Building a culture of candour

Healthcare organisations, including hospitals and GP practices, must usher in a new culture of candour so that patients and their families are told honestly about any harm that has been caused and what will be done to put it right, an independent review has concluded.

Following the Government’s response to the Mid Staffs Public Inquiry, Health Secretary Jeremy Hunt asked Professor Norman Williams, President of the Royal College of Surgeons, and Sir David Dalton, Chief Executive at Salford Royal NHS Foundation Trust, to undertake a review on how to enhance candour in the NHS.

The group was asked to examine the threshold at which a new statutory duty of candour should apply to organisations, and how they can be incentivised to be more open and honest.

The central recommendation is that the old days where errors were not disclosed must give way to an environment that allows staff to be trained and supported in admitting errors, reporting them and learning fully from mistakes.

Being open ‘is not simply an add-on or a matter of compliance’, the report states. ‘Patients and their families want to know that when things do go wrong not only is every effort made to put them right for them but every effort is made to prevent similar incidents happening again to somebody else.’

The group, set up in December 2013, has taken evidence from a wide group of organisations on a range of issues relating to candour and openness. The review was asked by the Secretary of State to look at whether the threshold for organisations reporting harm should be set to include moderate harm to patients, as well as death or serious injury.

Healthcare professionals are already required by their professional codes to disclose harm to patients when things go wrong. The new duty of candour applies to providers of healthcare registered with the Care Quality Commission and not to individuals.

The review concluded that the new duty should include ‘moderate’ harm, as defined under the NHS’s existing National Learning and Reporting System (NRLS). This would include incidents that do not cause permanent harm, but which most patients would regard as ‘significant’ events.

The review recommends that a new category of ‘significant harm’, corresponding to the current ‘moderate, severe and death’ NRLS standards, should be created, with incidents notifiable to the Care Quality Commission. This should be broadened to include prolonged psychological harm.

The report also makes recommendations for what should happen when an organisation breaches its duty of candour. It concludes that the focus of any sanctions on organisations found to be in breach of the duty should have an impact on an organisation’s reputation. For example, they could face a number of sanctions ranging from warning notices through to the removal of board members, prosecution, deregistration, or face a penalty notice from the CQC.

The review was also asked to look at how the NHS Litigation Authority might incentivise candour by seeking reimbursements from trusts in cases where they had not been candid with a patient or family about a patient safety incident which then turns into a claim. The review concludes that this should be explored further by the Government through consultation.

Professor Norman Williams, President of the Royal College of Surgeons said:

“The evidence that we heard during the course of this review reaffirms what we already knew: that when things do go wrong, patients and their families want to be told honestly about what happened, how it might be corrected and to know that it will not happen to someone else.

“Medical care is inherently risky and staff are not infallible. Errors will always be made and clinical staff will always find themselves in the position of having to discuss harm, or potential harm, with a patient.

“A willingness to be open with patients must also include honesty about organisational problems that may have contributed to harm, such as losing notes, problems with discharging patients or poor management of resources. What matters is for organisations to support staff to be honest about those errors, learn from them, apologise when it’s the right thing to do and then improve the care and treatment in order to minimise harm in the future.

“We hope that the review will play an important role in helping to create a culture of openness and honesty which always places the safety and needs of a patient above the reputation of an organisation.”

Sir David Dalton, chief executive of Salford Royal NHS Foundation Trust said:

“We believe that a duty of candour can make a highly important contribution to creating a culture of openness. Above all, it will require a commitment from hospitals and GP practices to create effective systems for training and supporting staff. This is not about creating a new bureaucracy but about ensuring that staff can know that there is a very strong incentive and support to be open, and learn from errors.

“We don’t underestimate how difficult or challenging this can be for many organisations, but that is not a reason to hold back from placing that expectation upon the provider of healthcare. As our report says, it is crucially important that organisations create a culture where staff feel supported in reporting errors and speaking honestly to patients and their families if something unexpected happens. It is vital that both staff and patients then know that lessons will be learned and systems will be improved.

“If the NHS embraces this new culture and takes it seriously - thinking about all the things you would need to put in place to make a reality of candour – this could be the basis of a profound change to the ways in which organisations and staff interact with patients.”

The government is expected to publish its response to the review in the next few weeks.

Notes to editors

Read a copy of the review ‘Building a Culture of Candour’

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