Good patient communication strategies are an essential prerequisite for developing an effective NHS patient safety culture and the NHS needs to improve on its efforts. We have seen repeatedly in reports of investigations into NHS patient safety crises that major failings have been identified.
If we take some of the most recent patient safety reports, we see tragic failings in communication to patients and between health professionals, such as in East Kent.
‘Staff were disrespectful to women and disparaging about the capabilities of colleagues in front of women and families. A family member heard a consultant describe the unit they were in as “unsafe” to a colleague in the corridor, which was hardly the way to raise any legitimate concerns they may have had.’
In Shropshire and Telford, the review found evidence that complaint responses lacked transparency and honesty:
‘The review team has identified families where care was sub-optimal, where different management would likely have made a difference to the outcome, however the complaint responses justified actions, delays and omissions in care. In addition, they often lacked compassion and in a number of responses it was implied that the woman herself was to blame.’
Ockenden, 2022:44-45
I would ask what these reports tell us about the practical operation of professional and statutory duties of candour, as they cover events after the statutory provision came into force. Collectively they show that the concept of candour was poorly understood by a significant number of staff.
Patients deserve the truth
It is possible to say that the NHS is getting better with administering the statutory duty of candour, as are staff with their professional, individual duty of candour. There are green shoots in areas of governance and regulation. Negri (2018) found some improvement in duty of candour regulation and enforcement practice but that still more could be done. Quick (2022) discussed the duties of candour in health care and ‘safe spaces’ exempt from disclosure to the Healthcare Safety Investigation Branch (HSIB). He concluded that patients who have been harmed and their families ‘deserve to know the whole truth’.
The Care Quality Commission (CQC) discusses the statutory and professional duties of candour:
‘Both the statutory duty of candour and professional duty of candour have similar aims — to make sure that those providing care are open and transparent with the people using their services, whether or not something has gone wrong.’
CQC, 2022: 2
However, we can see this failing to take place on an industrial scale in several reports of investigations. There is an evident mismatch between duties of candour in theory and practice; this mismatch needs urgently addressing. Nurses, doctors, and others do need to take duties of candour much more seriously.
Action against Medical Accidents (AvMA), the charity for patient safety and justice, has recently highlighted this recurring candour problem (AvMA, 2023). It reports that a lack of explanation about a medical accident, and attendant lack of an apology, made up 45% of inquiries to the charity in 2022. Of the 419 written requests for advice and assistance from UK patients, nearly half were duty of candour related. Paul Whiteing, Chief Executive of AvMA, argued that these failures constitute what could be regarded as an own goal. This omission will drive the patients to take court action to find out what happened and to secure an apology.
Still some way to go
The AvMA (2023) report shows that the NHS has still some way to go in properly dealing with duty of candour issues. The failings in the investigation reports discussed above only go on to compound the unsatisfactory nature of the situation that exists. The Professional Standards Authority (PSA) (2019) has provided some excellent discussion of issues relating to the exercise of the professional duty of candour. Factors that encourage and discourage candour were discussed. The workplace can affect the exercise of professional candour. A predominantly blame-oriented, defensive working environment is not conducive to being open and honest. The importance of timeliness was discussed. Heavy workloads on nurses and doctors mean they don’t always have the time to respond quickly to incidents. The importance of education is discussed, along with the inhibiting fear of litigation and being called before a regulator on a disciplinary charge:
‘The twin prospect of regulatory and criminal or civil prosecution proceedings may discourage professionals from being candid. Some stakeholders considered that professionals may worry that regulators may not be fair to professionals who have been candid, and that the regulator may be perceived to be punitive or looking to apportion blame.’
PSA, 2019:16
The PSA (2019) made some fair points, which need to be carefully considered in developing patient safety policies and practice. If we wish to save scarce financial resources and work to develop proper strategies to avoid patients escalating issues to the courts, then NHS duty of candour practices need to significantly improve. Patients and their relatives, as a matter of basic honesty, truth and common decency, need to know the truth.
A personal duty of care
The PSA (2023) also shared some interesting perspectives on the issue of the duty that is both legally and professionally placed on the individual nurse or doctor to take care. It stated the importance of individual accountability, and considered the problems that arise when there is a focus on systemic and institutional failings and not on those of the individual:
‘Attempts to improve safety that focus on systemic and institutional failings alone can obscure the responsibility of individuals (both regulated and unregulated) within that system, leaving them unaddressed. They also assume that none of the behaviour was in fact “blameworthy”. While this is probably the case most of the time, the pattern of almost systematic lack of candour uncovered by public inquiries shows that these assumptions can be misplaced.’
PSA, 2023: 69
Systems theory approaches do underpin NHS patient policy making and practice, this can be seen in the NHS patient safety strategy:
‘The ‘systems’ approach therefore underpins the NHS Patient Safety Strategy including the new Patient Safety Incident Response Framework …and A Just Culture Guide …’
NHS England/NHS Improvement, 2019:8.
When reading the reports of investigations into patient safety crisis incidents, including the ones mentioned above, a significant amount of personal, staff error has been identified, but this then seems to be engulfed in discussions of system improvement and collective, institutional remedial action. Individual responsibility for the problems in many instances seems to get kicked out of touch. The PSA stresses the individual professional accountability of the health professional in relation to the professional duty of candour and in relation to their exercise of their duty of care towards the patient.
The NHS Staff Survey
As the adage goes, ‘to know where you are going, you have to know where you have been’. In patient safety terms this is crucial, although we need to maintain a forwardlooking approach in developing policies and practices, we also need to be able to look back to see what has worked or not.
The NHS Staff Survey provides a useful barometer in terms of how NHS staff see patient safety and deal with problems. The latest version had new questions on patient safety (Survey Coordination Centre, 2023):
- 33.5% of staff said they have seen errors, near misses or incidents in the last month that could have hurt staff and/or patients/service users (Q17)
- 58.1% of staff said their organisation treats staff who are involved in an error, near miss or incident fairly (Q18a)
- 86.1% of staff said their organisation encourages staff to report errors, near misses or incidents. (Q18b). More than 8 in 10 staff in all types of trust agreed that reporting is encouraged
- 67.3% of staff said that when errors, near misses or incidents are reported, their organisation takes action to ensure that they do not happen again (Q18c)
- 59.8% of staff said that they are given feedback about changes made in response to reported errors, near misses and incidents (Q18d).
The report’s overall figures could be much higher. It is concerning that we have a figure of 58.1% for question 18a on staff being treated fairly when adverse healthcare incidents take place. This finding reinforces the concept of a blame-focused culture in the NHS for error. The figure of 67.3% for health organisations taking action to make sure events are not repeated is also concerning. This reinforces the age-old perception that the NHS is slow at learning the lessons from past patient safety crises.
Conclusion
The duty to be open and honest with patients can never be overstated. This is the bedrock on which a patient safety culture is based. It is a vital prerequisite for the delivery of safe care in the NHS. Several recent investigation reports into major NHS patient safety crises have shown that more needs to be done about applying the statutory and professional duties of candour.
The mindset should be that the individual professional who is at fault does not always shift responsibility back to the employers/institution for clinical negligence and error. They too must take some responsibility as part of their professional duty. Also, it should be recognised that there are dangers with the systems theory approach that underpins current NHS patient safety policy making, thinking and practice. The NHS Staff Survey presents a useful barometer into the health of patient safety in the NHS and the latest figures are concerning and must be improved on.