5. Findings from Interviews
This section describes this review's findings, which were informed by the visits, phone-calls, and contact with and to NHS Boards. These sections reflect the over-arching themes that presented themselves during the informal interviews. The findings and associated observations are aimed at NHS Boards collectively rather than any particular Board.
5.1. Qualitative Themes
Several over-arching qualitative themes arose from engaging with the NHS Territorial Boards, Special Boards, and Primary Care providers. Those contacted and engaged with can be seen in Appendix 1. The topic guide and clarifying questions for the informal interviews and any subsequent follow-up clarification can be seen in Appendix 4.
Overall, five main themes emerged around duty of candour;
1. Implementing the duty of candour procedure,
2. Producing the report
3. Guidance for reporting
4. Liaising with primary care providers
5. The purpose of duty of candour. These are discussed below.
5.1.1. Implementing Duty of Candour Procedure
Implementation of the Duty of Candour was raised in several interviews. A number of Boards expressed difficulties in understanding the legislation and policy behind it, and what this meant for the Board in practice. Several also referenced the guidance which they felt had come a bit too late in the process. Confusion around where the duty of candour procedure aligned with other reporting systems such as Adverse Events, Significant Adverse Event Reviews and the Datix system also caused confusion.
On the other hand, some Boards found implementation relatively straightforward. They put this down to integrating their reporting systems from the start, receiving advice on the guidance and interpretation, and pre-implementation training. They also credited the guidance with being clear on what the reporting requirements are.
Several Boards also felt that decision making regarding which incidents required duty of candour to be activated was inconsistent. There was confusion over what constituted a duty of candour incident across different parts of Scotland. Some Special and rural Boards felt that the guidance and procedure did not take into account their unique needs, and felt isolated in their decision making.
5.1.2. Producing the Duty of Candour Report
Some confusion and concern over producing the actual annual duty of candour report was raised by all Boards engaged with. A number felt the official guidance produced and disseminated came too close to the publication of the regulations to be helpful. Many also found the guidance itself confusing, as well as "too general".
The other issue raised for producing the report itself was confusion around time-scales – a number of Boards were unsure or did not know when or where to submit the report. Another issue was the lack of a standardised template to be used. Although a template was available on the Scottish Government website, it was not a requirement that this be used and certain Boards found this confusing. A number voiced the preference for a set template to be issued with clearer sub-sections. Others mentioned reviewing other Boards' published reports before publishing their own to get a sense of the report style, but again many did not find this helpful as the reports were not standardised across the Service.
Several Boards also cited "stress over getting it right" and felt the loose time frame for submitting reports did not help this feeling. Others also mentioned a nervousness around how these publically published reports could be used in the future by interested parties, such as the media. They felt that lack of reassurance or guidance on this matter was an oversight.
5.1.3. Guidance for Reporting Incidents
Many Boards cited confusion over reporting incidents, namely by their type in the table provided in the suggested template provided. Several cited confusion over how the table for reporting duty of candour incidents was set out, particularly the categories within the table. A few Boards also expressed concern over interpretation of these table categories and gave examples of how a set of hypothetical incidents that would trigger duty of candour could fall into or between several of the categories within the table. Where examples were sought, they were not considered to be universal or applicable to the Board and were considered unhelpful.
5.1.4. Liaising with Primary Care
Liaising with primary care providers within the territorial Boards was brought up by all Boards. Some mentioned not being aware of who was responsible for contacting or making the primary care providers in their area aware of their duty to provide an annual duty of candour report.
Other Boards struggled with liaising with primary care providers as they were not aware of the numbers within their territorial area, nor did they have a list of all concerned to get in contact with.
Other Boards expressed a concern and confusion over who was the responsible person whose duty it is to get in touch with primary care providers in the said territorial area to make when aware of providing a report. There was also concern cited about how this responsible person would be held accountable for their actions – or lack thereof. Other Boards did not seem aware of the concept of the responsible person in relation to primary care duty of candour reports within their territorial area.
5.1.5. Purpose of Duty of Candour
Several Boards questioned the purpose of the duty of candour procedure and reporting arrangements in light of several active systems. Most of the territorial Boards contacted cited feedback from front-line staff and concerns over increased work load and paperwork when systems were already in place to deal with incidents that would trigger duty of candour.
Another interesting point raised by some Boards was the idea that the duty of candour procedure could prove traumatic and cause more harm to families or persons involved in the incident. One Board cited an example of an incident that triggered the duty of candour procedure in retrospect, in which grieving had already commenced. They cited concerns over length of time the procedure took due to waiting on post mortem results and then the triggering of the new duty of candour procedure was thought to have "re-opened old wounds" for family members involved in the incident.
Other Boards felt there has been an overall inconsistent approach to rolling out the duty of candour procedure and reporting requirements across Scotland, which failed to take into account some of the unique challenges faced by certain Boards, including Special Boards, or rural Boards who cited feeling isolated in the process.
5.2. Good Practice in Action
Some Boards have fully integrated the duty of candour procedure with their existing Adverse Events system. This was thought to make adapting to the new procedure run more smoothly and 'cast a wider net' in order to identify incidents that would trigger the duty of candour procedure, including past incidents already in the system.
Another Board found having dedicated duty of candour multidisciplinary meetings helped ease staff concerns, ironing out front line problems, and encouraging debate around the process.
One Board has included duty of candour procedure training into its yearly refresher training package for all staff, even if they were not clinically trained or placed to make decisions on duty of candour.