Time to End “Heads on Spikes” Approach

1.

• link to article
https://www.theguardian.com/healthcarenetwork/2018/apr/06/time-end-heads-onspikes-approach-failures-nhs-leaders

2. Time to End "Heads on Spikes" Approach Transforming NHS leadership from a culture of blame to a culture of learning and

Time to End "Heads
on Spikes"
Approach
Transforming NHS leadership from a culture of blame to a
culture of learning and improvement.
Completed by: Isyaev R.P. UB-02

3. Introduction

• Reviewing Richard Vize's analysis on
healthcare leadership and safety
culture.

4. Article Information

Richard Wise's article in the Guardian
criticises the 'executions' of NHS
management.

5. Systemic Pressure

NHS leaders are under
pressure and their
reputations are being
unfairly damaged by the
system.

6. The Key Issue

• A
learning culture addresses
systemic causes of errors
instead of exemplary
dismissals.

7. Defining the Moral Line

• It is necessary to distinguish
between intentional violations
and errors of an overloaded
system.

8. Dangers of Immediate Dismissal

• A culture of mutual blame
encourages the concealment of
mistakes, threatening patient
safety.

9. Origins of Healthcare Failure

• Systemic Factors (80%)
80/20 Rule • Individual Moral Failure (20%)
*Indicative distribution based on healthcare complexity
analysis.*

10. Creating a Learning Organization

• Refusing to look for
scapegoats allows us to find
the true causes of mistakes.

11. Reforming the 'Fit and Proper' Test

Reforming the 'Fit and
Proper' Test
Proposed Reform
Core Objective
Clear Ethical Boundaries
Defining moral breaches (e.g., managing by
fear).
Independent Assessment
Moving to objective, external evaluations.
Contextual Review
Assessing performance within financial/staffing
realities.
Development Pathways
Creating routes to improve skills instead of
ejection.

12. Stylistic Analysis

For true security, the system
needs transparency,
openness and psychological
comfort.

13. Conclusion & My Opinion

Conclusion & My Opinion
• Tolerance of management failures will return the
focus to patient safety.