Has the NHS “Just Culture” Pendulum Swung Too Far?

Reflections on the Thirlwall Inquiry, accountability, and patient safety

The publication of the Lady Justice Thirlwall Inquiry report has prompted uncomfortable but necessary reflection across the NHS. Among its many findings is a challenge to one of the dominant themes in healthcare leadership over the past decade: the pursuit of a “just culture” and the rejection of blame-based approaches to error and harm. While the Inquiry does not advocate a return to a punitive culture, it raises a significant concern that the NHS may, in some circumstances, have become so focused on avoiding blame and identifying a system failure, that it has become reluctant to hold individuals properly accountable.

This is a debate that NHS leaders, clinicians, HR professionals and patient safety specialists can no longer avoid and was a key discussion point at the recent HSJ Patient Safety Congress session we led on The Thirlwall Inquiry: From Findings to Action - Strengthening Patient Safety, Culture and Accountability in the NHS.

The rise of “just culture”

The development of just culture in healthcare was both rational and necessary. Following inquiries such as Mid Staffordshire, researchers and patient safety experts increasingly recognised that adverse events rarely arise from the actions of a single individual. More commonly, harm occurs because of a combination of system weaknesses, resource pressures, communication failures, inadequate supervision, poor processes and human error.

This philosophy is embedded in the NHS Patient Safety Incident Response Framework (PSIRF), which replaced the Serious Incident Framework – a model which frequently defaulted to identifying frontline human error as the core issue, triggering a culture of fear or "blame-engineering" rather than deep systemic reform. In contrast PSIRF has as its focus the need to understand how incidents occur and how systems can be improved. NHS England describes PSIRF as a major shift towards learning, improvement and compassionate engagement rather than assigning blame.

Few would argue against these principles. Fear-driven organisations conceal mistakes. Staff who believe they will be punished for honest errors are less likely to report concerns. A culture of openness is essential if healthcare organisations are to learn and improve.

The challenge from Thirlwall

The Thirlwall Inquiry asks a difficult question: can an organisation become so committed to avoiding blame that it becomes incapable of confronting poor behaviour or misconduct?

Throughout the events examined by the Inquiry, repeated concerns were raised by clinicians about patient safety. Yet senior leaders delayed decisive action, appeared reluctant to confront uncomfortable possibilities, and often prioritised organisational reputation over patient protection. The report concludes that concerns were not acted upon with sufficient urgency and that leadership failures contributed to prolonged risks to patients.

Particularly striking is the Inquiry's analysis of NHS culture. Lady Justice Thirlwall observes that decades of NHS discussion about openness, learning and safety culture have not prevented repeated failures across the service. The report highlights continuing difficulties in accepting mistakes and taking accountability for ensuring learning is translated into action.

The implication is not that just culture is wrong. Rather, it is that some organisations may have interpreted it incorrectly. Just culture was never meant to mean “no accountability”. One of the misconceptions that has developed in parts of healthcare is to equate just culture with an absence of personal accountability.

That was never the intention.

The NHS's own guidance increasingly emphasises that learning from systems and holding individuals accountable are not mutually exclusive. Indeed, many organisations implementing PSIRF now use NHS England's “Being Fair” approach, which was specifically designed to examine both system factors and individual conduct in a balanced and proportionate manner.

A truly just culture distinguishes between:

• Human error.

• At-risk behaviour.

• Reckless or intentional conduct.

• Leadership failures.

• System weaknesses.

Only the first category should not, as a general rule, attract personal sanctions. The others may legitimately require performance management, professional regulation, disciplinary action or, in extreme circumstances, referral to external authorities. The challenge is ensuring organisations have the confidence to make those distinctions.

Why accountability matters for patient safety

There is a tendency to assume that accountability and safety sit at opposite ends of a spectrum. In reality, they are often mutually reinforcing.

Patients and families who experience harm generally want three things:

• An honest explanation.

• Meaningful learning.

• Appropriate accountability.

When accountability is absent, public confidence can quickly evaporate.

This point is particularly relevant following the succession of major healthcare inquiries over the past two decades. Whether examining Mid Staffordshire, maternity services, mental health services or now the events considered by the Thirlwall Inquiry, a recurring criticism has been that organisations are often better at identifying lessons than implementing consequences when serious failures occur.

For the public, hearing that an organisation has "learned lessons" can sound hollow if no one appears responsible for decisions that placed patients at risk.

The accountability gap in NHS leadership

One of the most significant themes emerging from the Thirlwall report is leadership accountability.

Clinical staff operate within well-developed professional regulatory frameworks. Doctors, nurses and allied health professionals understand that serious professional failings may result in regulatory scrutiny.

Historically, the position for NHS managers has been less clear.

The government's response to the Inquiry has already highlighted plans to strengthen accountability mechanisms for senior NHS managers, including work on regulatory and barring arrangements for leaders who fail in their responsibilities.

Whether these proposals ultimately prove effective remains to be seen. However, they reflect growing recognition that accountability frameworks should extend beyond clinicians and encompass those making operational and strategic decisions affecting patient safety.

Finding the balance

The real challenge for the NHS is not choosing between a just culture and accountability. It is recognising that effective organisations require both. An overly punitive culture creates fear and suppresses learning. Organisations as well as individuals can need space to recover and heal in order to learn. An overly permissive culture risks minimising responsibility and tolerating poor performance. Neither supports patient safety. The most mature organisations are those capable of asking two questions simultaneously:

What system factors contributed to this event?

Who, if anyone, failed to discharge their responsibilities appropriately?

These questions are complementary, not contradictory.

A moment for recalibration

The Thirlwall Inquiry should not be interpreted as a rejection of the principles that have shaped patient safety thinking over the last twenty years. The NHS still needs openness, psychological safety, compassionate engagement and a relentless focus on systems improvement.

But the Inquiry serves as a warning against a simplistic interpretation of "no blame" culture. When concerns are raised, when patterns emerge, when leaders fail to act, or when individuals repeatedly disregard professional responsibilities, accountability matters.

The lesson from Thirlwall is not that the NHS should become more punitive. It is that being fair requires courage: courage to understand system failures, courage to support staff who make honest mistakes, and, when necessary, courage to hold individuals and leaders properly accountable.

That may be the most important patient safety lesson of all.

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