How can we promote candour in healthcare, if it so often brings blame?
Recent high profile cases show the problems only too well.
On clinical errors, the need for candour is clear. It’s vital for learning that, in turn, may offer solace to the harmed.
But candour isn’t easy; especially if the systems where we work aren’t candid; and if blame is like tax – paid by some, avoided by others.
In #BawaGarba, the hospital wasn’t overly candid about their investigation, and the failings identified. Had it been so, it might have been the one charged with manslaughter. The lawyers and court weren’t candid if, as reported, they kept said investigation from her jury. The Crown Prosecution Service wasn’t candid, if it knew her institution shared culpability, but charged only individuals.
We’ll see how candid the BBC is about Dr Hammond’s dismissal. He says he’d checked with it before announcing.
In reality, our institutions lack candour. This frees them from blame.
The Gosport inquiry criticised the General Medical Council’s (GMC) lack of candour over potential conflicts of interest, and the recent and heavy redaction of documents.
The Hyponatraemia Inquiry deplored that medics had to have the truth “dragged” from them; and misled inquiries over how children died. Some who did, have kept valuable careers.
The British Medical Association (BMA) admitted on oath it’s not “open and candid”. It claims members are protected to report serious concerns. But privately, the BMA know the doctor’s likely to lose their job; be pressed to sign up to confidential pay-offs; and / or face reprisal by other members – that the BMA simultaneously support in an undeclared conflict of interest.
Certain hospital managers aren’t candid either. Alder Hey repeatedly claimed serious concerns, including child deaths, had been investigated and found baseless; when in fact, concerns were true or left un-investigated. Their blatant falsehoods were even sent to Parliamentary committees.
Managers can do this because courts aren’t candid, suppressing reports that would expose NHS failures. After all, judges are lawyers, with a life’s experience of confidentiality agreements. Hearings may be quietly pre-determined, by the cards each side’s allowed to play. Courts can even be slow to disclose their own potential conflicts of interest.
The dearth of candour at each level gives staff a brutal dilemma. If they go with the institution’s lack of candour, they may keep their job, but leave families in the dark.
But if they’re candid about their own failures, they may face prosecution. And if they’re candid about others’, they may face persecution as whistleblowers.
Taking unaddressed concerns to the press, brings a witch-hunt for the sources; and though journalists can protect identities, no such protection exists for whistleblowers. Once hunted, they’re forced to choose candour or survival.
How could we ever build a more candid culture?
Let’s consider timing first. We find it easier to admit initial uncertainties, rather than indelible errors. So candour (and forgiveness) after the event might be best cultivated by candour beforehand. In essence, this is about consent.
Consent as pre-emptive candour
Legally, consent has now to surpass the Bolam standard (roughly speaking; telling the patient what other doctors would), and meet the Montgomery one (roughly speaking; going over any matters a reasonable patient would want to know). So doctors need to work on language and cooperation.
Talk of diagnoses and complications may need inclusion of e.g. personal goals and function. We need imagination; forseeing how choices that may seem small to us (eg to have a scan), may have life changing effects. We need to work together, recognizing how other specialties may have better insight into the later outcomes of our treatment.
Institutions have to take consent seriously too. Failures in consent at Bristol were repeated also at Alder Hey and Solihull. Even now, the GMC can apply the wrong legal test (Bolam, when it’s Montgomery) thus failing to seek data to protect patients.
In this sense, a just culture has first to be an informed one.
Candour’s hard after the event.
Institutions fear for their reputation. Practitioners fear prosecution; whistleblowers, persecution.
It’s easier upfront. One way to promote candour (but give peace) when things go wrong, may be through greater candour in the consent process; through better mutual understanding, not just a signature.
So for candour, as with comedy, perhaps one secret is timing.