There’s such a compelling case for a ‘no-blame culture’ in health and social care that it would have been in place years ago, were it just a matter of deciding to have one. The key element in any ‘no-blame culture’ is that speaking up about errors is a fundamental duty for all involved: and that mistakes are seen as part of human nature, not a shameful indication of general inadequacy. Open, blame-free, discussion allows attention to what went wrong, whilst not muddying the water with personal attacks and self-righteous outrage, and the consequent defensiveness, shame and humiliation in those who were involved.
Blaming comes naturally to us all. If something goes wrong we readily blame ourselves or others, depending on our character. This has some uses: in its most neutral form, blame attributes responsibility for a fault, or wrong. Sometimes it is seeking acknowledgement, justice and learning from experience. But blaming is usually more than a simple causal analysis. It’s more often an attack, a call for retribution, for punishment. This is more than just wanting something put right.
This type of attack might make sure the same thing doesn’t happen again: a primitive form of education. There is, however, another powerful driver for blame, related to revenge: it allows the discharge of painful and powerful emotion by those who have been, or feel, injured. This may not just be for those who have directly suffered the injury or loss. Other people may be horrified by what has occurred, and feel empathically indignant. Less commendably, they might also have found a chance to vent feelings related to other grievances, or just a chance for some self-righteous sadism.
When a story gets in the public domain, sensational reporting in the press, and other media, compounds the situation. Such stories can emphasise ‘wrongdoing’, and narratives that divide and demonise individuals, often from implicit positions of self-righteousness. Sometimes these stories have covert political agendas; sometimes they are just ‘for the hell of it’. Naming, shaming and blaming are portrayed as self-evident civic virtues, with little concern or compassion for the consequences. This occurs on both the ‘right’ and ‘left’ – only the targets are changed.
Eileen Munro, who has reviewed the UK’s Child Protection procedures in detail, wrote an opinion piece in The Guardian, the year before her review was commissioned. She observed:
When a plane crashes, the starting point is that the pilot didn’t want the plane to crash, and would have done everything in their power to prevent it . . . Serious case reviews . . . make no such assumptions about the professionals involved – doctors, police officers, and social workers . . . Both public opinion and formal investigations conclude that children are harmed or killed because people working in child protection are stupid, malicious, lazy or incompetent . . . Why is this assumed? Surely it is reasonable to believe that people who choose to work in this demanding field want to help children, rather than allow them to be hurt? . . . (Munro, 2009)
The strategies and actions of government, the civil service, and various levels of management in our services, have involved, and will, inevitably, involve misjudgements, errors, omissions and inefficiencies. At some point in the future, such matters may be made clear by any number of inquiries, and there may be political and other prices to pay. The pandemic, and even the most effective measures to contain it, as well as promoting fellow-feeling, evoke, however unconsciously, anxiety, rage and confusion across society. Such an emotional climate makes it entirely understandable that many, in professional groups, the press, and beyond, find it hard to manage the tension between constructive criticism and contemptuous blame. We are, however, currently in a dangerous crisis. What is required is improvement and action, in real time, from people focused on the task, informed by feedback and advice, rather than distracted and undermined by the fear of humiliation. If a plane is at risk of going down, the pilot requires timely, clear, calm feedback and advice about urgently putting things right, not fury, sanctimony and personal attack. Whether we like it or not, the current pilot – the government, with its advisors and various departments – is at the helm, and will be for some years.
Decisions made about the urgency and nature of the UK response to Covid-19, or shortages of PPE, are not minor problems that can or should be overlooked, any more than the murder of children who should have been protected, or life-changing medical misadventures. We must be careful, however, about how we formulate our complaints, and how we help to put things right – or the water sure gets muddy.
If we force our government and managers to be preoccupied and defensive, let alone shamed, afraid and humiliated, there’s a lot of collateral damage, despite any amount of righteousness to our cause. The first problem is that things get missed – until, of course, it’s noticed that they’re missed, and then there’s more blame… Why weren’t we ALL discussing the situation in Care Homes much earlier … now if we try and put this right by blaming those ‘in power’ for the failure, they’ll get preoccupied with that, and miss the next thing… such as what we might do to help our children… The second problem is that recipients of blame become even less competent as they become preoccupied with defending themselves from possible humiliation and attack. Blame, and the evasion of shame evoked in its targets, are the enemies of openness to reality, constructive, proactive thought, and intelligent action.
There may be two dynamics that need to be thought about separately. One concerns the Press, who pursue whatever is the current story, often in an unimaginative, combative, and self-righteous manner. Inevitable disagreements between experts, or evidence of shortcomings and problems, are frequently harnessed to feed outrage. The other concerns us all. The difficulty is that at times of high anxiety and trauma, groups can revert to deeply programmed, readily available ways of functioning. This can be ‘heart-warming’ – applauding our NHS heroes, and sticking up our pictures of rainbows: but it can rapidly turn bad. Such ways of behaving are fundamentally expressions of primitive feelings at times of high anxiety. These can be generous, but also vicious. What happens when disillusion sets in? This is not simply an issue of how we now, and when the dust settles, hold our politicians to account: the potential for our nastily turning on each other is, arguably, more serious.
The challenge is to recognise the old familiar ways in which we think, and the ready satisfaction that comes from ‘the same old story’. We have to attend to how we distinguish between legitimate concerns, and the playing out of psychic dramas. We need to find new ways forward, not take old ones off the shelf. We have, individually and as a society, to recognise and manage our rage and anxiety, not to silence ourselves, but to channel our experience and views constructively. A ‘no blame culture’ has been aspired to for years in health and social care, but it’s needed everywhere. ‘Do unto others as you would be done by’: that’s never easy, but very good advice for us all.
Chris and John