have the data behind the decision,14 and indeed the data from all the vaccine trials.15 On a positive note, because junior doctors spoke out, the UK regulator has responded to concerns about women who are breastfeeding being advised against having the vaccine16; and because patients spoke out, there is progress—however slow—towards a register of doctors’ financial interests.17

Not everyone can or will want to speak out. For those of you looking to make a difference in other ways, there is our charity appeal.18 We have passed previous records in the amount already donated. Families in need will thank you for your generosity.

Read the article here: https://www.bmj.com/content/372/bmj.n24

References

1. ↵Mahase  E. “In the 1980s NHS there wasn’t today’s climate of fear around speaking out”—Allyson Pollock. BMJ2021;372:m4930doi:10.1136/bmj.m4930.FREE Full TextGoogle Scholar
2. ↵Coombes  R. Covid-19: Frontline doctors speak out about struggle to maintain care standards. BMJ2020;371:m4971.doi:10.1136/bmj.m4971 pmid:33384300FREE Full TextGoogle Scholar
3. ↵Mahase  E. Covid-19: Logistical problems frustrate GPs ready to deliver vaccine in England. BMJ2020;371:m4849.doi:10.1136/bmj.m4849 pmid:33323366FREE Full TextGoogle Scholar
4. ↵McGregor J. Vaccination rollout: there is no time to get this wrong. BMJ Opinion. 7 Jan 2021. https://blogs.bmj.com/bmj/2021/01/07/jane-mcgregor-vaccination-rollout-there-is-no-time-to-get-this-wrong.
5. ↵So  AD, Woo  J. Reserving coronavirus disease 2019 vaccines for global access: cross sectional analysis. BMJ2020;371:m4750.doi:10.1136/bmj.m4750 pmid:33323376Abstract/FREE Full TextGoogle Scholar
6. ↵Wang  W, Wu  Q, Yang  J, et al. Global, regional, and national estimates of target population sizes for covid-19 vaccination: descriptive study. BMJ2020;371:m4704. doi:10.1136/bmj.m4704 pmid:33323388Abstract/FREE Full TextGoogle Scholar
7. ↵Schwartz  JL. Equitable global access to coronavirus disease 2019 vaccines. BMJ2020;371:m4735.doi:10.1136/bmj.m4735 pmid:33323384FREE Full TextGoogle Scholar
8. ↵Hanif  W, Ali  SN, Patel  K, Khunti  K. Cultural competence in covid-19 vaccine rollout. BMJ2020;371:m4845doi:10.1136/bmj.m4845.FREE Full TextGoogle Scholar
9. ↵Rimmer  A. Covid-19: Health secretary vows to reduce bureaucracy faced by vaccination volunteers. BMJ2021;372:n13.doi:10.1136/bmj.n13 pmid:33397687FREE Full TextGoogle Scholar
10. ↵Pierce B. We need clear and simple upfront messaging on covid-19 vaccines. BMJ Opinion. 5 Jan 2021. https://blogs.bmj.com/bmj/2021/01/05/benjamin-f-pierce-we-need-clear-and-simple-upfront-messaging-on-covid-19-vaccines.
11. ↵Mahase  E. Covid-19: Order to reschedule and delay second vaccine dose is “totally unfair,” says BMA. BMJ2020;371:m4978.doi:10.1136/bmj.m4978 pmid:33384299FREE Full TextGoogle Scholar
12. ↵Iacobucci  G, Mahase  E. Covid-19 vaccination: What’s the evidence for extending the dosing interval?BMJ2021;372:n18doi:10.1136/bmj.n18.FREE Full TextGoogle Scholar
13. ↵Salisbury  H. Helen Salisbury: Don’t squander patients’ trust in the vaccine rollout. BMJ2021;372:n3.doi:10.1136/bmj.n3 pmid:33397643FREE Full TextGoogle Scholar
14. ↵Robertson J. Covid-19 vaccines: to delay or not to delay second doses. BMJ Opinion. 6 Jan 2021. https://blogs.bmj.com/bmj/2021/01/05/covid-19-vaccines-to-delay-or-not-to-delay-second-doses.
15. ↵Doshi P. Pfizer and Moderna’s “95% effective” vaccines—we need more details and the raw data. BMJ Opinion. 4 Jan 2021. https://blogs.bmj.com/bmj/2021/01/04/peter-doshi-pfizer-and-modernas-95-effective-vaccines-we-need-more-details-and-the-raw-data.
16. ↵Hare  H, Womersley  K. Why were breastfeeding women in the UK denied the covid-19 vaccine?BMJ2021;372:n4doi:10.1136/bmj.n4.FREE Full TextGoogle Scholar
17. ↵Dyer  C. Where the mesh inquiry leaves us regarding a register of doctors’ interests. BMJ2021;372:m4839doi:10.1136/bmj.m4839.FREE Full TextGoogle Scholar
18. ↵Feinmann  J. Community support that’s more than a sticking plaster. BMJ2021;372:m4959doi:10.1136/bmj.m4959.FREE Full TextGoogle Scholar

When: 28th September 2020

Where: Virtual conference (CPD certified)

How, sign up here: https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/doctors-in-difficulty-and-difficult-behaviour

Why:

• Network with colleagues who are working support doctors in difficulty

• Reflect on the experience of a Doctor with lived experience

• Learn from outstanding practice in working with doctors to tackle unprofessional, difficult or disruptive behaviours which can impact on patient safety and outcomes

• Develop practical solutions to bring joy back into day to day practice

• Reflect on national developments and learning

• Explore the practicalities of managing doctors in difficulty from a Clinical Directors perspective

• Improve the way concerns are identified and responded to

• Develop your skills in managing and working with difficult behaviour

• Understand how you can improve support for doctors experiencing mental health, physical health or clinical performance concerns

• Identify key strategies for enabling resolution and remedial/developmental action

• Understand the HR and Legal context

Dr Batt-Rawden was also to join a panel on patient safety, which Jeremy Hunt was also scheduled to appear at, but unfortunately the former secretary pulled out at the last minute.

In her speech to the Westminster Health Forum Sammy outlined the Bawa-Garba case, which saw a paediatric trainee scapegoated for widespread system failures. She went on to explain how this became a lightning rod for the medical profession, with doctors feeling ‘on any given day in the NHS that could have been me’.

Sammy went on to explain that the fall out from this case has been disastrous; that DAUK had heard from hundreds of doctors wanting to quit, or had quit the NHS saying it was “no longer worth it”, doctors leaving specialties deemed “too high risk”, specialties like Emergency Medicine, Intensive Care, General Practice, which are already short and desperately need them.

Sammy made the point that the blame culture is no doubt a cause for low morale in the NHS and likely contributing to a staffing crisis, which is being compounded by a punitive pensions tax.

Outlining the impact on patients, Sammy explained that the blame culture is changing the way doctors practise, and making the NHS a less safe space to speak up when things go wrong. Sammy also spoke about our Learn Not Blame campaign and what DAUK has been doing to address the blame culture in healthcare.

The session was an overwhelmingly positive event, with many speakers including Leslie Hamilton referencing Learn Not Blame and our work in this area.

Coverage in Pulse:

The GMC’s chief executive has admitted the legal advice the regulator received during the Dr Hadiza Bawa-Garba case was wrong and if the same case were to take place now he would not try to have a doctor barred from practice.

Charlie Massey said he ‘completely accepts’ the legal advice he was given to pursue the striking off of Dr Bawa-Garba – who was convicted of manslaughter by gross negligence following the death of a six-year-old patient – was ‘not correct’.

In response, Dr Batt-Rawden said: ‘The acknowledgment that his decision to appeal the MPTS verdict in Dr Bawa-Garba’s case was incorrect was long overdue and will be welcomed by doctors and the public.

‘DAUK wrote to the GMC as far back as February 2018 in a letter signed by over 4,500 doctors in protest of the GMC’s appeal against Dr Bawa-Garba. In that letter we brought to light that the Professional Standards Authority had found this decision to be “incorrect” and “without merit” and that the MPTS “considered all relevant principles and applied the case law appropriately”.

‘DAUK also pointed out that the Supreme Court established that professional tribunals were better placed than courts to determine professional competence in 2016. We were therefore astonished by the GMC’s actions in this case. We were pleased that DAUK was found to be correct in the Court of Appeal in August 2018 and that Dr Bawa-Garba was rightly restored to the medical register, something we have long fought for during our Learn Not Blame campaign.’

She added: ‘To my knowledge this was the first occasion that Charlie Massey accepted publicly that this decision was wrong. This represents a crucial first step in repairing the damage done to the medical profession by the Bawa-Garba case.

‘The GMC still has a long way to go in regaining the trust of doctors, but for the first time in this interview I saw that some genuine reflection and learning had taken place. I hope this signals change in tone from the GMC and we look forward to working with them in moving from a culture of blame, to one of learning.’

Read the full article here:

http://www.pulsetoday.co.uk/news/gp-topics/legal/gmc-chief-executive-admits-bawa-garba-legal-advice-was-wrong/20038855.article

This week I had the opportunity to interview Charlie Massey, the chief executive of the General Medical Council (GMC), for a BBC Radio 4 documentary on why doctors are leaving the NHS. It didn’t start well. I found myself on a train to Portsmouth instead of London having been up most of the night; proof that tired doctors do indeed make mistakes.

Generously Charlie did meet with me, some hour and a half late. I felt it was crucial that we acknowledge the impact that the blame culture has had on recruitment and retention.

I was surprised and encouraged, when Massey admitted publicly that the decision to take Hadiza Bawa-Garba to the High Court to have her erased from the medical register was wrong.

To me, this was an incredible acknowledgement from the GMC. But I have no doubt that doctors will be asking: why did it take so long?

Read the full article in the BMJ:

https://blogs.bmj.com/bmj/2019/06/12/a-change-of-tone-from-the-gmc-but-can-they-win-back-doctors-trust/

Today, there is widespread relief amongst the medical profession. However, the verdict is no cause for celebration. At the heart of this case is a child, Jack Adcock, who tragically lost his life to sepsis. Our hearts go out to the Adcock family as they continue to grieve for Jack.

When a child dies it is our duty as doctors to do all we can to prevent the same tragedy from occurring again. We strongly feel that scapegoating an individual doctor or clinician for human errors made whilst whilst working under enormous pressure, does not serve this purpose. Instead, the criminalisation of medical error creates a culture of fear and blame, where clinicians feel afraid to speak up, afraid to reflect, and afraid to learn when things go wrong.1

Therefore, we welcome the verdict of the Medical Tribunal Practitioners Service (MPTS) today, who, after considering all the system failures and the context in which Dr Bawa-Garba made errors, has found her safe to return to medical practice, albeit with conditions on her license. We are especially pleased that the MPTS had accepted Dr Bawa-Garba has “fully remediated”. With widespread support from the medical profession and the Royal Colleges we hope that she will be fully supported in a return to work.

Dr Jenny Vaughan, Law and Policy Officer DAUK and Founder of Manslaughter and Healthcare said:

“I’m a patient, doctor and a mother and I know that Jack Adcock should have received better care. However, Dr Bawa-Garba was working in appalling conditions that day in an NHS hospital and all the evidence of what the hospital actually needed to put right was not heard by the jury. There is a culture of blame in the NHS at the moment which, if left unchecked, will mean patient safety is not what it should be as staff will be too scared to admit their mistakes. The next generation of those who want to care will simply vote with their feet. It’s right that Dr Bawa-Garba is going to be restored to the medical register as the hospital too was at fault and should have provided better care. We are calling for a just culture so that the system here is made safer as locking up individuals achieves nothing.”

Dr Samantha Batt-Rawden, Chair of The Doctors’ Association UK said:

“Today’s verdict, whilst welcome, is no cause of celebration. There are no winners in this desperately sad case. However, restoring Dr Bawa-Garba to the medical register is the right outcome and will go some way in addressing the current climate of fear and blame in the NHS which is so toxic to patient safety. I have no doubt that Dr Hadiza Bawa-Garba will now be the safest doctor in the hospital, and as a doctor and a mother I would have no hesitation in allowing her to treat my child. ”

Contact

Contact@dauk.org

NOTES TO EDITORS

1. In November 2018 DAUK launched our campaign Learn Not Blame in Parliament, for a just culture in the NHS. DAUK continues to campaign for the decriminalisation of medical error and feels strongly that no clinician should face criminal charges for honest errors. https://www.dauk.org/learnnotblamedauk

You can read the full article profile below but here are some of our favourite bits:

‘Jenny Vaughan is a consultant neurologist in London. She is a leading campaigner for reforming the law on gross negligence manslaughter when applied to people working in healthcare. She articulated the unease many people felt at the conviction of the surgeon David Sellu, and as the campaign chair for his appeal, was successful in getting his conviction overturned.

Along with Sellu’s legal team she is widely credited for having modernised the law in this area. She has been equally vocal in defence of Hadiza Bawa-Garba and was a leading supporter of her successful bid against erasure. Vaughan’s contribution helped shape the conclusions of the Williams review in June 2019. She now campaigns for a “just culture” in healthcare and form improvements to patient safety by working with The Doctors’ Association UK (DAUK) and the BMA.’

Here are some of the questions put to Jenny.

What personal ambition do you still have?

‘To continue working to improve patient safety by working closely with patients and healthcare professionals. All of us at DAUK, along with my neurologist buddy David Nicholl, have now launched the campaign Learn Not Blame.’

Read the full article here: https://www.bmj.com/content/364/bmj.l1024