Flagging the need for communicating certainty in a world of uncertainty

Admiral Lord Nelson was born in 1758. Some 20 years later he took command of his own ship in the Royal Navy. He eventually became a ‘flag officer’; that is, he was entitled to fly a flag signifying that he was an admiral and the ship that flew the flag was the one where the orders of battle originated from. Much has been written about Nelson. He was a transformational leader, an astute military strategist, a people person first and foremost and a superb communicator. Obviously, radios, mobile phones and so on hadn’t been invented, and Nelson used a system of flag signals to command his fleet of ships. In so doing he was able to defeat the so called ‘invincible’ Spanish Armada, and the French navy. Although he often used unorthodox strategies, it was his ability to communicate that made him stand out. Nelson’s communications to his sailors was safe, timely, effective and always aligned to the task at hand. Sound familiar?

It should do as many of us who work in health and care services have long understood the importance of effective communication when engaging with our patients. Yet so often it appears we get it wrong. Last week I read a report on complaints that patients and their relatives had made following their treatment and care. Poor communication appeared to be at the heart of many of these complaints. The latest data published by NHS Digital, revealed that nearly a third of all written complaints received were about poor communication. The care patients received was the second highest reason for a complaint being made. As hard as we might try to ensure things don’t go wrong with an individual’s care, sadly there will be occasions when care doesn’t go as planned, and in some cases, even leading to the patient being harmed. When things do go wrong, such occurrences need to be recorded, logged and most importantly, learnt from.

Whilst such learning needs to take place locally, the National Reporting and Learning System (NRLS) is the UK’s central database for collecting and collating such reports. In fact, it is the world’s largest and most comprehensive patient safety incident reporting system. Unlike the current so called NHS ‘Test and Trace’ system, it is truly world beating.  Over 2 million reports are received each year. The system is currently undergoing a bit of an upgrade. Whilst the NRLS provide important national patient safety alerts, it is what happens at a local level in response to when things go wrong for patients that interests me.  

In my experience, a big step forward in how to deal with the consequences of such incidents was making the Duty of Candour a legal requirement for NHS organisations in 2014. If you don’t know what the Duty of Candour means for you, here is a quick (CQC approved) guide. Essentially health care organisations have a legal duty to be open and honest with patients (and their families) when something has gone wrong with their care or treatment, whether it has led to or could cause future harm. How such a conversation is undertaken is, of course crucial. Here is a brilliant example of why such communication is critical for the longer term health and wellbeing of individual patients and their families. It’s a pandemic-orientated paper, but the issues are equally applicable across the board in terms of the way difficult conversations are engaged with.

Nelson was famously known for his genuine concern for the health and wellbeing of those he worked with. Apparently, he was able to consistently demonstrate a close personal interest in the individuals who made up the various crews he led. Its said he had an ability to ‘imaginatively’ engage with people’s particular needs and problems.  I’m sure if he were around today, he would be a great candidate for a Chair or CEO role in one of the emergent Integrated Care Services. He would be able to pull together the many disparate strands and make it possible to arrive at a single communicable plan of the successful way forward. 

Sadly, although it was International Men’s Day last week, Nelson is not here, and he would perhaps have been a great role model for others (leaving Emma to one side).  However, we do have the benefit of his legacy. He knew that despite the best plans and precautions in the world, accidents and unforeseen events sometimes mean the plan gets derailed. In his world such derailments might lead to harm, death and defeat. He also knew that whilst a natural inclination might be to blame the individual concerned, and punish them, this was not the answer to avoiding similar outcomes in the future. Nelson realised that the problem was often not the fault of the individual, but the system within which they worked. If you change the people without changing the system, the problems will continue.

In some ways Nelson was the forerunner of what we now know as a ‘just culture’, see here and here. Last week I took part in a webinar that was looking at patient safety and the role that a Non-Executive Director might have in promoting a just culture. There was much discussion about the need to develop a culture where people can proactively look at their workplace and raise concerns over risky processes and or behaviours. We know that that even the most competent of professionals can make mistakes. How we deal with such incidents is important. In a ‘just culture’ individuals are not only accountable for their choices, actions and behaviours, but they are also accountable to each other. Of course, this means that organisations need to move from a ‘blame and shame’ response to one that embraces learning. That is not to say that where there has been a wilful or deliberate neglect on the part of the individual professional, they shouldn’t face disciplinary action. They clearly should. We perhaps should take a leaf out of Nelson’s book on leadership and create a culture where people can speak up and challenge poor practice without the fear of being discriminated against in the future.   

 

Ps. – not many people know this, but Nelson never wore an eye patch, and likewise, Nelson was 5’ tall in real life, whereas his statue in Trafalgar Square is 17’. That’s a Horatio of around 3:1