Contemporary ambulance services are providing and treating more and more people with more and more complex conditions outside hospitals with an increasing number of staff with an enhanced scope of practice. It could be suggested that there will be more opportunity for a duty of candour to apply.
A catch phrase, a buzz word, that has very quickly become popular within and without the health service is ‘duty of candour’. The Prime Minister, the Secretary of State for Health, the investigative senior lawyer Sir Robert Francis and others have been using it to describe how employees of the NHS should start behaving. The nearly 300 ‘do this’ recommendations emanating from the Francis Report (The Mid Staffordshire NHS Foundation Trust Public Inquiry, 2013) are replete with a need to be open and transparent.
The Berwick Report (The National Advisory Group on the Safety of Patients in England, 2013) that followed soon after was in essence a rehash of the sterling work carried out and published by Sir Robert Francis. This report called for the need of a culture of transparency and learning in order to eradicate mistakes, more openness and transparency in the service, reinforcing the need for candour. The issue of how this ‘new’ culture was to be realised was not raised by Berwick, instead this was left up to the Government as to how this could be achieved. The Government has planned a range of measures to strengthen the values of openness and transparency. In the case of the most serious failings in candour, sanctions will be imposed possibly through fines, criminal sanctions along with reputational damage.
Francis defines candour as:
‘The volunteering of all relevant information to persons who have or may have been harmed by the provision of services, whether or not the information has been requested and whether or not a complaint or a report about that provision has been made’.
It is also associated with the potential to cause harm or distress (Nursing and Midwifery Council (NMC) and General Medical Council (GMC), 2015).
Acting in an open and transparent way requires providers to be clear, honest and effective when communicating with patients, their families and carers throughout their care and treatment, including when things go wrong. Being open enables concerns and complaints to be raised freely without fear and questions asked to be answered. Allowing information about the truth, about performance and outcomes to be shared with staff, patients, the public and regulators is acting in a transparent manner. Candour requires that any patient harmed by the provision of a healthcare service is informed of this and an appropriate remedy is offered, irrespective of whether a complaint has been made or a question has been asked about it.
It should be expected that virtues such as being open and transparent are the very fabric of what it is that gives us the privilege of providing care to the public, the very essence of being professional and as such the duty of candour is implicit. There exist professional obligations in professional standards (the Code) where registrants are informed that they must behave with honesty and integrity, justifying the trust that people put in them (Health and Care Professions Council (HCPC), 2012).
‘The paramedic… has to be mindful of what is in the current obligations concerning being candid when something goes wrong from an employee and employer perspective’
Nevertheless, the NMC together with the GMC have introduced guidance concerning openness and honesty when things go wrong (NMC and GMC, 2015). Maybe this has been done in reply to Francis and Berwick or in response to the Statutory Duty of Candour that the Government has introduced. NHS providers are required to comply with the duty of candour, providers must be open and transparent with service users about their care and treatment, including when it goes wrong. The duty applies to all NHS Trusts, foundation Trusts and special health authorities.
The paramedic, just as is the case with all others who come into contact with patients, has to be mindful of what is in the current obligations concerning being candid when something goes wrong from an employee and employer perspective. The NHS Constitution (Department of Health (DH), 2015a) and the Handbook to the NHS Constitution (DH, 2015b) have been updated to reflect the duty of candour, where the NHS is aiming to foster a spirit of candour and a culture of humility, openness and honesty with patients, relatives and carers.
The complex issue of candour traverses statutory, contractual, ethical and professional frontiers, applicable at different times, to various groups, with a myriad of definitions and many routes for reporting non-adherence to candour. Those who have managerial responsibilities or are responsible for clinical governance, have a duty to help staff report any concerns and in so doing this will enable people to act on those concerns that have been raised.
The duty of candour should not be seen as a stick to beat staff with. It is incumbent on employers and professional bodies to also be clear in providing staff with up-to-date guidance on employee obligations, this will require the provision of training and education. Staff may need to be reminded of their responsibilities and how they are expected to report concerns. Paramedics will have to ensure that they are aware of their organisation's policies along with any professional edicts in the form of guidance.
A joint statement from the chief executives of eight statutory regulators of healthcare professionals has put their name to the professional duty of candour (General Chiropractic Council et al, 2014). It is interesting to note that one of the regulators, the HCPC, has not put their name to the joint statement.
What lies at the heart of the duty of candour has to be the safeguarding of the people who we offer care to; it must be focused on public protection. If this desire to be open, honest and transparent is to amount to anything and not just more legislation, more ticking of boxes, then there is an absolute need to transform the complex, convoluted and frustrating systems of checks and balances that are in place across the health service and the professions. It may be time for consideration to be given to a single regulator.