Comment Blog 11 April, 2019

Beyond blame: The NHS is not the only public service that struggles to learn from its mistakes

For two decades health secretaries have said that there is a culture of blame in the NHS. Doctors continue to report that this is the case. Last year 55 per cent of 7,887 doctors surveyed reported that they felt they would be unfairly blamed for errors resulting from systemic pressures, and 45 per cent were fearful of making mistakes in their work.

The NHS is often the focus of discussions around “blame culture”, but poor responsiveness to failure can occur in any organisation. It is certainly a wider issue in public services.

Failure is part of any effective learning process. This can be seen in the way that certain NHS Foundation Trusts have responded to criticism from the Care Quality Commission: University Hospitals Bristol Trust was rated ‘outstanding’ in 2017, having ‘requir[ed] improvement’ in 2015.

Reluctance to admit to and learn from mistakes hinders improvement. An independent review of HM Revenue and Customs (HMRC) published in February found that employees were ‘keen to find fault and not [to] forgive’, and that individuals who challenged behaviour were marked as trouble-makers. Last month, the outgoing chair of the National Police Chiefs’ Council said that blame culture also threatens policing and makes it harder for officers to learn from ‘difficult situations’ they face.

As standard, the organisations that deliver our public services should foster an open culture conducive to learning and improvement, where staff feel comfortable discussing theirs and others’ practice.  Variation in the civil service is concerning. The Department for Digital, Culture, Media and Sport advocates a ‘no-blame’ culture’, with staff encouraged ‘to challenge and take personal responsibility for getting the job done well.’

It must be acceptable and encouraged for people to say when something has gone wrong. If it is not, it will be difficult to prevent failings. There is continued emphasis on the need to create a more open culture in the NHS, but much still needs doing.

The Freedom to Speak Up Review published in 2015 recommended that across NHS bodies there should be a standard procedure for raising concerns without fear of bullying or recrimination, driven by strong leadership and training to all staff, where ‘blame-free’ investigations are used to establish the facts of an incident.

Where public safety is in question, as in policing and healthcare, the need for ‘strong external accountability to the public [and] an open culture’ must be balanced. ‘Blame-free’ investigations that are distinct from disciplinary or misconduct proceedings are appropriate in both sectors.

It should also be the case that if problems are identified, it is acceptable to reflect on them and change course as a result. Personal reflection, which is integral to any doctor’s personal development, can receive less attention next to operational pressures in public services. For example, the Permanent Secretary of the Ministry of Justice, Sir Richard Heaton, recently told the Public Accounts Committee that his department ‘[couldn’t] afford [the time] to pause’ and reconsider the way probation services are delivered. The head of HM Inspectorate of Probation’s has said the current model is ‘irredeemably flawed’.

Across public services, organisations need to get better at learning from their mistakes. This will require open, honest working cultures where failure is acknowledged and built on. But further, organisations should look around them to see how their counterparts are tackling the issue – even if they seem at a greater risk of playing the blame game.