One of the most important modules I teach my medical students is on patient safety. We cover why safety incidents occur, how to learn from them and most importantly how to prevent them.
There are lots of different ways of learning from our mistakes in medicine, most of which involve Sherlocking through the events to understand the pinch points where error occurred. Often mistakes are made because of a lack of something: not enough staff, not enough equipment, not enough time, not enough leadership. They are very often singular events, and the people involved are horrified that the mistake has occurred on their watch.
But, as so many scandals of the last two years have demonstrated, sometimes they are not singular events. Sometimes safety incidents are indicative of a wider, more persistent culture that promotes and condones actions that perpetuate unsafe and even deadly practices.
How does such a culture develop and persist? A single common idea runs through all the different reasons why: when leadership fails to signal the importance of staying safe, safety will suffer and people will die.
I’ve been thinking about that idea a lot lately. That to create a culture you do not need to be proactive, but often inactive, signalling to all those around you what you do and do not care about. In the wake of new and further evidence that No 10 and Boris Johnson have been doing whatever they damn well please in the pandemic, something I quote to my students keeps repeating in my head: “The standard you walk past, is the standard that you accept.” It means that, as a leader, if you allow actions to occur that you know to be wrong or unsafe, you signal to those around you that you are accepting that they have happened. By doing nothing, you contribute to the culture that is injuring and even killing others.
Normally when I share that quote with my students, I am talking about accidents and incidents on hospital wards, but we could just as easily be talking about the Cabinet Office and parliament these days. While Boris Johnson has been generous with blustering words about his anger at these incidents, he has nonetheless allowed them to happen. In patient safety speak he has “walked by” so-called wine and cheese work events, “walked by” party invitations from his principal secretary, “walked by” advisers who ignore rules to stay at home, “walked by” not wearing a mask in hospital. He has shown the country what standards he will accept. It is simply not good enough.
In my world of patient safety, we know that leadership is one of the most important aspects of promoting and maintaining safety. Examined through the lens of patient safety research, these are not isolated incidents, but a pattern of behaviour that develops a culture that, at best, signals to government staff that there are in fact two sets of rules: one for them and one for us. And at worst, it tells the country that the protective measures put into place since March 2020 are silly, unwarranted and unneeded. It shows the standard of safety accepted by Johnson’s government, and that standard is low. As the UK surpasses 150,000 dead from coronavirus, it is a message that has already proved deadly.
So how do we fix it? From a patient safety perspective, the answer seems obvious. Change the culture, which changes the standard that is accepted. This can be done in a number of different ways, but the most effective is to change the leadership itself. By bringing in a new leader, who signals and expects a different, higher, safer standard, the culture can shift rapidly to meet these new expectations. The cycle of unsafe practices can be broken by simply not walking past, but stopping and noting that this is not the expected or accepted standard.
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That being said. I’m no fool. While the email leak about the 20 May party will likely result in a resignation, it probably won’t be the big man.
That leaves the people trapped in the unsafe culture themselves to start leading by example, in small ways, to affect change. It can be done. I’ve seen it in practice and the research backs it up too. It is a slower, more difficult road to safe practices, but it is one that gets there in the end.
So, as we enter 2022 and the third year of the pandemic, it is to the country that I turn to ask, what standard are you willing to accept? What are you willing to walk past? Think carefully, because the answer will shape our future health and wellbeing.
Dr Alexis Paton is a lecturer in social epidemiology and the sociology of health and co-director of the Centre for Health and Society at Aston University. She is also chair of the Committee on Ethical Issues in Medicine at the Royal College of Physicians and a trustee of the Institute of Medical Ethics
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