Commentary: Imagining and implementing a responsibility culture in healthcare

Current approaches to investigating patient safety incidents in the NHS are focused on systemic learning, while the degree of personal accountability and/or remediation is explored via just culture (JC) or ‘being fair’ frameworks. The cultural aversion to individual accountability is referred to as no blame culture (NBC) and is supported by evidence that exposure to and fear of blame inhibits improvement. However, NBC has been criticized for discouraging a formal assessment of individual error, and there are numerous examples where patients and relatives were left frustrated that personal accountability was lacking. Responsibility culture (RC) has been proposed in preference to NBC, whereby a balance is struck between identifying systemic versus personal causation. In this commentary the advantages of RC over NBC are described, and an approach to its implementation (including modification of incident reports and supportive messaging from senior clinical leaders) is proposed. Current governance processes, including incident reporting, the patient safety incident response framework, duty of candour, JC framework and the relationship between safety and available resources are explored in detail. In conclusion, NBC and JC may not adequately meet the expectations of patients and families following avoidable harm incidents. Any change in approach would require great caution to minimise both the fear and the actual occurrence of scapegoating among medical staff, and this will require robust and fair processes combined with consistent cultural messaging.