In the development of health quality and patient safety policy over the years, the NHS has not been slow in creating important buzz words and concepts to describe its policies. We have had such terms as ‘patient advocacy’, ‘clinical and integrated governance’, ‘controls assurance’ and ‘intelligent transparency’ to name but a few. One of the latest is ‘a just and learning culture’. It is important to debate such concepts and terms as the discourse itself is useful in aiding further understanding and practical application. Often these concepts are very general in nature and have the potential to be used for very different and diffuse meanings.
It is important to remember that the label itself is not necessarily that important, it is the ideas behind it that matter. In patient safety and health quality there are many legal and ethical issues and the terms used can be broad and capable of several meanings. There are in law strict definitions of concepts, but the judges always try, certainly in tort law, to maintain their ability to be flexible in order to do justice in the case in front of them. It is not a good idea to be conceptually ‘boxed in’ with intransigent, strict definitions as that can close off discussion, end discretion and lead to debates becoming ossified and stale.
Being fair
NHS Resolution has just published guidance on ‘Being fair: supporting a just and learning culture for staff, patients and carers following incidents in the NHS’ (Chaffer et al, 2019).
The guidance is wide-ranging and includes examples of just and learning culture development practice in the NHS. The first example is a ‘just and learning culture charter’ that trusts can adapt or adopt. NHS Resolution collaborated with organisations including NHS Improvement and the UK charity for patient safety and justice, AvMA (Action against Medical Accidents), who supported the creation of this charter. The charter provides a sample introductory pledge:
‘Our organisation accepts the evidence that we will provide safer care and be a healthier place to work if we are a learning organisation. Humans are fallible; they make mistakes and errors.’
There are then 20 clauses, which include:
This charter is clear, unambiguous and expresses the right, just actions and expectations that should underpin a just and learning culture.
The second example of good practice in the guidance document is Mersey Care's restorative approach, which was informed by the work of Sidney Dekker (Dekker, 2017a; 2017b; 2017c). This trust saw one clinical division have a 64% reduction in disciplinary cases between 2016 and 2017. Attention was focused on the initial stages of the disciplinary process and when, if at all, to instigate formal proceedings. Making sure appropriate information was available with a clearly documented rationale and new templates, and investigating and understanding the incident first:
‘The focus is very much on investigating and understanding the incident first, changing questions from ‘who’ to ‘what’ to get to a place of understanding.”
Chaffer et al (2019) go into some detail on academic, research theories underpinning good practice and policy development in the area. Concepts include learning what works well in the daily care environment and what does not go as planned or expected (Hollnagel, 2014). The work of Sidney Dekker is extensively referred to.
‘Underpinning this learning is a culture which is kind, respectful and which enables people to speak out openly, and to share issues, concerns and ideas without judgement (Dekker, 2018).’
Claims by NHS staff
There is also a section in the report where legal claims made to NHS resolution relating to staff stress and bullying are discussed with costs and trends identified. It is always good patient safety and clinical risk management practice to do a closed claim analysis. To explore the themes and lessons that have underpinned the legal claims that have been brought against an organisation. NHS Resolution has several functions, which include managing legal claims brought against NHS trusts and other health organisations. Over the last 5 years there have been 317 claims relating to staff stress and bullying (Chaffer et al, 2019). The claims cover a range of incident dates, with over 50% of them being in the years 2013 to 2018. The total claims value was £27 479 003. The claims mainly came from staff employed in NHS acute or foundation trusts, which included 36 mental health organisations. The gender breakdown of people making claims was 212 women and 105, men. The guidance identified what problems lay behind the claims and these included:
Descriptions of harm that the claimants stated in their claim included:
NHS Resolution hopes the guidance will help avoid inappropriate disciplinary action being taken against staff. Also, that the rights of patients, carers and relatives to have proper redress, explanations of what went wrong, apologies and to be part of any subsequent reviews and investigations into adverse events is recognised and developed as an essential part of a just and learning NHS culture. A culture that puts the patient's physical and mental health and wellbeing at its heart.
Taking account of the NHS working environment
The guidance on creating and maintaining a just and learning NHS culture is to be welcomed as providing practical and well-researched guidance. The Mersey Care example provides very good evidence of proof of the concept. There are, however, serious challenges in the NHS that will impede attempts to develop a just and learning culture, which should not be underestimated.
The British Medical Association (BMA) (2018) surveyed members as part of its ‘Caring, supportive, collaborative’ project and just under 8000 completed the survey. The project is aimed at helping develop an understanding of the challenges, opportunities and problems that face doctors working in the NHS today and possible solutions to these. People are living longer and presenting with multiple complex conditions, the NHS is being used more. There are major staff shortages and acute resourcing issues causing intense pressures on doctors, nurses and other health carers. It is clear that sorting out these endemic working environment problems is necessary before an ingrained just and learning NHS culture can be developed. Key findings in the survey report included (BMA, 2018: 2):
Nurses similarly face major workforce challenges. Solutions need to be made to these workplace problems to properly lay the foundation stones for the development of a just and learning NHS culture. There is an overstretched nursing workforce in many areas and specialties, which can be seen to be struggling to cope. The House of Commons Health Committee (HCHC) (2018) discussed the issue of the nursing workforce. Evidence presented to the committee expressed concerns that workforce pressures are having an adverse effect on nursing morale, retention, and standards of care for patients:
‘The nursing workforce needs to be expanded at scale and pace. We heard a clear message about relentless pressures which, at their most extreme, meant that nurses felt their professional registrations were at risk because they were struggling to cope with demand.’
Written evidence to the committee presented by the Care Quality Commission (CQC), raised serious safety concerns relating to nursing shortages (HCHC, 2018). The CQC identified common patient safety issues occurring where there are nursing shortages. These included inconsistent identification and management of life-threatening conditions such as sepsis, incomplete, inconsistent and ineffective audits of key safety priorities and quality improvement projects. The CQC also noted poor infection control procedures, staff not receiving essential patient safety training, insufficient record keeping, poor sharing of information practices and so on. The CQC stated that these issues are not entirely due to a shortage of nursing staff but that the overall impact of staff shortages on a clinical team make these issues occur all too frequently.
Conclusion
The concept of a just and learning culture is a commendable one. We do need, however, to look beyond the concept label to the ideas behind it—to embark on a thorough and detailed discussion of the concept. Otherwise there is a real risk that it will be consigned to the NHS history books with other past patient safety, health quality, regulatory concepts and buzz words. For the concept of a just and learning culture to become successfully ingrained into the NHS, the practical workface challenges facing nurses, doctors and other NHS staff must be properly met. The findings of the BMA (2018) and HCHC (2018) reveal the stark and everyday workface problems they face. The development of a just and learning culture is intrinsically linked to maintenance of proper NHS resources—the fewer health professionals you have the more likely it is that an error will occur in a complex healthcare environment such as the NHS, which is so dependent on human skill.