Reflection and Culture: UK Medicine
By Johann Malawana
Over the last week the UK medical profession has been knocked sideways by the story of Hadiza Bawa-Garba. Much has been written about the case and its legal and professional implications have been analysed in several articles (1). But what is the wider societal cost of the case?
On the surface, medicine promotes a culture of self-reflection, reporting of errors and learning. However, the true reality has been exposed with this case. The reality facing junior clinicians is a broken culture in healthcare.
The case has rallied many doctors, but only when the High Court said that this particular doctor would not be allowed to practice medicine anymore. What about when this doctor, and the nurse that was working alongside her, were charged and put on trial for gross negligent manslaughter? The implications of our reaction (and I count myself in this) is that, somehow, being unable to practice medicine is a far greater punishment than anything else, even the law.
The reality is that we all contribute to this culture. This case could be any doctor in the NHS. Perhaps this is the reason that so many feel so scared and have reacted with such anger to what happened. But we are all also to blame for allowing this situation to result.
How many times do you see doctors proudly boast about the excessive hours they work, about being run off their feet, about not taking any breaks at work?
How many doctors do you see questioning the work ethic or professionalism of a colleague for calling in sick, for not seeing patients fast enough or even hesitating at the prospect of sacrificing their own family to turn up to work and keep a a crumbling system afloat? How many times do we actually report what is going on, using the mechanisms that are available to us?
We are encouraged from medical school to be in fear of reporting systems, often by the very people that are publicly supporting a learning culture. Often by those who are meant to be leaders within the NHS. If the message from the top is to cover up the reality of the frontline, what hope do we ever have of building a genuine learning culture in the NHS?
Many doctors remember how their professionalism was called into question by the country’s most senior medic when Sir Bruce Keogh questioned whether doctors with a legitimate protest about their working conditions, would return to work in the event of a terrorist incident (2). It is this type of pervasive attack on the motives of young clinicians that ensure that few juniors will feel that they can speak out.
However, speak out we all must. I don’t mean about protests, drawn out social media posts, or even writing articles like this. We need to speak out in our work. We need to actively change the culture through our actions. That means making it absolutely clear that part of being an NHS professional is to report what is going on on the frontline.
For junior doctors, the key way is through the exception reporting mechanism. It is a hard fought-for tool that is disliked by a system that tries to ignore responsibility for political and managerial decisions. If used correctly, it is one of the safest and most comprehensive reporting mechanisms seen in healthcare. It is a mechanism that comes with layers of additional protection should individuals then be targeted as a result.
Over the last few years, doctors fear that should they raise any kind of concern, there could well be career ending outcomes. The reality is that the nature of protection for doctors, when they do report, has been hugely strengthened. Whistleblowing, in the strict legal definition, was once a rare occurrence. Now junior doctors are armed with protections that were drawn up and evaluated by some of the leading barristers in the country. Doctors training in England should be reassured that the protections that were fought for are now there to protect them on the frontline(3). In the coming months, those protections are going to be extended to junior doctors in Scotland.
The real cancer at the heart of the NHS is telling clinicians that they should not use these mechanisms. Why? Because it undermines patient safety and the ability of the NHS to learn from tragedy.
So why does it happen? Because it makes life more comfortable for those in charge of departments, hospitals and healthcare systems. As soon as a junior doctor reports, it is those in a leadership position who could be held responsible. If a junior doctor doesn’t report, that responsibility remains with frontline staff. Those with power and vested interests in the system, whether that is the supervising consultant, the educational supervisor, the director of medical education, the medical director, the chief executive, or even NHS England and the Department of Health have a disincentive to junior staff reporting. As long as individual junior doctors or nurses can be blamed and scapegoated, no leader has to take responsibility.
We all know the current situation in the NHS is unsustainable. More than that; it is wrong. It is time we stopped pretending as a profession, an NHS or as a society that it is anything other than all of our responsibility. We need to own this problem and make sure that our frontline staff do not have their voices stifled and shut down purely for expedience. It is time we all took responsibility in the NHS and highlighted the unprofessional behavior of the consultant that tells you not to report, the manager that puts pressure on departments to put pressure on their juniors, the director that turns a blind eye, the chief executive that buries their heads in the sand due to the problem being too hard, the politician that says one thing, whilst facilitating a system that does the opposite.
None of these individuals are the enemy. None of these individuals are deliberately trying to cause harm. To anyone who truly understands how healthcare systems work, it is clear that the pressure to deliver outcomes travels all the way up the system, even on the politicians that we find easiest to blame. However, we need to be clear that the solutions to these tragedies rest not in laying blame at individuals, but working together to build a system and culture that does not stifle reporting.
Ultimately we are all to blame for what happened to Jack Adcock, Hadiza Bawa-Garba and Isabel Amaro. We must go beyond ranting on social media and moaning amongst colleagues. We must start actively facilitatating a culture where it is unacceptable to cover up the truth of clinicians’ working patterns, safe staffing numbers and basic levels of acceptable care. If we do not change the culture in the NHS, this won’t be the last tragedy we will face.