19th August 2026
Part of the CEO Blog
This article is a part of the CEO Blog, a regular series written by Avma’s Chief Executive, Paul Whiteing.
The 14 August edition of The Economist published a letter from Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB). I have a great deal of respect for both Baker and the organisation he chairs.
Responding to the article ‘The lying doctors’ (4 July), Baker argues that mandatory disclosure rules can unintentionally discourage honesty in healthcare.
His main points are:
- Reports of moderate-harm incidents in Nottingham fell after the statutory duty of candour was introduced, suggesting staff may have reclassified harm rather than reported it openly.
- Staff are unlikely to give candid accounts of mistakes when they fear blame, litigation or sanctions.
- Effective safety learning therefore requires a protected “safe space”, similar to the approach used by HSSIB and in aviation.
- Removing failing leaders is insufficient because it does not change the underlying incentives that suppress honesty.
- Learning investigations should be formally separated from enforcement and accountability processes. Otherwise, new leaders will inherit the same conditions and further patient-safety failures are likely.
But this letter troubles me greatly.
I am not convinced that openness and accountability are competing objectives, nor that meaningful candour depends upon shielding individuals or organisations from accountability.
The premise appears to be that healthcare professionals will only be fully honest if they are protected from the prospect of blame, sanction or other consequences. While that may sometimes be true in practice, it raises a more fundamental question: should a culture of candour be contingent upon immunity from accountability?
Patients expect honesty
Patients and families rightly expect honesty because it is a professional, ethical and human obligation. It is enshrined in the Duty of Candour which Parliament is currently extending to a wider class of public officials under the new Hillsborough Law. Patients, their families and the public should not have to accept a trade-off in which the truth is available only if questions of responsibility are set aside. Openness should be the norm, not something secured through protection from scrutiny.
Accountability is not synonymous with punishment
From the perspective of people harmed by healthcare, accountability is not synonymous with punishment. When patients seek accountability, they are usually seeking acknowledgement of what happened, assurance that the right lessons have been learned, and confidence that the same failings will not be repeated. Accountability is often part of the healing process. It can restore trust where trust has been damaged.
The real distinction is not between learning and accountability, but between blame and accountability. A blame culture is rightly rejected because it scapegoats individuals, discourages reporting and ignores wider system factors. However, a just culture still requires accountability. It requires organisations and professionals to take responsibility, to explain decisions and actions, and to demonstrate that learning has led to meaningful change.
A lack of accountability still causes frustration
Indeed, one of the frustrations repeatedly expressed by patients and families is not an excess of accountability but a lack of it. The NHS has produced innumerable reports, inquiries, investigations and reviews identifying remarkably similar themes:
- Failures of communication
- Failures to listen
- Failures to investigate properly
- And failures to respond compassionately after harm
The challenge is often not discovering what went wrong but ensuring that lessons are acted upon. Learning without accountability can become a process of identifying problems without creating sufficient imperatives to address them.
There is also a risk that, in focusing on protected spaces for candid professional disclosure, the needs of those most affected by healthcare harm can become secondary. Creating psychologically safe conditions in which healthcare professionals can speak openly is important for learning and understanding what went wrong.
But this cannot, on its own, provide the full response that patients and families need after harm.
They also need to be heard and involved, to receive honest answers and acknowledgement, and to have confidence that learning will lead to meaningful change. As we set out in the Harmed Patient Pathway, a just and restorative response should support candid disclosure while also providing for responsibility-taking and fair accountability where appropriate.
Accountability is not the enemy of patient safety
Patients have a legitimate interest in understanding not only what happened, but also who is responsible for putting things right. Accountability is not the enemy of safety. Properly understood, it is one of the mechanisms through which safety is improved and public trust is maintained.
The objective therefore should not be to separate learning from accountability. It should be to create a culture in which openness, learning, responsibility and accountability coexist. Patients deserve all four.