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.

It has emerged that in a new case, relatives of retired lorry driver Horace Nunn were not told of suspected mistakes in his care until two months after an injury in hospital that contributed to his death in July 2016. They only learned of a problem when a staff member tipped them off that the hospital was planning to investigate delays in the diagnosis of a neurological problem, known as an epidural haematoma, in March.

The new tipoff raises further questions about patient safety standards at the Bury St Edmunds hospital, and a possible breach of the strict NHS-wide “duty of candour” obligation to tell patients and relatives about damaging lapses in care. Last month the Guardian revealed Hancock repeatedly failed to respond to concerns the hospital was bullying and intimidating senior staff to prevent them raising patient safety issues.

Last week, the Guardian further disclosed the trust had spent more than £2,500 on handwriting and fingerprint experts in its hunt for the whistleblower in the Warby case.

Dr Rinesh Parmar, chair of the Doctors’ Association UK, said: “We are incredibly concerned that a second whistleblower has had to raise concerns directly with a family regarding possible harm at West Suffolk. “This pattern speaks of a toxic culture where clinicians feel unable to speak up when things go wrong for fear of retribution. Given recent reports of West Suffolk’s ruthless response to hunt down anonymous whistleblowers, these fears appear to be well founded.”

Excerpt from The Guardian, read the full article here: https://www.theguardian.com/society/2020/jan/24/west-suffolk-hospital-faces-fresh-questions-over-whistleblower-tipoffs

The lexicon of a “just culture” in the NHS has become popular over recent months, notably in the publication of Being Fair: Supporting a just and learning culture for staff and patients following incidents in the NHS by NHS Resolution.

We are taught that to create this culture, when things have gone wrong, we need to focus on three questions (Dekker 2017): Who is hurt? What are their needs? And whose responsibility is it to meet those needs?

There is much to celebrate in the increased focus on “just culture”– not least that this has become accepted parlance within the NHS mainstream and more widely in the regulatory community. The phrase can be found in the National Patient Safety Strategy from NHS England/NHS Improvement.

It is advocated in the General Medical Council-commissioned review on gross negligence manslaughter and culpable homicide. There is A just culture guide, from NHS Improvement, which “encourages managers to treat staff involved in a patient safety incident in a consistent, constructive and fair way”.

Yet from the perspective of patients and families, the narrative to date can seem somewhat one sided. In our view, a “just culture” has to give equal importance to being fair to staff and patients.

In the aftermath of a patient safety event resulting in serious patient harm or death, the response of the organisation to the patient or family is crucial. Yet too often, rather than the restorative approach Dekker calls for, harmed patients and bereaved families experience a response that in many cases significantly exacerbates their grief, trauma and distress.

Given the notion of justice encompasses concepts of fairness and equity, the pursuit of a just culture must also ensure further harm to patients and families is avoided.

At recent events hosted by AvMA and The Doctors’ Association UK, harmed patients and families sat side by side with clinicians and researchers. It was moving and heartening to hear the empathy felt by both “sides” expressed for all affected by the fallout from patient safety incidents.

Read more

Read the full article here

“Campaign group The Doctors’ Association UK (DAUK), who last month called for an investigation into the GMC’s ‘aggressive pursuit’ of Dr Bawa-Garba, said the regulator had used its right to appeal ‘in every case to impose harsher conditions or sanctions on doctors’, adding that the GMC has ‘failed to appropriately reflect on its ongoing use of appeals’.

Doctors’ confidence

Dr Rinesh Parmar, DAUK treasurer, said: ‘Doctors’ confidence in their regulator the GMC has been severely damaged in the wake of the Bawa-Garba case. This [is] evident with thousands of doctors signing letters to the GMC throughout the case and following Dr Bawa-Garba’s appeal.

‘The actions of the GMC during the case and its desire to continue with these appeals further damages the relationship between doctors and their regulator. The GMC is seen as an organisation that is unable to appropriately reflect on its actions, learn from mistakes and remediate going forwards when seeking to impose harsher conditions to those determined by an independent tribunal.

‘DAUK will be calling on the government to confirm when it will be upholding the recommendations of the Williams review and stripping the GMC of its right of appeal.’”

In our letter DAUK also:

-expresses concern regarding the news that the GMC has continued to appeal MPTS verdicts following the judgment in Bawa-Garba v GMC

-expresses concern that this week Lord Justice Bean urged that the GMC show ‘restraint’ when exercising this power in the judgment of Raychaudhuri v GMC on the 14th September, and in discussing the case appeal judges expressed ‘regret that it was brought’.

-expresses concern that the GMC is currently appealing the MPTS verdicts of four doctors in the courts in order to impose a higher sanction. DAUK has asked Mr Massey to grateful clarify if this is indeed the case.

-states that we still do not feel that doctors, the patient safety community and the public, have been provided with a clear understanding of how the GMC came to the decision to appeal the MPTS verdict in Dr Bawa-Garba’s case, or indeed the processes which the GMC follows when deciding to appeal the MPTS verdicts of other doctors’ cases.

-confirms that Dr Sarah Wollaston has informed us the Health Select Committee will hold an evidence session on gross negligence manslaughter and patient safety in the Autumn.

-informs Mr Massey that we will be urging the Government to move forward with the legislative changes needed to repeal the relevant amendment to Section 40A that allows the GMC to appeal MPTS verdicts in a timely matter.

-calls upon Massey to cease appealing MPTS verdicts urgently.

-supports the petition started by Dr Jenny Vaughan that calls on the GMC to ensure that the court fees awarded to Dr Bawa-Garba are not paid for from the subscription fees of the doctors who supported her.

-extends an invitation to both Mr Massey and Professor Terence Stephenson to the formal launch of our Learn Not Blame campagin in Westminster hosted by Dr Philippa Whitford MP in November.

read the full letter here

We welcome Mr Massey’s apology and will be taking him up on his offer to meet DAUK. We will be responding to this this week in light of the news that the GMC has continued to appeal MPTS verdicts in the courts. This is despite the recommendations made by the Williams Review and widespread concern following the GMC’s actions in Dr Hadiza Bawa-Garba’s case.

read charlie massey’s reply in full

The Doctors’ Association UK believes the GMC made a serious error of judgement in aggressively pursuing Dr Hadiza Bawa-Garba in the courts, when it sought to have her struck off for honest mistakes made whilst under immense pressure.(1) This was against the advice of its own expert panel, the Medical Practitioners Tribunal Service (MPTS), who determined that Dr Bawa-Garba presented no greater risk to patients than any other competent doctor. The GMC’s action prompted widespread concern amongst the medical profession and patient safety campaigners that a junior doctor was being scapegoated for widespread systemic failures.

On Monday 13th August, the Court of Appeal threw out the GMC’s arguments and ruled that Dr Bawa-Garba could be reinstated on the medical register.

The Doctors’ Association UK believes that the GMC has shown it cannot be trusted to take a balanced and non-punitive view in its assessment of doctors in the context of system failures. The Doctors’ Association UK’s central campaign, launched in response to the GMC’s actions in Dr Bawa-Garba’s case, is Learn Not Blame, which seeks to address the problems of the blame culture within the NHS. In the spirit of this, we do not seek to scapegoat any one particular individual or group of individuals working within the GMC.

Instead, The Doctors’ Association UK has brought together over 1200 GMC-registered doctors, including Dr Philippa Whitford, MP, in writing to the GMC. Signatories include Mr David Sellu, whose conviction for Gross Negligence Manslaughter was quashed after he spent 15 months in prison. Other signatories include prominent whistleblowers and campaigners. Collectively, we call for the GMC to take responsibility for its actions and learn valuable lessons from the outcome of this case. Applying a genuinely reflective approach, as is expected of doctors in their practice, would be a significant step in restoring the confidence and trust in the GMC as a regulatory body. Lessons must be learnt to ensure that learning, openness and honesty is prioritised over blame, defensiveness and scapegoating.

Dr Samantha Batt-Rawden, Chair of DAUK, said “The GMC’s decision to pursue Dr Hadiza Bawa-Garba’s erasure from the medical register has led to an unprecedented loss of confidence in the GMC. As doctors, we recognise that mistakes happen. The GMC must now hold itself up to the same level of scrutiny that the GMC expects of doctors. We call on the GMC to reflect openly on its actions and to refer itself to the Health Select Committee for consideration of a public investigation. This, we believe, is a crucial first step towards restoring the trust of doctors and the public in the GMC.”

Dr Cicely Cunningham, Learn Not Blame Campaign (2) Lead, said “The GMC’s actions have set the patient safety agenda back by decades. We would like to see the GMC reflecting openly and honestly on its misjudgements in this case. A genuine attempt to learn from its mistakes would be a step towards restoring the confidence of the medical profession, and in moving towards the just culture the NHS so desperately needs”.

CONTACT

Contact@dauk.org

NOTES TO EDITORS

1. On 28th February The Doctors’ Association UK (DAUK) wrote a letter to Mr Charlie Massey, Chief Executive of the GMC expressing overwhelming concern regarding the handling of the Bawa-Garba case. This letter was signed by over 4500 doctors and several MPs.

2. Following the case of Dr Hadiza Bawa-Garba DAUK launched our campaign Learn Not Blame, seeking to change the way medical error is approached in the UK. Our aim is to transform the current culture of blame and fear, into one of learning. We believe this is vital for patient safety, and have received cross-party support for the campaign, as well as backing from our peers. More information on the campaign can be found here.

The Doctors’ Association UK is pleased that the report agrees with our written submission that the provision for the HSSIB to accredit NHS trusts to do their own ‘safe space’ investigations is an enormous conflict of interest. We are therefore delighted that the report has recommended that the entirety of part 3 of the draft Bill, relating to Trust accreditation, be dropped.

The Doctors’ Association UK is also pleased that the report agrees the value of the HSIB as an independent body, bringing medicine in line with the rail and aviation industries. ‘Safe space’ investigations will allow staff to speak freely and determine what went wrong to prevent similar mistakes happening again. If ‘safe space’ investigations are to carry the confidence of the public, the independence of the HSIB must be assured.

The Doctors’ Association UK’s central campaign is entitled “Learn Not Blame”, and seeks to engender a national conversation about the need for a just culture in the NHS. We are campaigning for a step change in the NHS so that honest error is used to drive learning and change for a safer, better NHS, rather than being a focus for individual blame. The creation of a truly independent body is a welcome step towards this.