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Views And Reviews

Improving patient safety: we need to reduce hierarchy and empower junior doctors to speak up

BMJ 2019; 366 doi: (Published 02 July 2019) Cite this as: BMJ 2019;366:l4461
  1. Peter A Brennan, consultant maxillofacial surgeon and honorary professor of surgery1,
  2. Mike Davidson, pilot and union representative2
  1. 1Queen Alexandra Hospital, Portsmouth, UK
  2. 2British Airline Pilots Association
  1. peter.brennan{at}
  2. Follow Peter on Twitter @BrennanSurgeon

Empowering doctors to speak up when they have concerns is essential to making our NHS safer, say Peter Brennan and Mike Davidson

Aviation and medicine are sometimes compared, but in reality are fairly diverse professions. Unlike medicine, in aviation one mistake can result in large scale loss of life. Healthcare can still, however, learn a lot from aviation and other high risk organisations, particularly in how they’ve embraced and applied human factors, the importance of looking after ourselves at work, and reducing hierarchy.

Analysis of cockpit voice recorders has historically shown that the majority of pilot related errors were because of failures of interpersonal skills, communication, decision making, and leadership. In particular, the steep hierarchy that existed between captains and co-pilots was well known as a safety threat, with several fatal crashes occurring as a result of this power dynamic and the communication barriers it created. Indeed, the crash of a United Airlines DC8 in Portland in 1978 was an important driver in introducing what was then called cockpit resource management. Through such training and the understanding of how human errors impact safety, aviation has slowly managed to change its culture. Yet, sadly, the equivalent steep “cross cockpit gradient” still exists in many healthcare teams.

Today, the most senior captain could be disciplined if they failed to listen to, or act upon, concerns raised by even the most junior of co-pilots.1 Can we say the same in healthcare?

In recent years, healthcare has been hit by several scandals that show the pernicious impact of staff not feeling able to speak up. This includes the Bristol children’s heart surgery scandal, which saw a number of babies and children die after heart surgery at the Bristol Royal Infirmary in the early 1990s. The resulting Kennedy inquiry found that the institution’s higher incidence of mortality could be traced back to an imbalance of power, with “too much control in the hands of a few.” Teams within the organisation were “profoundly hierarchical,” and this sense of hierarchy influenced “who gets listened to within the organisation when questions are raised.”

Steep hierarchical gradients can be linked to other damaging behaviours in the workplace, and have a negative effect on team relationships and the tendency for conflict avoidance. Sadly, the fear of speaking out is still widespread across healthcare, with the Gosport inquiry serving as just one recent example. Once again, a steep hierarchy prevented staff from speaking up with confidence.

We need a change in culture so that any doctor can question the decision or actions of another in a non-confrontational way and with no loss of face by either party. Too often, junior doctors are afraid of the repercussions, fearing that they may create conflict in the workplace, harm their career progression, or just upset the status quo. By contrast, the workplace culture in aviation actively encourages employees to share their safety concerns at the earliest opportunity.

The perceptions that people have of raising concerns do not exist in a vacuum; they are set by everyday examples. On day one of employment for a major UK airline, new pilots are met by both management and union representatives and empowered by both to speak up on the flight deck if they have any safety concerns whatsoever, without fear of retribution. During undergraduate and postgraduate medical training, doctors are taught that they have a duty to speak up if they think that patient care or safety is being compromised. Yet hospital trusts and their senior staff need to actively apply this principle and give staff opportunities to voice their concerns. For example, this message could be strongly reinforced by trusts during induction days at the start of new placements—especially if senior management and consultants championed and actively encouraged it.

We are not advocating a flat hierarchical gradient across teams, which can be equally as damaging as a steep one. Team leadership can be an effective lever for patient safety and the “captain” is ultimately responsible for all actions. Yet knowing that any doctor (or other healthcare professional) can speak up without fear of retribution will surely make healthcare safer, as well as improving our working relationships. Pointing out risks to patient safety (perceived or real) should not be detrimental to the challenger or those they are challenging, but serve as a learning opportunity for all. If we want a no blame culture, then we need to encourage people to speak openly about mistakes, not only in their aftermath, but when we see them taking shape in front of us.

As the Care Quality Commission (CQC) recognised in its recently published report, Opening the Door to Change, hierarchical cultures are “inimical to safety.” As it points out, however, “in the NHS this lesson has not been learnt.” The CQC suggested that multidisciplinary team working is a way to reduce this hierarchy and encourage a culture that helps staff speak up. A number of initiatives from across the NHS, big and small, were also held up as tools to help tackle this problem, from consultants and junior doctors being encouraged to call each other by their first name, to involving patients and families in investigations.

In 2017 aviation had a benchmark year with no deaths among International Air Transport Association airlines, yet the association’s safety review still noted that “we must keep focus and continue with our work: the promotion of safety first.” The culture in aviation is one of ongoing improvements and a professional desire to be safer by learning from mistakes, accidents, and near misses. This is helped by an active reporting culture, which brings to light the near misses or the bottom of the iceberg. Aviation has tried hard to leave hierarchy behind in a safety process that should have no ego.

Errors will inevitably continue to happen, but failing to learn from mistakes that recur across the NHS on a daily basis is unacceptable for patients who place their trust and lives in our care. We need to look and learn from other high risk organisations and change the culture across the health service for the better. Is it the fear of possible repercussions or recrimination that prevents colleagues from speaking up? That question can only be answered by individuals, but empowering healthcare professionals to speak up when they have concerns is essential to making our NHS safer and can’t come soon enough.


  • Competing interests: none declared.

  • Not commissioned, not peer reviewed.