Creating a Healthy Risk Culture

Some risks are worth taking!

Creating a Healthy Risk Culture - Dr Ollie Hart

One of the most important things we leaders can do, is cover risk. It is such an enabler when leaders reassure their team, that if they innovate and things going wrong, they will have their back.

This emerged from one of our recent support events for proactive care in PCNs, where we heard an insightful reflection, from a PCN manager. They gave an example of when they were organising a community MSK event (support and advice for joint pains) in a sports centre and one of the team raised a concern “What if someone comes in with spinal cancer?”. Of course, this is incredibly unlikely and after discussion they realised there would be ways to escalate concerns in a timely manner. But this manager was feeling quite restricted by people over thinking and over stating risks.  This type of fearful mindset can commonly hold back new ideas.

This prompted someone else to describe how for years as a community nurse, they were not allowed to offer a ‘first catheterisation’ at home. After months of challenging these long held guidelines, it was agreed that for elderly patients, often with dementia and at end of life, it was worth the ‘risk’ to keep people in their own home. A few years on there have been no problems, and it feels much kinder for all concerned.  This approach has become ‘the norm’. It seems you don’t need an ultrasound scan as standard before doing a first catheterisation.

Perhaps we should recognise this normal human defence mechanism. Change is often perceived as threatening. We know from Daniel Kahneman’s Nobel prize winning work, that humans are programmed to be twice as alert to risk than reward. Most of us naturally see the problems before we visualise the benefits. But what may have kept us safe in a bygone era, can be quite restricting as we seek imaginative ways to improve things.

Creating a context in which you have permission to experiment, with an expectation that sometimes this will lead to some degree of failure, feels essential to me. I reflect that often the NHS is very intolerant of any form of failure.  In emergency situations a ‘play it safe mindset’ can be lifesaving, but the rest of the time, it often severely restricts our progress.

Interestingly, I observe that one of the many benefits of genuine co-production with patients is the opportunity to share risk. Whether it is sharing decisions about treatment on a one-to-one basis, or designing services together, sharing these dilemmas can be empowering for all. As clinicians, I think we anxiously cling to an unrealistic view of what our services can offer and that they need to offer it all! In contrast, our patients come at things with a more real-life view-point. In my experience, patients are used to making trade-offs all the time. We mostly know what is good and bad for us, from smoking a cigarette, to breaking the speed limit, but we take risks. Life is risky.

We have to find the right balance. A callous, or thoughtless approach where risk is not considered at all, is equally dangerous.

The current NHS conditions make both these extremes, more common, I think. The prevailing top-down messaging is target driven, micro-managed, CQC inspection orientated, creating a culture of low trust and zero tolerance of risk.

When staff feel threatened, underappreciated, under pressure to increase productivity, they are often driven into ‘over cautious mode’.  Alternatively, when burnt out and fed up, some staff go the opposite way and stop caring and may even take excessive risks.

I think it comes back to leadership and culture. We are so much more productive if the tone is set right. We need permission to experiment and follow our gut. We need some time to think carefully about likely outcomes, but encouragement that if it doesn’t go perfectly, you will be supported. Strong brave leadership enables thoughtful risk taking and creates the best conditions for learning. Ultimately this is safest and healthiest for all of us, staff and patients.