Responding to Concerns

Accountability – Just Culture

Learning from Serious Untoward Incidents

My Background

Dr Umesh Prabhu MBBS, DCH, MRCPCH

Consultant Paediatrician (1992-2010)

Clinical Director (1992-1998)

Medical Director of Bury NHS Trust (1998-2003)

NPSA Board Member (2001-2003)

NCAS Adviser (2003-2015)

Medical Director of Wrightington, Wigan and Leigh FT (2010-2016)

My Contact Details

• Dr UmeshPrabhu Twitter ID

• Linkden Dr Umesh Prabhu

• Email pupprabhu101@yahoo.com

My Book Is About To Be Published

• eli@kingshampress.com

• file:///C:/Users/Palimar/AppData/Local/Packages/Microsoft.MicrosoftEdge_8wekyb3d8bbwe/TempState/Downloads/Prabhu_v8%20(1).pdf

• Transformational Leadership

My Values!

• My values come from my grandma

• Mahatma Gandhi

• Nelson Mandela

• Martin Luther King Jr

• Florence Nightingale

• I also studied Hitler and Saddam Husain

Fatima 7 year old died!

In 2010 I Joined Wrightington Wigan And Leigh As Medical Director

• Within 8 years we reduced harm to patients by 90%

• We transformed culture of bullying and discrimination to kind caring compassionate learning and supportive culture

• Inclusive leadership

• We empowered staff to speak up

• We implemented duty of candour

• We implemented good governance

WWLFT

• 70 staff came to meet me in confidence

• We engaged our staff and we created culture of staff happiness

• We put patient safety at the heart

• The Trust received 45 awards

• 450 more patients survive

• 90% reduction in harm to patients over 8 years!

• I myself got few awards

• For staff happiness in 2011 we were bottom 20% and by 2016 we became the third best Trust to work in NHS

• To each department we appointed kind caring compassionate diverse leaders!

• We had to change few Board Leaders, few managers, few nurses and had to dismiss few bad doctors

• In 2016 Brexit happened and I left the Trust

• To help NHS, India and UK

WWLFT

My interview and how WWLFT was transformed

• https://youtu.be/9PuaA9XETZs

• https://healthmanagement.org/c/healthmanagement/issuearticle/happy-staff-safe-patients

• https://www.youtube.com/watch?v=fxh95M_85PM

Who Is A Leader?

• Leader sets himself or herself a very high standard of behaviour and quality of work

• He/she supports staff to provide same high standard of care and behaviour

• He/she is a role model for the staff

• He/she creates a team of good leaders

What Do You Think Of Brexit?

• Who is a better leader

• Mr Hunt or Mr Johnson?

• Or Jeremy Corbyn

I Met Jeremy Hunt And Matt Hancock

Bob McDonald (businessman)

Living a life with a purpose is much more

meaningful than meandering through life

without a purpose

Transformational Leadership

• Ethical leadership

• Compassionate leaderships

• Moral Leadership

• Value based Leadership

• Transformational Leadership

Doctors and NHS

• Most doctors work hard under very difficult circumstance

• Most doctors are excellent

• 10 to 20% need help, support, guidance and feedback

• Early feedback is the best way to change human behaviour

• 80 to 90% of Serious incident there are systems failures

• Do not blame doctor or a nurse for systems failures

• Most doctors need help, support and guidance

• Very rarely doctors or nurses must be dismissed to protect patients or professional integrity

For leaders fairness. Justice and truth matters a lot!

Case 1

• GP makes two mental health patients pregnant

• What do you think should happen?

Case 1

• GP must be held to account

• Suspend the GP

• Inform the GMC

• Start investigation

• You may have to contact police as they are vulnerable patients

• Always follow the local policy and procedures

• Contact NCAS for advice

Case 2

• Consultant tries to kiss a patient

• She says No

• Consultant apologises and says I am sorry

• What should happen?

Case 2

• Investigate properly

• Talk to both

• Talk to NCAS

• Talk to GMC ELA

• Then decide what action

• Some would give final warning

• Some would say dismissal

• Some would deal informally

• GMC is best placed to advice

Do You Know These Cases?

• Bawa Garba – Punished severely for systems failure

• David Sellu – Went to prison for systems failures

• Dr Chris Day _ punished for raising concerns about patient safety

• Edwin Jesudasan – Punished for whistle blowing

Do You Know These families

• Will Powell – Looking for justice 30 years after his son died due to Medical Errors

• Gareth Roberts – Looking for justice after sister died of medical errors

• Gosport _ Many patients have died

What is Just Culture?

• Honesty

• Sincerity

• Integrity

• Fairness

• Proportionality

• Consistence

What Is Culture?

• How we do things when no one is watching

• How we behave when no one is watching us

• Human beings are loyal to culture

• Changing human behaviour is the most difficult thing

• To change culture – You must understand the culture

• Culture is ‘mindset’ of people

Culture

Good Culture

• Kindness

• Compassion

• Supporting

• Helping

• Learning together

• Working together

• Supporting

• Openness and honesty

• Fairness and consistency

Bad Culture

• Bullying

• Working in isolation

• Creating ghettos

• Club culture

• Old Boys network

• Lies

• Cover up

• Selfishness

• Unfairness and injustice

How Do You Change The Culture?

• Appoint right leaders

• Empower staff to speak up

• Empower patients to speak up

• Build good teams

• Implement good governance

• Implement duty of candour

• Take action

Let Us Understand Quality and Safety

• 12 year old child developed brain damage

• 21 year old patient found dead in the ward!

Examples of Improvement

1. Elderly care

2. Medicine Management

3. AE department

4. Mortality

Some of the Serious Incidents I had to deal

• Locum consultant sexually molesting patients - Dismissed

• Consultant bullying staff and many patients wrong diagnosis

• Consultant can not get on with anyone

• 12 year old girl developed ‘Brain damage’ following appendicectomy

• 21 year old girl found dead on Boxing day!

How do you improve things?

1. Appoint a good leader – Role Model

2. Create a great team

3. Remove blame, bullying, harassment, victimisation

4. Create kind, caring, compassionate, learning and supportive culture

5. Implement good governance – Discipline

6. Put measurements and audits - Dashboard

7. Delegate responsibility

8. Support staff and the team to do a good job

9. Put simple measurements and audit – Dashboard

10.Audits and checks and feedback

11.Give time, resource and guidance

12.Empower staff to speak up

13.Take action and keep on improving

14.Thank and appreciate staff and create positive energy

How do you improve things?

Protecting Patients and Supporting Staff Are Two sides of the Same Coin

• Happy staff – Happy patients

• Supporting staff doesn’t mean accepting poor behaviour or poor care

• Supporting staff to change their behaviour and improving quality and safety

• Good governance and accountability is crucial

• It is called Just culture!

• Early feedback is the best way to change human behaviours

Human beings need lot of help to change!

• Vast majority will change if you engage them, value them, respect them and tell them the benefit to patients and to them.

• 19% need help, support, retraining

• 1 to 2% - Need serious action which may be warning or retraining or dismissal in very rare cases

Just Culture

• Honest Culture

• Sincere Culture

• Honest Culture

• Fairness Culture

• Justice Culture

• Truth Culture

Do not punish doctors for genuine mistakes

• Each human being makes 5 to 7 mistakes

• To err is human

• Most doctors need support, help, guidance

• Learn not blame

• But accountability is a must

• Accountability doesn’t mean blame, punishment but learning

• But in case of serious misconduct one has to dismiss the doctor to maintain the integrity of the profession

• Action taken must be fair and proportionate

• Future is digitalisation and robotics

• Future is skill mix

• Health and social care integration

• Community care and Primary care

• Stop wasting money in hospital

• Not stopping what is important

• But stop doing what is not necessary and wasting money and harms patients!

Future of NHS

Finally

• Patient safety should matter to us

• Staff happiness should matter to us

• What happens to your healthcare should matter to us

• You all need safest and the best Health and Social care

• Being a doctor or a leader is simply serving the humanity with kindness and compassion and great courage