We would all want a good degree of honesty from anyone caring for us or treating us for a medical condition. Trust is one of the essential components of a good nurse/patient or doctor/patient relationship. One of the issues Robert Francis exposed in his reports into the Mid-Staff Scandal was that there was a culture of cover ups silencing those raising concerns at the Mid-Staffordshire NHS Trust, and this was one of key reasons that none of the regulatory bodies knew what was going wrong.
So it was that the UK and national governments across the British Isles brought in organisational duties of candour in the last year. This emphasised the responsibility of trusts, clinics and GP practices to have policies in place for staff to report adverse incidents through the correct channels, and to communicate these incidents appropriately to patients.
This week, the regulatory professional bodies followed suit with duties of candour for nurses and doctors. These stress the importance of identifying when something has gone wrong, and once dealt with, to report to the relevant bodies and to communicate with patients and/or relatives. This includes apologies and clear statements of not only what went wrong, but what steps are being taken to avoid similar incidents happening again.
The emphasis in this guidance (produced jointly by the GMC and NMC) is on a team approach. The appropriate team leader should meet with the individual patient, and/or their next of kin to make the apology and outline the details and steps being taken, and if necessary issue a written apology. The emphasis is on finding not only the right person, but the right timing – making sure that the patient and/or family is in the right physical and mental state to hear the details. It also makes it clear that ‘near misses’ should only be discussed with patients when it would be reasonable and in the patient’s best interest to know. One of the concerns we raised with the early drafts was that a duty of candour could mean patients being given information that they could not process, or that increased stress and anxiety unnecessarily. The new guidance recognises the role of professional judgement and acting in the best interests of the patient, which is greatly to be welcomed!
One of the reasons that there has been poor reporting of adverse incidents has been fear of litigation – i.e. that to admit to a mistake and make an apology is to lay an individual or an NHS trust open to legal challenge. Other reasons have been the fear that it would reflect badly on the professional’s record or on the trust’s statistics. But this has been at the cost of public trust.
Certainly, this all sounds very reasonable. It is particularly welcome that the professional guidance has come out after the organisational guidance – meaning that NHS trusts and other bodies should have adequate policies and procedures in place to ensure that health workers will not suffer undue penalties for being open and honest. One of the big worries has been the culture not only of secrecy, but of the vilification and marginalisation of whistleblowers who have raised concerns in the past. The stories of how many doctors and nurses have been hounded out of their jobs, and even their professions, for speaking out is truly disturbing.
However, there is a deeper issue that these guidelines cannot really erase – the human tendency to cover our own back and not tolerate ‘snitches’. While the guidance should go a long way towards challenging workplace cultures of silence and cover ups, it cannot totally eliminate them. While we have a blame and litigation culture, there will continue to be huge pressure to keep silent. Yet at the other end of the spectrum there is always a danger of over-disclosing in an attempt to follow the guidelines studiously, rather than recognising that there are ways, means, times and people to break news about mistakes and make apologies in ways that won’t heighten the distress of patients and next of kin. In short, the embrace of candour needs to be at a deeper level than merely ticking boxes and rigidly following guidelines. We have seen with the Liverpool Care Pathway (LCP) how a process that should have improved patient care at the end of life, in a number of cases did not achieve this simply because there was a lack of clinical judgement in how the guidance was applied.
Speaking the truth in love (Ephesians 4:15) is a core Christian virtue as well. I think any Christian professional would feel a duty of candour was a vital part of what it was to serve Christ in their profession. Yet Jesus constantly challenged the Pharisees not over their zeal in religious observance (or their scrupulous holding to the letter of the law), but over their enforcement of ever more rigid codes of behaviour on themselves and others, while completely missing the big picture. ‘You tithe mint and rue and every herb, and neglect justice and the love of God. These you ought to have done, without neglecting the others.’ (Luke 11:42)
Let’s work hard to ensure that a duty of candour does not become a tick box exercise, but a genuine, deep change in values and culture in the places where we work, in how we conduct ourselves as professionals, and that in the process we maintain that vital public trust in our institutions and professions.