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The professional duty of candour: widening the lens

In our latest guest blog Annie Sorbie and Zahra Jaffer of the University of Edinburgh’s School of Law, discuss that momentum needs to be maintained on embedding the professional duty of candour in healthcare professionals, but we also need to widen the lens beyond individual interactions and direct attention to the wider context in which healthcare is provided.

Annie Sorbie Blog photoZahra Jaffer Blog photo

Annie Sorbie is Lecturer in Medical Law and Ethics and Zahra Jaffer is a PhD candidate.  Annie worked with the Authority to facilitate discussion groups with staff from regulators and fitness to practise panellists for our recent report Telling patients the truth when something goes wrong - how have professional regulators encouraged professionals to be candid to patients?

Across healthcare there has been a renewed focus on the need for healthcare professionals to be open and honest when something has gone wrong with patient care (this was highlighted in in the latest blog by Michael Warren). As recently as January 2018 the report of the Hyponatraemia Inquiry of Northern Ireland identified repeated failures in openness and honesty. The Professional Standards Authority’s 2019 Report – Telling patients the truth when something goes wrong – reflects its continued commitment to reviewing how the duty of candour has been embedded – and indeed enacted – in the wake of events at Mid-Staffordshire Foundation Trust and following the regulators’ joint statement on candour in 2014.

Maintaining momentum

In this blog we consider some of the work that has been done to continue the momentum created by the 2019 Report. In particular we reflect on insights from the Professional Standards Authority’s annual academic conference and our joint interactive workshop on the duty of candour that we delivered at that event. We also consider how widening the lens on candour – for example by looking at research and initiatives across professions, sectors and jurisdictions – can provide valuable lessons for the implementation of the duty of candour as it is translated from policy to practice.

What is it to be a good regulator?

The central question of the Professional Standards Authority’s 2019 academic and research conference, held last month, asked: what is it to be a good regulator? The programme, curated in partnership with Professor Deborah Bowman (St George’s, University of London), explored the myriad challenges and opportunities of achieving ‘goodness’ and provoked varied and thoughtful responses.

To those of us who have been working on the duty of candour it was striking how strongly these presentations and discussions resonated with the key themes of the 2019 Report. For example, Dr Suzanne Shale, Clearer Thinking, and Sharon Burton, General Medical Council, underlined the importance of creating compassionate workplace cultures and the link between positive workplaces and better patient outcomes, a recurrent theme across both days. In our consideration of the factors that can encourage or discourage candour in the 2019 report, we too had found that ‘toxic workplace environments with a blame/defensive culture are not places where openness, honesty and transparency will thrive’. Fiona Browne, General Osteopathic Council, spoke about the need to embed professional standards into healthcare professionals’ everyday practice. This again echoed our findings on the need to bridge the gap between regulation and policy, on the one hand, and practice on the other. The conference also offered broader insights to the value and contribution of academic research to regulation at the coalface, as exemplified by the work of Professor Rosalind Searle (University of Glasgow) on workplace sexual violence.

A key feature of the Authority’s work on candour so far has been its focus on the operationalisation of this duty, and how it can best be communicated and embedded on a day-to-day basis. Here Harry Cayton’s presentation on governance was particularly pertinent. He noted, amongst other matters, that ‘…much of what is said about good governance misses the point by concentrating on board and committee procedures rather than on the personal qualities, skills and behaviours of board members.’ He elaborated further on the key role of ‘thoughtful, respectful relationships’. It seems to us that the same observations might also be made in relation to the professional duty of candour. In particular, the view of the discussion group participants was that candour was something that professionals needed to ‘take to heart’. Further the 2019 Report suggests that collaborative work and consistency are key to supporting professionals and encouraging candour. Harry Cayton’s observations, albeit in a different context, point us back to ‘skills and behaviours’ and away from reliance solely on a top-down, rules-based approach to regulation.

In our own interactive workshop on the professional duty of candour we continued to benefit from participants’ views on matters including how to take into account patient and carer views on candour, the communication skills required by professionals and the role of authentic apologies.

Looking forward: next steps

Our workshop also provided us with the opportunity to introduce and seek feedback on our new research on the professional duty of candour in the context of surgery. This is being undertaken in a collaboration between the Professional Standards Authority, the Royal College of Surgeons of Edinburgh and the University of Edinburgh. This project is just getting underway and has commenced with a literature review that builds on that undertaken by the Professional Standards Authority in 2013. Some preliminary observations from our review are already proving interesting. It is perhaps predictable that, since 2013, there has been a growing body of literature addressing the duty of candour as a stand-alone concept.  However, we have noted that academic attention has often focused on the technicalities of the operation of the statutory duty of candour at an organisational level – and in particular on reporting thresholds – rather than on the professional duty of candour and the factors that underpin whether and how this is enacted. In considering the underlying factors that can encourage or discourage candour we have also looked across jurisdictions, for example to learning on ‘open disclosure’ practices in New South Wales, Australia. This work is ongoing and we look forward to disseminating our findings in due course, as well as tailoring these to the specific context of surgery.

Concluding thoughts

The need for openness and honesty in healthcare is by no means a new concern, but the implementation of the duty of candour remains persistent and pressing. Our research, research across the wider regulatory and healthcare sectors, and work across jurisdictions underlines that consideration of candour is not just about interactions on an individual level. Our attention is also directed to the wider context in which healthcare is provided and the links between positive workplace cultures and better patient outcomes. Complex issues require multi-faceted responses and now is the time to widen the lens on our consideration of the professional duty of candour if we are to effect a step-change towards its full implementation by professionals.

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Please note the views expressed in these blogs are those of the individual bloggers and do not necessarily reflect those of the Professional Standards Authority.