A few weeks ago, Jeremy Taylor, CEO of National Voices, wrote about the contradictory narratives around the NHS’ 70th birthday celebrations. In particular, he noted, “it [the NHS] “puts patients at the heart” of all it does and ignores people’s voices and rights”.
How can both of these statements be true? As a doctor, like the vast majority of doctors, nurses and other healthcare professionals, I go to work every day to look after patients to the best of my ability. The people using the NHS are the heart of what I do and what I care about.
A high risk environment
But I know that the NHS doesn’t always provide perfect care, and in the high risk environment that is medicine dealing with very sick people, misjudgements, miscommunications, misunderstandings and mistakes can lead to harm, even to the most catastrophic events for a family – the loss of a child, or a dearly loved mum or dad gone before their time. The likelihood of these things happening is compounded when the individual is not able to speak up for themselves or where there is prejudice and unconscious bias at play.
Families have questions when catastrophic events happen, and mostly just want open, honest answers, clear acknowledgement and an apology when things have been sub-optimal, and real change to make sure this doesn’t happen again. When this doesn’t happen, people may feel that their voices are not heard, and they have no choice but to pursue their desire for justice for their family through what Julie Bailey, founding member of the mid-Staffs campaign group Cure the NHS, called “the torture of the NHS complaints procedure.” If they are met with denial, defensiveness, and dismissal of concerns, or even worse, cover-up – as has been the case too many times in the NHS – it is easy to see how grief and loss turn to frustration and anger.
But it is not just families who are affected by tragic events. Such tragedies affect healthcare staff deeply, especially if we know that we may have contributed to poor care. It weighs heavily and stays with us. Most of us would jump at any chance to make things better for those affected and those to come.
Learn not Blame
I believe we need a revolution in how the NHS deals with such catastrophic – and less catastrophic – events. Imagine an NHS where, when things go wrong, families are welcomed with open arms to talk about it. Their story is heard, concerns listened to. Staff can debrief openly and reflect about what happened and why, without fear of retribution or blame. As a result, learning takes place, change happens and families know that their tragedy will at least lead to something positive.
Pie in the sky, you may say. But it CAN happen. The inspirational Leilani Schweitzer, who lost her son Gabriel to unrecognised shunt failure after a well-meaning nurse switched off equipment alarms to let her get an undisturbed nap, spoke in a TED talk about how this process had enabled her grief to become positive:
“Transparency is healing; it finds truth and can take away the infection of guilt and doubt… it give[s] me the opportunity to help people and that makes [Gabriel’s] life bigger”.
This is the essence of the Learn Not Blame campaign from the Doctors’ Association UK. It’s a campaign unique in its desire to bring together patients, families, doctors and all healthcare staff in calling for a revolution in how the NHS talks about and acts on harm. We hope you will join us.