Duty of Candour

The professional duty of candour: new guidance for doctors, nurses and midwives

Executive summary

On 29 June, the Nursing and Midwifery Council (‘NMC’) and the General Medical Council (‘GMC’) issued long-awaited new, joint guidance, “Openness and honesty when things go wrong: the professional duty of candour”, following consultation with their members in response to the new statutory duty of candour, which sets out the standards expected of doctors, nurses and midwives in respect of their professional duty of candour. As well as setting out what is required of individuals, the guidance also highlights the need for healthcare organisations to create open and honest working environments which support the reporting of incidents and help to build a culture of learning from mistakes. The production of joint guidance is intended to ensure that all UK doctors, nurses and midwives (around 950,000 professionals in total) will be working towards a common professional standard.

Background

The new guidance is the latest in a series of reforms following the public inquiry into the well-documented failings at Mid-Staffordshire NHS Foundation Trust, published in February 2013. On 11 February 2015, Sir Robert Francis QC published his final report on the Freedom to Speak Up review, which looked at the raising concerns culture in the NHS. The report made a number of key recommendations for NHS organisations and professional and system regulators to help foster a culture of safety and learning in which all staff feel safe to raise a concern. The new guidance “Openness and honesty when things go wrong: the professional duty of candour“ builds on these recommendations.

In addition, the new guidance sits alongside the statutory duty of candour which has been in force for NHS providers since 27 November 2014 and for independent health and adult social care providers since 1 April 2015.

It is worth remembering that all healthcare professionals have long had a professional responsibility to be honest with people in their care when things go wrong. The overarching guidance for doctors is the GMC’s ‘Good medical practice’ while for nurses and midwives, it is ‘The Code: Standards of conduct, performance and ethics for nurses and midwives’, both of which cover fundamental aspects of the healthcare professionals’ roles.

The GMC also has specific guidance on whistle blowers in ‘Raising and acting on concerns about patient safety’, which highlights the duty of doctors to raise concerns where they believe that patient safety, dignity or care is compromised. Similarly, the NMC has published its own specific guidance, ‘Raising concerns’.

In detail

Under the new guidance Openness and honesty when things go wrong: the professional duty of candour doctors, nurses and midwives should:

Speak to a patient, or those close to them, as soon as possible after they realise something has gone wrong with their care.
Apologise to the patient - explain what happened, what can be done if they have suffered harm and what will be done to prevent someone else being harmed in the future.
Use their professional judgement about whether to inform patients about near misses – incidents which have the potential to result in harm but do not.
Report errors at an early stage so that lessons can be learned quickly, and patients are protected from harm in the future.
Not try to prevent colleagues or former colleagues from raising concerns about patient safety.

In addition, managers must make sure that if people do raise concerns, they are protected from unfair criticism, detriment or dismissal and this was reiterated by Niall Dickson, GMC Chief Executive, who said, “We also want to send out a clear message to employers and clinical leaders - none of this will work without an open and honest learning culture, in which staff feel empowered to admit mistakes and raise concerns. We know from the Mid Staffordshire enquiry and from our own work with doctors that such a culture does not always prevail. It remains one of the biggest challenges facing our healthcare system and a major impediment to safe effective care.”

Conclusions and implications

It is widely hoped that, in addition to improving overall standards in patient care, the introduction of this new guidance, coupled with the statutory duty, will help to reduce the increasing number of clinical negligence claims which are brought against NHS bodies, currently costing around £1.3 billion per year in damages and legal costs. This argument is predicated on the basis of research that claims to show that many patients only resort to legal action because they feel that they have not been told the truth about a lapse in safety.

Some concerns have been expressed that ‘owning up’ to errors will leave employees more vulnerable to internal disciplinary procedures or even dismissal. However, an individual who has not complied with the regulators’ new guidance is likely to be open to criticism in internal investigations as well as any fitness to practice inquiry by their professional body.

Importantly, the guidance seeks to reassure staff by emphasising that apologising does not mean that they are expected to take personal responsibility for system failures or the mistakes of others.

The new guidance is the latest step in the process of systemic and cultural change for healthcare professionals and organisations which was set in motion after the Mid-Staffordshire review. The challenge remains for individuals to embrace the opportunities for openness provided by the new guidance and for organisations to create and sustain working environments sympathetic to and supportive of a culture which, instead of focusing on blame, is instead built on improvement through learning from mistakes.