Nurse holding a patient's hand

Toward a Just and Learning Culture in the NHS

By John Tingle

NHS Resolution has several functions in the NHS (National Health Service) in England which include managing legal claims brought against NHS hospitals and other health organisations, as well as important patient safety responsibilities. They have recently published guidance on supporting a just and learning culture for staff, patients, and caregivers following incidents in the NHS.

The guidance is wide ranging and includes examples of just and learning culture development practices. Example one is a just and learning charter that NHS hospitals and other health organisations can adapt or adopt. The NHS charter provides in the first paragraph a sample introductory pledge:

Our organisation accepts the evidence that we will provide safer care and be a healthier place to work if we are a learning organisation. Humans are fallible; they make mistakes and errors (p10).

There are then 20 clauses which include:

Patients’ physical and mental health must remain the paramount concern of any treating health professional, whether or not there is a dispute over treatment or a clinical error is alleged to have been made.

Clinical incidents have a real and deep impact on people’s lives. Patients (or their partners or relatives) who have been affected have a right to explanations and to seek apologies, assurances and/or financial compensation for injuries caused where appropriate (p10).

The charter is clear, unambiguous, and expresses the actions and expectations which should underpin a just and learning culture.

Mersey Care’s restorative approach

Example two of good practice in the guidance document is Mersey Care’s restorative approach. This organisation saw a 64% reduction in disciplinary cases in one clinical division between 2016 and 2017. Leaders focused on the initial stages of the disciplinary process and when, if at all, to instigate formal proceedings. The guidance also goes into some detail on academic research theories underpinning good practice and policy development in the area. Importantly, the guide identifies costs and trends related to staff stress and bullying and how claims made to NHS Resolution about such matters are discussed.

Over the last five years there have been 317 claims relating to staff stress and bullying. Most staff members making these claims were employed in NHS organisations. Two-hundred and twelve women and 105 men made such claims. Problems included:

Failure to follow policies effectively relating to investigations and workplace stress;

Failure to provide a safe system of work and have regard for staff members’ mental health and personal safety;

Failure to carry out suitable or sufficient assessments of the risks to the staff members’ mental health (p30).

The guidance also goes into the descriptions of harm that the claimants stated in their claim, including:

Work-related stress-staff member subjected to bullying and abusive behaviour by a consultant;

Work-based stress resulting in suicide;

Stress at work caused by workload and lack of resources (p31).

NHS Resolution hopes their guidance will help avoid inappropriate disciplinary action being taken against staff. Furthermore, it is the NHS’s goal that the rights of patients, caregivers, and relatives receive proper redress, explanations of what went wrong, apologies, and are made part of any subsequent reviews and investigations in adverse events.

John Tingle

John Tingle

John Tingle is a regular contributor to the Bill of Health blog. I am a Lecturer in Law, Birmingham Law School, University of Birmingham, UK; and a Visiting Professor of Law, Loyola University Chicago, School of Law. I am also a Patient Safety Specialist at ECRI Institute. I was a Visiting Scholar at Harvard Law School in November 2018 and formerly Associate Professor at Nottingham Law School, Nottingham Trent University in the UK. I have a fortnightly magazine column in the British Journal of Nursing where I focus on patient safety and the legal aspects of nursing and medicine. I have published over 500 articles and a number of leading texts in patient safety and nursing law. My current research interests are in global patient safety, policy and practice, particularly in African health care systems. My most recent publication is: "Global Patient-Safety Law Policy and Practice," edited by John Tingle, Clayton O'Neill, and Morgan Shimwell, Routledge 2018.

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