The concept of blame is a controversial one in the NHS when it comes to patient safety policy development and practice. The prevailing NHS view is that it is important to move away from a blame culture which focusses on the individual. This it is argued inhibits people properly reporting errors, and they worry unduly about the legal and other consequences. Patient safety lessons go unlearnt, the same or similar patient safety errors are repeated and so the unfortunate cycle continues, unabated.
The NHS Patient Safety Strategy, puts the issue of blame and NHS patient safety culture development in perspective stating that fear is too prevalent across NHS staff particularly when they are involved in patient safety incidents, the report further states:
“Blame is a natural and easy response to error. It allows the cause of mistakes to be boiled down to individual incompetence, carelessness or recklessness and asserts that the problem is the individual. Blame relies on two myths. First, the perfection myth: that if we try hard, we will not make any errors. Second, the punishment myth: if we punish people when they make errors, they will not make them again. (P,7).”
A strong sense of NHS feeling against blame
There is a strong sense of feeling against the ‘blame’ concept expressed in the NHS patient safety strategy. The underpinning approach which underpins how the NHS deals with patient safety and drives efforts towards proper culture development is a system based one. A focus on the system rather than on the individual as stated in the NHS patient safety strategy:
“Healthcare staff operate in complex systems, with many factors influencing the likelihood of error. These factors include medical device design, volume of tasks, clarity of guidelines and policies, and behaviour of others. A ‘systems’ approach to error considers all relevant factors and means our pursuit of safety focuses on strategies that maximise the frequency of things going right.”(p.8).
Major NHS patient safety initiatives advocate and are based upon the systems approach such as the Patient Safety Incident Response Framework (PSIRF) and the NHS Patient Safety Strategy. The concept of blame does not sit well in the current system-based NHS patient safety policy framework. It’s seen largely as the antithesis to a just and learning NHS patient safety culture
NHS Clinical Negligence Litigation.
The NHS patient safety system does not operate in isolation from the civil justice system and fault based, clinical negligence litigation. There can seen to be tensions between the two.
The tensions have recently come to the fore with a newspaper article by Jeremy Hunt, the former Secretary of State for Health and Social Care. Writing in The Guardian newspaper, he discusses maternal deaths, poor care, blame culture, no fault compensation in Sweden and so on. He controversially states:
“If we want to break the cycles of fear and blame that are so common at the moment, we need to reform a system that often means a bereaved family’s only friend is their lawyer. The primary focus of the law is – rightly – justice, but we should not rely on it to improve patient safety.”
Jeremy Hunt further states that the NHS spends more settling litigation claims for baby harm and death every year than the entire cost of NHS maternity services and advocates for the Swedish no fault-compensation system to be adopted here.
The tension
The tensions can be seen earlier in the evidence and discussions in the NHS Litigation Reform Inquiry Report, chaired by Jeremy Hunt. The relationship between clinical negligence and NHS patient safety is fully discussed and important recommendations made. The central recommendation being the setting up of an independent administrative body to be responsible for investigating cases and determining eligibility for compensation in the most serious cases, the report states.
This recommendation has not been put into effect, and the Government have still not made a formal response to the NHS Litigation Reform Inquiry. They are looking at the issue of high costs of claims as stated in the recently published NAO (National Audit Office) report on clinical negligence costs.
” DHSC has asked David Lock KC to advise on how to improve patients’ experience of clinical negligence claims and manage rising legal costs”, (p.10).
National Audit Office Report, Costs of clinical negligence,
Linked to the issue of the role of blame in the NHS patient safety framework are the high financial costs of clinical negligence litigation. The emotional toll on the injured patient, their loved ones, and the staff involved in the incident should also not be forgotten and must be factored into any debate on the issue.
A recently published report by the NAO takes a deep dive into clinical negligence costs. Several key findings are made which include but are not limited to:
-At £60 billion, the government’s liability for clinical negligence claims has
quadrupled since 2006-07 (p.6).
-The annual cost to settle claims has more than tripled over the last two decades (p.6).
– Legal costs for low-value claims vastly exceed the damages payable to claimants. (p.8).
– Although forecasts remain uncertain, it is likely that the costs of clinical negligence will continue to grow substantially (p.9).
Conclusion
However, the concept of blame, fault is viewed it can still be seen to be an essential part of the NHS patient safety framework. Given the nature of our tort based clinical negligence framework which it is linked to. The high costs of clinical negligence have been an issue of continuing debate and concern for many years, and the government are shortly to report on the matter.
This blog is based on a column recently submitted to the British Journal of Nursing.