Beware the Bronze Lancet

Lord Hamurabi served as King of Babylon in the 18th century BCE (Before Common Era).

He is famous (in Babylonian scholar circles anyway) for introducing a series of 282 laws which became known as the Code of Hamurabi. This was one of the first ever written codes of law in recorded history, inscribed on stone tablets over 8 feet tall. The code set out a series of rather useful rules and protocols such as “if a son strike his father, they shall cut off his fingers”.

But it is rule number 219 that caught my eye, and reminded me sadly of much of modern day NHS management. It reads:

"If a physician operate on a man for a severe wound with a bronze lancet and cause that man's death; or open an abscess (in the eye) of a man with a bronze lancet and destroy the man's eye, they shall cut off his fingers.”

I have never been a fan of management by fear. Stick (as opposed to carrot) strategies are not the way to get the most from people. I do not believe that the majority of hardworking, caring individuals who choose to work in the delivery of health and social care deliberately come to work to fail. And as Roy Lilley, @roylilley, recently pointed out in his nhsManagers.net blog, the fear of being shamed is more likely to drive people to hide failures in the system, rather than to openly discuss them and try to find solutions.

I know of one organisation that thrives on failure. They are a grant awarding body and every year look at how many of the projects they funded have failed. This is very clever. They know that if everything has gone well, and every scheme succeeded, they are simply not being risky enough, or taking enough chances.

And what about “Google X”, a laboratory where inventors and engineers are encouraged to innovate and create new solutions to old problems? One of their team, the improbably named Astro Teller states "You must reward people for failing. If not, they won't take risks and make breakthroughs. If you don't reward failure, people will hang on to a doomed idea for the fear of the consequences. That wastes time and saps an organisation's spirit."

It is now 10 years since the introduction of Clinical Governance in the NHS. One of its main achievements has been to get multi-disciplinary teams to discuss instances of what went wrong to understand what could have been avoided, and so what could be avoided in the future. This helps introduce a culture where errors and avoidable harm are discussed as part of an open learning process, in the interest of improving the quality of services.

So the real challenge for Health and Social care organisations is to create a culture where staff feel able to innovate and try new things, but with safety nets in place to ensure they can do no harm.

This is not easy and like a lancet (bronze or otherwise) it can be a double-edged blade: do you admit your failures and risk criticism or discuss errors openly to inform a vital learning and improvement process? But without innovation and risk, the Health and Social Care system will just not deliver the necessary improvements and efficiency savings. Surely we don’t need 8 feet high tablets of stone to tell us this?