Leading a ‘Duty of Candour’ in healthcare culture

Candour and trust are the basis of culture. They’re necessary for a strong sense of belonging and they’re the difference between culture helping or harming.

This month, another set of incidents at an NHS Trust has resulted in criticism of a defensive culture that lacks trust. Even more tragically, this time the circumstance is around midwifery and neonatal care, resulting in the deaths of babies and mothers. The Health Secretary has asked NHS England to look into cluster of deaths at Shrewsbury and Telford Trust that were deemed avoidable.

The death of a baby is an unimaginable tragedy. The loss for families may never be resolved. The trauma is felt by the professionals involved, who commit their vocation to the wellbeing of the mothers and babies they support in labour.

Yet we still hear reports of a culture that lacks openness and a willingness to address contributing causes or assess practice.

The issues behind any healthcare failing are complex. Partly clinical, partly training, partly communication, partly compassionate treatment. Ultimately, the professional and regulatory bodies agree these issues stem from an unhealthy culture.

A culture of defensive behaviour results in a lack of openness. In some instances staff are not up to date with training, do not listening to each other or are overruled when raising concerns.

As well as a lack of candour, questions have arisen around whether staff were ordered by more senior colleagues to keep quiet and to alter the information recorded in the notes.

Once again, this tragic series of events highlights the need for a culture of candour in healthcare.

In any organisation, an atmosphere of trust and candour is essential for good decision-making and openness when things go wrong. An atmosphere of blame, intimidation or recrimination will not only increase the risk of failure, it also reduces the likelihood that lesson will be learned.

Every break in the chain of trust exacerbates this. In a culture where lack of candour is normal, it is very hard to change the habits.

Leaders must initiate the change, setting the tone from the top – visibly and palpably. From our work we’ve seen the importance of habits, alongside accountability and appreciation, when putting ethics at the heart of culture.

It has been four years since the Francis report was published about the failings in care at Mid Staffordshire NHS Foundation Trust that began more than ten years ago, between 2005-2009. Last year a major recommendation of the Francis Report was finally enacted with the ‘Freedom to Speak Up’ whistleblowing guidance. See our blog post for more about the release of this report.

NHS England and any NHS trusts have been assiduous – and invested – in reinforcing the Francis principle of ‘Duty of Candour’.

It elicited a response and gained commitment from the professional bodies, including the Nursing and Midwifery Council.

NHS England enshrined a Duty of Candour, supporting this with straightforward advice on difficult issues from the NHS Litigation Authority.

In March 2015, Care Quality Commission, the independent regulator of health and social care in England, published the duty of candour guidance as part of the standards it expects. Regulation 20 states:

“The intention of this regulation is to ensure that providers are open and transparent with people who use services and other ‘relevant persons’ (people acting lawfully on their behalf) in general in relation to care and treatment.”

In October of last year, Dr. Henrietta Hughes began the new role of the national guardian for the NHS. This new role, recommended by Sir Robert Francis, aims to encourage an open culture where concerns can safely be raised.

Ethics is an invisible force of culture which can either help or harm an organisation. While it’s easy to overlook in critical healthcare operations where clinical judgement is paramount, ethics needs to be as high on leaders’ agendas as good medical care. For the health of the organisation, and the communities it serves.

So why is candour in healthcare – or any other sector – still a challenge?

Culture, whether bad or good, prevails through everyday habits and the demonstrated practice of leaders. It’s not just what you say as a leader, but what you do that matters. Blame, or symbolic ‘heads on sticks’, won’t change things. Strides have been made in the last few years with bold commitments of policy and standards; the challenge now is putting that policy into action in everyday behaviour.

Leaders: if you want to change culture, DO things differently. Make sure people see what you are doing differently, understand why it matters – and replicate your behaviour.

Ultimately, leadership makes the most difference to fostering a culture of candour.

How healthy is the level of candour in your organisation?
Would it be easy for employees to challenge the decisions of senior colleagues? Or for peers to discuss what went wrong?
In your culture is it okay to say when something’s not okay?

This is one of the areas of our work that makes the most difference to the effectiveness of organisations and to the healthy working environment for employees.