Paterson: why process change won't work without the right culture

Inquiry report: cover page

As Francis Bacon wrote: ‘Knowledge itself is power’. Few examples so poignantly illustrate this as the case of discredited surgeon Ian Paterson.  

The report identified that had patients access to clear, unbiased information; received communication directly; audits undertaken with greater oversight of practice and concerns properly shared, it’s probable that fewer patients would have been harmed.  

Along with the governance failures, the authors highlighted the pervading culture which allowed alarms to be silenced and ignored – for concerns to be suppressed. As a medicolegal expert previously working as a clinician at the time Paterson operated, the findings disturbed me, but did not, sadly, totally shock me. 

The Government’s response to the Inquiry recognises the issues in knowledge sharing, regulation and systems which permitted this tragedy to occur. While the Government’s comments on the report’s recommendations and sentiment are welcome, several issues remain unresolved. Given that some of Paterson’s crimes date back more than two decades the pace of change is far from ideal, and I believe we can all do more to respond quicker and help reduce avoidable harm. 

Systems and process changes across the health sector are continuing to be implemented and governance has improved significantly including the appreciation that anonymised data and information should be shared, especially when concerns arise about patient safety. In this case, knowledge is safer when it’s in more people’s hands. 

Recommendations of the Paterson Inquiry report

I note, however, a fundamental omission from the report’s recommendations. These do not address the underlying culture which not only allowed, but also enabled these terrible crimes to be committed and patients to suffer avoidable harm.  

Experience has shown that increasing regulation or penalties, creating new bodies to oversee quality and patient safety have limited success without a focus on human factors and behaviours, as recognised in the many reports into healthcare scandals which span the decades. If what is required is an open and honest culture then the Government’s approach – small carrot, large stick – may have the opposite effect. 

AXA Health, in our role as a supportive partner to our members, understands the need for accountability if things go wrong. We take a strong stance on behalf of our members and focus unapologetically on their needs and best interests.  But we also want to shift the focus towards sharing knowledge and move on from the culture of blame and fear.   

Serious incidents will, unfortunately, always occur in healthcare, given the unique complexities and inherent risks. It is how we deal with them, from the reporting and initial discussions with the patient, through to how investigations are conducted, change implemented and communicated. We all have a part to play in designing, implementing, and funding resilient systems which safeguard patients. That is why we are working with our providers to support collaboration and transparency by sharing data, discussing adverse incidents and complaints as part of an open, trusting partnership. 

Dr Pallavi Bradshaw,
Deputy Chief Medical Officer, Medicolegal

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I hope the Government’s response will enable implementation of recommendations to keep patients safer. However, the onus falls to all in healthcare to keep up the momentum and focus at a more granular level on preventing avoidable harm through both systems AND culture.  

We all must promote an environment which fosters the ability and willingness of clinical staff and managers to learn from mistakes, not blame them: to share knowledge. Together we must rebuild the trust and confidence that has been damaged by Paterson’s actions, treating patients and clinicians with dignity and respect. This must come from everyone working in healthcare, not from more regulation from above.