Final Report > Chapter 22: The Culture of the NHS > Looking to the future > A culture of openness

A culture of openness

24 We have already referred to that aspect of the culture of the NHS which tends to be defensive and secretive, and to old-style attitudes of paternalism and self-protection. This is not fertile ground for a patient-centred service in which communication, openness and honesty are essential to the restoration and maintenance of trust. We have no doubt that, as an organisation, the NHS and those who work within it must embrace a culture of openness. Equally, we are aware of how difficult this is to achieve. On the face of it, the recent past may suggest that circumstances are not propitious. Stories of scandal and malpractice seem to dominate the media coverage of the NHS. A complex, but accurate (and more fair), analysis based on systems and an understanding of how people function inside organisations is much more challenging to portray. Sometimes it can seem as though NHS problems all boil down to questions of individual responsibility and blame. Meanwhile, dissatisfied and damaged patients, frustrated by poor communication, having failed in their search for explanations, defeated by the culture of defensiveness, resort to the media or the law, or both. And, of course, this requires that someone be singled out for blame.

25 It may be objected by some within the NHS that asking them to be open is to give `the invaders the keys to the city'. But this is too pessimistic. If trust is to be established and maintained, there is only one choice available to those who work in the NHS. They must let in those currently kept outside. They must accept that the public are not `invaders' and that, once let in, they will behave with the maturity which being an insider demands.

26 The process of embracing openness involves taking very many small steps. One such step is to make available to patients information on measures taken to safeguard safety. Another is the regular publication of information on the quality of care: in particular, on the outcomes of particular treatments at particular hospitals. Another is the prompt acceptance of responsibility when things have gone wrong, accompanied by an appropriate apology. All of these take courage. All may well, initially, attract hostile criticism. But, we are convinced that they must be done. As Professor Marc de Leval noted: `... physicians must become more open and comfortable with their fallibility and the patients must accept their own vulnerability.' [14] Some may object that, if the public had more information about clinical performance, they would not want to go to those hospitals which perform less well, and those hospitals which perform best of all would be overwhelmed with demand. In this regard the experience of New York state is instructive. In the early 1990s, information was made public showing mortality rates following coronary artery bypass grafts. The data referred to individual hospitals and individual surgeons. In fact, the net result of this greater openness was not a mass desertion of the poorly performing hospitals, quite the opposite. There was a rapid improvement in their mortality rates. The information, therefore, was used to improve outcomes for patients. [15]

27 For a culture of openness to succeed, those who work in the NHS must be confident that they will be supported by the organisation at all levels. Openness must be valued and rewarded. Otherwise, healthcare professionals will understandably be reluctant to embrace it. What this means, crucially, is that blame and stigma should not be the response of managers or colleagues. Adopting the words used by Professor Marc de Leval: while regretting them, we must all learn `to treasure mistakes', because of what they can teach us for the future. This calls for an extremely mature organisation and, equally, a mature society. It means an abandonment of the easy language of blame, in favour of a commitment to understand and learn. It calls for significant leadership. It calls for practical action geared to being more open about error and mistakes and it calls, as we will argue later, for the removal of one of the greatest of all barriers to openness: the fear of clinical negligence litigation.

28 If the culture of openness between the NHS and the public has to change, so too does the internal culture within the NHS, so as to allow for greater openness with and between staff. Currently, there continues to be a sense among the workforce that they cannot discuss openly matters of concern relating to the care of patients and the conduct of fellow workers. There is a real fear among junior staff (particularly amongst junior doctors and nurses) that to comment on colleagues, particularly consultants, is to endanger their future work prospects. The junior needs a reference and a recommendation; nurses want to keep their jobs. This is a powerful motive for keeping quiet.

29 The workforce must feel that they will be safe if they wish to raise and have discussed matters of concern. Managers must put in place mechanisms to facilitate this process. We were much impressed during our Seminars by the way the airline industry has approached the issue by providing a neutral reporting system to which staff can report errors, near misses or concerns about safety. There is much here for the NHS to learn.

30 The editor of the `British Medical Journal' summed up the challenge well:

`We need a culture that allows doctors to express fears, doubts and vulnerabilities; identifies and helps those in difficulties; refuses to condone inappropriate delegation; values teamwork and continuous learning and improvement; and genuinely puts the interests of the patients first.' [16]

We agree. We would add that such a culture is needed not only for doctors but for all who work in the NHS.

Footnotes

[14] de Leval M. The Edgar Mannheimer Lecture, 1996

[15] Chassin MR. `Improving the quality of care'. `N Engl J Med' 1996; 335:1060-3. Centres with high mortality rates took radical action to improve their performance including temporarily suspending their coronary artery bypass programmes and restricting hospital admission privileges of some surgeons who performed a low volume of surgery and whose risk-adjusted death rates were found to be well above the state average

[16] Smith R. `Managing the clinical performance of doctors'. `BMJ' 20 November 1999; 319: 1314 -15 www.bmj.com