By Richard von Abendorff Patient Safety Campaigner and Dr Minh Alexander NHS whistleblower and former consultant psychiatrist, originally published 1 September 2016
‘Just culture’ is a term for principles of respectful governance, with fair and proportionate accountability and a focus on learning. Politicians and senior NHS officials say they want just culture  but so far, it has been elusive in the NHS. Why so?
The literature often focuses on how just culture should apply to the NHS frontline and provider organisations, and less so on commissioners, watchdogs and politicians.  This distracts from the root causes of unjust culture.
In his statement of 6 February 2013 about the MidStaffs Public Inquiry, Robert Francis noted failure at all levels of the NHS:
“Regrettably there was a failure of the NHS system at every level to detect and take the action patients and the public were entitled to expect.” 
The Public Administration Select Committee noted last year that culture comes from the top:
“Throughout the past five years, the recurring theme of our findings and recommendations reflects the importance of effective leadership in creating effective organisations. Our work has shown that it is the positive or negative attitudes and behaviour in the people and the culture of an organisation which determines success or failure..….the same issues will keep arising until there is a comprehensive determination to address the attitudes and behaviour of all the most senior Ministers and officials.” 
The deficit of just culture in the NHS can be traced to the top. Numerous NHS inquiries into healthcare failures have shown the contribution of poor leadership by politicians and senior officials in creating a culture of fear and reputation management, and wilful blindness to harm and risk to patients.
The Department of Health suppressed 3 major reports on NHS culture and quality improvement in 2008, which were critical of the Department’s leadership of the NHS.    They were not released until 2010, and only via a Freedom of Information request. It appears that the Department of Health did not wish to reveal findings that:
- The NHS had a culture of “fear and compliance” and “shame and blame”
- Managers in the NHS “look up, not out” (that is, NHS managers manage to please those above in the hierarchy, as opposed to prioritising the interests of patients and families)
- Patients and families were not central to those at the top of the NHS, and were little mentioned – “We were struck by the virtual absence of the mention of patients and families”
- That there was “an absence of an improvement imperative within the Department of Health and the NHS”
At the Midstaffs Public Inquiry, evidence was given by several senior officials about negative political interference in the NHS, and a driving imperative not to “embarrass the Minister”. 
In another matter, a leaked email by a civil servant revealed collusive practices to prevent a whistleblower, Raj Mattu, from gaining access to a Minister.  Similar ruses to ensure political deniability are common and continue. NHS whistleblowers often appeal to the Secretary of State and Department of Health as a final port of call when they have exhausted attempts to raise safety concerns with regulators. However, the typical response of the Department of Health is to dismissively claim that it does not get involved in ‘employment issues’ and to refer anxious and frustrated whistleblowers back to the regulators who have failed them.
Similar stonewalling is experienced by NHS complainants, despite official lip service to the immense value of feedback provided by complainants. Years of repeated reports about failure of NHS complaints governance have not resulted in improvement, and the number of complaints has actually increased.  Families find out time and again that loved ones died or suffered preventable harm because the NHS failed to properly learn from previous incidents or to mitigate known risks, and sometimes families do not get answers at all.
Complainants and whistleblowers alike are often badly mistreated if they raise concerns about NHS failure.  Politicians have decades of evidence of such malpractice, but it has never been effectively discouraged. The truth is that the NHS is not allowed to learn, because of the political pressure to suppress matters that may embarrass Ministers, and to avoid exposure of the fact that the NHS has long been under-funded. Indeed, there is evidence that wide-spread gagging of NHS staff continues despite headlines in 2013 that Jeremy Hunt supposedly banned gags. He did not. He simply asked NHS trusts to do better, but omitted to ensure effective oversight. 
Just culture requires that politicians and senior officials should also be held accountable for care failures that arise from poor stewardship of the NHS, and systemic failings. Staff struggling in a seriously underfunded, understaffed service that is in perpetual crisis can be expected to make mistakes. Politicians and senior officials who produce policy that makes unrealistic and unachievable demands, and creates oppressive and exploitative working conditions for NHS staff are guilty of disrespect. Such tensions have been highlighted by the junior doctors contract row. However, as Lucian Leape et al have noted, this form of disrespect is often normalised in health services.  When disrespect is evident, or justice is not seen to be done, this will naturally intimidate staff and deter them from speaking up.
Severe NHS cuts of all forms continue despite the obvious safety concerns of the workforce. Senior establishment figures in the Health community are united in voicing increasingly urgent concerns about NHS under-funding.   Yet key recommendations of the MidStaffs Public Inquiry are being jettisoned one by one. Jeremy Hunt has made much of ‘intelligent transparency’ and has said that he wanted the CQC to be ‘chief whistleblower’. However, CQC’s inspection reports present safety data in an inconsistent and incomplete way, which makes it hard to track the effects of government policy on patient safety.   CQC has also been criticised for failing to regulate the Duty of Candour properly.  Moreover, CQC has failed woefully on implementing Regulation 5 Fit and Proper Persons.   Not one manager whose fitness to lead has been seriously called into question has been removed by CQC. NHS England asked NICE to stop its safe staffing work, and NHS Improvement has been criticised for dismantling NICE’s previous work on safe staffing.   NHS Improvement has castigated trusts for spending on staffing, even where trusts were responding to CQC requirements to increase staffing levels to safeguard patient care.  Waiting time standards have also effectively been cast off.    Most recently, the leak of a DH risk assessment raised questions of whether the Secretary of State had unsafely ploughed on with the 7 day NHS initiative, despite even the concerns of his own officials.  Since the leak, the DH has not produced evidence that it has any means of mitigating the risks identified by civil servants. The Chair of Health Committee entered the fray with strongly worded criticism:
“Cannot keep piling ever greater responsibilities onto an overstretched service without realistic resource and workforce to cope”.
“Expect problems when thin evidence is used to bolster an under resourced political objective instead of policy following the evidence.” 
In just culture, accountability is acknowledged as an important part of creating psychological safety, and recklessness is considered a matter for sanction. The following are listed by Stedman as blameworthy acts that merit sanction:
- Reckless behaviour
- Disruptive behaviour
- Working significantly outside your capability
- Disrespectful behaviour
- Knowingly violating standards
- Failure to learn over time
- Failure to work as a team
- Covering up 
How then do the Secretary of State, the Department of Health and the Department of Health’s arms length bodies measure up against this sort of ruler? We contend that they do not measure up at all well, based on the evidence.
After the publication of the MidStaffs Public Inquiry, Jeremy Hunt wrote to NHS providers to say that he wanted lasting change to create a more open, compassionate and safer NHS, and not just “short term noise”.  But it seems from the escalating stream of news about NHS staff shortages, increasing rationing, service closures and repetition of the same clinical failures that although Mr Hunt loudly banged the patient safety drum, patients have in reality not been protected.
Professor Brian Jarman rightly described the NHS as a denial machine.  It remains so. Until there is mature political leadership of the NHS, based on evidence, diligent governance and just culture as opposed to hot air about just culture, this will continue.
 From a blame culture to a learning culture. Speech by Jeremy Hunt, 10 March 2016
 The NHS must move from ‘no blame’ to a ‘just culture’. James Titcombe Health Service Journal 8 August 2016
 Statement by Robert Francis about the Mid Staffordshire Public Inquiry 6 February 2013
 Our work in the 2010-2015 parliament. Seventh report of session 2014-2015. Public Accounts Committee, 28 March 2015
 When managers rule Patients may suffer, and they’re the ones who matter. Prof Brian Jarman BMJ 19 December 2012 BMJ 2012;345:e8239
 Achieving the Vision of Excellence in Quality. Recommendations for the English system of quality improvement. Institute of Health Improvement. 2008
 Quality Oversight in England – Findings, Observations and Recommendations for a New Model. Joint Commission International 2008
 Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, February 2013
 Bid to block whistleblower’s access to ministers. Civil Service World 14 May 2014
 Data on Written Complaints in the NHS 2014-15. HSCIC 26 August 2015.
 Complaints and Raising Concerns. Health Committee. Fourth report of session 2014-2015. 21 January 2015.
 Letter by Jeremy Hunt to NHS trusts about ensuring open culture 2013
 Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Lucian Leape at al Academic Medicine Vol.87, No 7/ July 2012
 Perspective: A Culture of Respect, Part 2: Creating a Culture of Respect Lucian Leape et al Academic Medicine, Vol. 87, No. 7 / July 2012
 Deficits in the NHS 2016. Kings Fund July 2016
 Feeling the crunch. NHS finances to 2020. Nuffield Trust August 2016
 How safe are NHS patients in private Hosptals. Leys & Toft Centre for Health and the Public interest December 2015
 CQC Deaths Review. All Fur Coat. Minh Alexander 13 August 2016
 Regulating the duty of candour A report by Action against Medical Accidents on CQC inspection reports and regulation of the duty of candour Hannah Blythe August 2016
 CQC’s Fit and Proper Parade. Minh Alexander 29 July 2016
 CQC to review whether fit and proper person rule needs to change. Will Hazel Health Service Journal 24 May 2016
 NHS England asks NICE to suspend safe staffing programme. NICE statement 4 June 2015
 NHS Improvement accused of ‘dismantling’ NICE safe staffing work. Shaun Lintern Health Service Journal 14 June 2016
 Third of ‘excess pay growth’ trusts were told by CQC to improve staffing.
Sharon Brennan Health Service Journal. 12 August 2016.
 Hospitals given green light to miss waiting time targets, Nick Triggle BBC 21 July 2016
 NHS Indicators, July 2016. House of Commons briefing paper, Number 7281 6 July 2016
 Feeling the wait. Patients Association Annual Report on Elective Surgery Waiting times. August 2016
 Secret documents reveal official concerns over ‘seven-day NHS’ plans.
Denis Campbell. Guardian 22 August 2016
 Tweets 23 August 2016 by Dr Sarah Wollaston MP and Chair of House of Commons Health Committee
 Blameworthy acts in a blame free safety culture. Roger Stedman November 2012
 Letter to trusts by Jeremy Hunt about Mid Staffordshire Public Inquiry 2013.
 Labour’s ‘denial machine’ over hospital death rates. Telegraph 14 July 2013