Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Accountability—individual blame versus a “just culture”

BMJ 2018; 361 doi: (Published 08 May 2018) Cite this as: BMJ 2018;361:k1802
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}

I’d love to stop the constant talk of “accountability” and individuals being “held to account” in state provided, free-at-point healthcare. Now, I don’t doubt for a minute that NHS clinicians and managers who wilfully break criminal law should face the same consequences as other citizens. And I believe that NHS clinicians are personally responsible for their own decisions and behaviours and for keeping their skills and knowledge up to date.

But the clamour for accountability goes well beyond this. Public debate in mainstream and social media is obsessed with the notion that, when things go wrong in healthcare, this must indicate failures by individuals. In such a narrative, systemic factors such as workforce shortages, poor logistics, insufficient capacity, or unmanageable workloads are seen as convenient excuses for individual error.

It’s the same for hospital managers, repeatedly “held to account” by national bodies for factors outside their control such as workforce supply and gaps, funding, or lack of capacity in local community and social care services. Clinicians and managers then face trial by media, often with no right of redress and no way to contest allegations without breaching patient confidentiality or appearing uncaring.

What many commentators seem to mean by “accountability” is that people should lose their jobs, be subject to legal action, or face punitive regulatory action. The adversarial, rather than investigatory, nature of the law is skewed towards pinning blame on individuals rather than on systems or organisations.

None of this helps. Literature abounds on the importance of a “no blame” and open culture in improving patient outcomes and safety. We must not scare people away from taking inherently difficult roles or drive them from practice, compounding the workforce shortage and thereby worsening care for other patients.

The adversarial, rather than investigatory, nature of the law is skewed towards pinning blame on individuals

Over the course of a long career we all make mistakes. It’s inherent in clinical practice. Some will be serious and cause harm. They will generally be made while acting in good faith, working to the best of our abilities, and trying to treat people.

We need to move towards what’s been described as a “just culture.” The implementation of this is set out wonderfully in a recent NHS Improvement guide.1 When things go wrong, when patients are harmed, the guide makes it clear that people should face consequences for committing deliberately criminal acts or wilfully ignoring best practice guidance they’re well aware of. And support should be given to those whose performance is affected by mental or physical health problems or addiction. For everyone else, we need to understand the mitigating systemic factors behind most errors or harm and must work to reduce their impact on future care.

For NHS executives in difficult operational roles, which are often far more politicised than private sector equivalents and harder to recruit to, a move towards a just culture is equally relevant if we want to recruit and retain the right people. If they feel demoralised and threatened it won’t help practitioners to deliver better care to patients.



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