Over the years there have been several buzzwords and phrases in the NHS—patient advocacy, accountability, clinical governance, to name but a few. These terms focused attention on certain issues with many study days and articles. They are general, open-ended terms and various meanings can be ascribed to them. In a sense, they can mean whatever we want them to mean. They instil debate, which is a healthy exercise.
The key point to remember is that it is the ideas behind the label that matter, not necessarily the label itself.
These terms are still with us but there are other, perhaps more contemporary, concepts that now vie for our attention. One of these terms is ‘just culture’. This term is frequently bandied around the NHS and people make regular pleas for it. The patient safety and justice charity Action Against Medical Accidents (AvMA) points out:
‘There is no single definition of “just culture” and most discussion of it is limited to the issue of being fair to healthcare staff.’
It calls for a nationally agreed definition that also places:
‘…equal emphasis on being fair to patients and families, and which covers the whole system, from policy formulation to the delivery of healthcare and what happens when harm occurs.’
The charity has produced a draft national vision of what a just culture should look like for both patients and health professionals (AvMA, 2021b), and its recommendation is an excellent one. A just culture cannot operate in isolation from the interests of patients and their families—the weaker party in terms of power and influence. For fairness and balance, any NHS system-wide definition of a just culture needs to include consideration of the interests of patients and families, as well as those of NHS staff.
Understanding a ‘just’ culture
There are two seminal policies and guides to a ‘just’ NHS culture, which are important to explore when discussing the concept.
Just culture guide
NHS Improvement (2018a) produced a just culture guide. This encourages managers to treat staff involved in a patient safety incident in a consistent, constructive, and fair way. The guide is narrative in format and poses several questions with recommendations on:
- Deliberate harm test
- Health test
- Foresight test
- Substitution test
- Mitigating circumstances.
According to NHS Improvement (2018a), the guide:
‘… supports a conversation between managers about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely. Action singling out an individual is rarely appropriate—most patient safety issues have deeper causes and require wider action.’
In the introduction to the guidance (NHS Improvement, 2018b) it is stressed that it does not replace the need for a patient safety investigation and should not be used as a routine or integral part of such. The idea behind the guidance is that it should only be used when there is already a suspicion that a member of staff requires some support or management to work safely, or as part of an individual practitioner performance/case investigation. Accompanying the guidance are scenarios to support training in using the just culture guide (NHS Improvement, 2019).
Being fair
NHS Resolution published a suggested ‘Just and learning culture charter’ within the report Being Fair (NHS Resolution, 2019a), which set out the arguments for organisations adopting a more reflective approach to learning from incidents and supporting staff. The charter has 20 clauses covering several issues, such as the primacy of the patient's interests. It states the patient's physical and mental health must remain the paramount concern of any treating health professional.
Other issues discussed include the need to take blame out of failure, learning about what works well and why, drawing the line between acceptable and unacceptable behaviour, and the formal investigation process, disciplinary action. The charter focuses on the need to build a restorative just learning culture, linking this to the work of Professor Sidney Dekker. Some details of costs relating to NHS staff stress and bullying are also provided:
‘The last four years have seen 317 claims notified to NHS Resolution worth £27,479,003 in relation to staff stress and bullying. These costs do not account for any associated payments for sickness absence or any replacement staff to cover duties or resources for investigation and management.’
Being Fair is an excellent reflective report containing useful advice. It also gives examples of ways in which parts of the NHS are building a just and learning culture.
Reflecting on progress
Culture change does not happen overnight. Given the size and complexity of the NHS a just culture will take some time to develop. The information is out there, but is enough progress being made? The NHS Patient Safety Strategy highlights the problem of effecting a just culture in the NHS. A blame culture predominates when errors are made:
‘Culture change cannot be mandated by strategy, but its role in determining safety cannot be ignored. ‘Just cultures’ in the NHS are too often thwarted by fear and blame. A consistent message in the consultation responses was that fear is too prevalent across NHS staff, particularly in relation to involvement in patient safety incidents.’
NHS England/NHS Improvement, 2019: 7
This issue of fear and blame is one that has constantly plagued the NHS over the years. The issue of a just culture was addressed in the seminal report An Organisation With a Memory (Department of Health (DH), 2000) when discussing the critical subcomponents of an informed culture:
‘A just culture: not a total absence of blame, but an atmosphere of trust in which people are encouraged to provide safety-related information—at the same time being clear about where the line is drawn between acceptable and unacceptable behaviours.’
Although the development of a just culture has been around as a concept for a long time, it cannot be seen to be truly ingrained in the NHS today and much more work needs to be done. The reports discussed above show that good efforts have been made to lay the foundations upon which to build the concept, but efforts can be seen to falter. There are two recent stark warnings of the need for more sustained efforts in developing a just culture in the NHS.
New warning signs
There are presently some warning signs that the development of a just culture in the NHS is facing serious challenges. Lintern (2021) interviewed Andrea Sutcliffe, head of the Nursing and Midwifery Council (NMC), whom he quotes as saying:
‘I genuinely do not believe you get safe effective care by making nearly 725,000 people scared of their regulator.’
Hospitals and care homes are failing to properly investigate incidents before referring nurses to their regulator, fuelling a blame culture and repeat failures. Lintern (2021) quotes Andrea Sutcliffe:
‘If your automatic reaction is to say “something has happened and who is to blame”, and the first thing you do is refer them to their professional regulator without considering anything else, then you don't get the learning, you don't really know what happened.’
This situation does not bode well for developing a just culture in the NHS. Meanwhile, over 1.2 million NHS employees in England were invited to participate in the NHS Staff Survey during October and November 2020; 280 NHS organisations took part, including all 220 trusts in England (Survey Coordination Centre, 2020). The report reveals several findings including:
‘The following percentage of staff said that their organisation …
60.9% … treats staff who are involved in an error, near miss or incident fairly (q16a) This is an improvement since 2019 (59.7%) and continues a positive trend since 2016 (53.9%).
73.4% … takes action to ensure that reported errors, near misses or incidents do not happen again (q16c) This has improved by over 2 percentage points since 2019 (71.1%) and continues a positive trend since 2016 (68.7%)’
Survey Coordination Centre, 2020: 35
That figure is not a very large percentage for treating staff fairly when an error, near miss or incident occurs. Although it is good to see a positive trend, there is still a long way to go in developing a just culture where blame is not seen as the predominating factor.
Conclusion
The phrase ‘just culture’ is one of those phrases that can mean whatever someone wants it to mean. This can be a useful trait because it engages debate over meaning and people can take personal ownership of the concept when they ascribe a meaning to it. However, there is now a need to have more central direction from Government in developing the concept.
There are worrying signs that in some parts of the NHS the concept is in serious trouble. Lintern (2021) highlighted urgent NMC concerns and the NHS Staff Survey does not show blisteringly high satisfaction figures when it comes to handling blame and adverse events. For 20 years or more the NHS has been grappling with the term in some way or another. Although some good efforts have been made more needs to be done to enshrine the concept in the NHS.