BMJ 2019;366:l4461 doi: 10.1136/bmj.
l4461 (Published 2 July 2019)
Views and Reviews
Improving patient safety: we need to reduce hierarchy
and empower junior doctors to speak up
Empowering doctors to speak up when they have concerns is essential to making our NHS safer,
say Peter Brennan and Mike Davidson
Peter A Brennan consultant maxillofacial surgeon and honorary professor of surgery , Mike Davidson
2
pilot and union representative
1
Queen Alexandra Hospital, Portsmouth, UK; 2British Airline Pilots Association
Aviation and medicine are sometimes compared, but in reality
are fairly diverse professions. Unlike medicine, in aviation one
mistake can result in large scale loss of life. Healthcare can still,
however, learn a lot from aviation and other high risk
organisations, particularly in how they’ve embraced and applied
human factors, the importance of looking after ourselves at
work, and reducing hierarchy.
Analysis of cockpit voice recorders has historically shown that
the majority of pilot related errors were because of failures of
interpersonal skills, communication, decision making, and
leadership. In particular, the steep hierarchy that existed between
captains and co-pilots was well known as a safety threat, with
several fatal crashes occurring as a result of this power dynamic
and the communication barriers it created. Indeed, the crash of
a United Airlines DC8 in Portland in 1978 was an important
driver in introducing what was then called cockpit resource
management. Through such training and the understanding of
how human errors impact safety, aviation has slowly managed
to change its culture. Yet, sadly, the equivalent steep “cross
cockpit gradient” still exists in many healthcare teams.
Today, the most senior captain could be disciplined if they failed
to listen to, or act upon, concerns raised by even the most junior
of co-pilots.1 Can we say the same in healthcare?
In recent years, healthcare has been hit by several scandals that
show the pernicious impact of staff not feeling able to speak
up. This includes the Bristol children’s heart surgery scandal,
which saw a number of babies and children die after heart
surgery at the Bristol Royal Infirmary in the early 1990s. The
resulting Kennedy inquiry found that the institution’s higher
incidence of mortality could be traced back to an imbalance of
power, with “too much control in the hands of a few.” Teams
within the organisation were “profoundly hierarchical,” and this
sense of hierarchy influenced “who gets listened to within the
organisation when questions are raised.”
Steep hierarchical gradients can be linked to other damaging
behaviours in the workplace, and have a negative effect on team
peter.brennan@porthosp.nhs.ukFollow Peter on Twitter @BrennanSurgeon  
For personal use only: See rights and reprints http://www.bmj.com/permissions
Page 1 of 2
BMJ: first published as 10.1136/bmj.l4461 on 2 July 2019. Downloaded from http://www.bmj.com/ on 19 December 2021 at University of Wollongong. Protected by copyright.
VIEWS AND REVIEWS
1
relationships and the tendency for conflict avoidance. Sadly,
the fear of speaking out is still widespread across healthcare,
with the Gosport inquiry serving as just one recent example.
Once again, a steep hierarchy prevented staff from speaking up
with confidence.
We need a change in culture so that any doctor can question the
decision or actions of another in a non-confrontational way and
with no loss of face by either party. Too often, junior doctors
are afraid of the repercussions, fearing that they may create
conflict in the workplace, harm their career progression, or just
upset the status quo. By contrast, the workplace culture in
aviation actively encourages employees to share their safety
concerns at the earliest opportunity.
The perceptions that people have of raising concerns do not
exist in a vacuum; they are set by everyday examples. On day
one of employment for a major UK airline, new pilots are met
by both management and union representatives and empowered
by both to speak up on the flight deck if they have any safety
concerns whatsoever, without fear of retribution. During
undergraduate and postgraduate medical training, doctors are
taught that they have a duty to speak up if they think that patient
care or safety is being compromised. Yet hospital trusts and
their senior staff need to actively apply this principle and give
staff opportunities to voice their concerns. For example, this
message could be strongly reinforced by trusts during induction
days at the start of new placements—especially if senior
management and consultants championed and actively
encouraged it.
We are not advocating a flat hierarchical gradient across teams,
which can be equally as damaging as a steep one. Team
leadership can be an effective lever for patient safety and the
“captain” is ultimately responsible for all actions. Yet knowing
that any doctor (or other healthcare professional) can speak up
without fear of retribution will surely make healthcare safer, as
well as improving our working relationships. Pointing out risks
to patient safety (perceived or real) should not be detrimental
Subscribe: http://www.bmj.com/subscribe
BMJ 2019;366:l4461 doi: 10.1136/bmj.l4461 (Published 2 July 2019)
to the challenger or those they are challenging, but serve as a
learning opportunity for all. If we want a no blame culture, then
we need to encourage people to speak openly about mistakes,
not only in their aftermath, but when we see them taking shape
in front of us.
As the Care Quality Commission (CQC) recognised in its
recently published report, Opening the Door to Change,
hierarchical cultures are “inimical to safety.” As it points out,
however, “in the NHS this lesson has not been learnt.” The CQC
suggested that multidisciplinary team working is a way to reduce
this hierarchy and encourage a culture that helps staff speak up.
A number of initiatives from across the NHS, big and small,
were also held up as tools to help tackle this problem, from
consultants and junior doctors being encouraged to call each
other by their first name, to involving patients and families in
investigations.
In 2017 aviation had a benchmark year with no deaths among
International Air Transport Association airlines, yet the
association’s safety review still noted that “we must keep focus
and continue with our work: the promotion of safety first.” The
culture in aviation is one of ongoing improvements and a
professional desire to be safer by learning from mistakes,
accidents, and near misses. This is helped by an active reporting
For personal use only: See rights and reprints http://www.bmj.com/permissions
Page 2 of 2
VIEWS AND REVIEWS
BMJ: first published as 10.1136/bmj.l4461 on 2 July 2019. Downloaded from http://www.bmj.com/ on 19 December 2021 at University of Wollongong. Protected by copyright.
culture, which brings to light the near misses or the bottom of
the iceberg. Aviation has tried hard to leave hierarchy behind
in a safety process that should have no ego.
Errors will inevitably continue to happen, but failing to learn
from mistakes that recur across the NHS on a daily basis is
unacceptable for patients who place their trust and lives in our
care. We need to look and learn from other high risk
organisations and change the culture across the health service
for the better. Is it the fear of possible repercussions or
recrimination that prevents colleagues from speaking up? That
question can only be answered by individuals, but empowering
healthcare professionals to speak up when they have concerns
is essential to making our NHS safer and can’t come soon
enough.
Competing interests: none declared.
Not commissioned, not peer reviewed.
1 Reynard J, Reynolds J, Stevenson P. Professional culture. In: Practical Patient Safety.
Oxford University Press, 2009.
Published by the BMJ Publishing Group Limited. For permission to use (where not already
granted under a licence) please go to http://group.bmj.com/group/rights-licensing/
permissions
Subscribe: http://www.bmj.com/subscribe