I first came across the concept of the ‘just culture’ in healthcare several years ago during my Darzi Fellowship, a highly respected national clinical leadership programme.

The concept of a just culture was one which was logical and the terms of it were clear to me but hadn’t been framed in formal terms in this way in my head before to ensure staff are treated fairly and supportively through a culture of learning when things go wrong. According to Professor Sir Norman Williams, who published a report looking at gross negligence manslaughter in healthcare in 2018 “a just culture considers wider systemic issues where things go wrong, enabling professionals and those operating the system to learn without fear of retribution”.

However, it was also striking to me that for the first few minutes of our talk on ‘just culture’ that my thoughts did not immediately connect with the incredibly important issues which Professor Sir Norman Williams published. It was a phrase I had seen and heard before but had wrongly assumed, based on my experience and without questioning, that it referred to another ‘just’ culture. This ‘just’ culture, however, was a version which existed in my head – the one I have sadly experienced at various points during my entire career in the NHS in numerous locations. Given how often I had heard the term ‘just’ being used in the NHS, I had wrongly assumed this is what everyone was always referring to when they spoke about a ‘just culture’ and that’s why people wanted to do something about it. The one I had in my head however was something altogether different to that of Professor Sir Norman Williams. Mine was the unseen or other ‘just’ culture – one of exceptionalism which refers to the culture of using ‘just’ as a prefix, often in a negative and derogatory fashion to justify treating someone differently or used to justify an action.

The ‘just’ prefix is sadly used far too often in healthcare and speaks of the culture which exists in the NHS. It is commonly used in all lines of healthcare and used liberally for tasks, behaviour and people. Whilst for tasks, this might be justified – ‘can you just insert a cannula for me’, it becomes a significant and damaging problem when it is used to dismiss or diminish unacceptable behaviour or used to describe and demean people and roles. For unacceptable or discriminatory behaviour, ‘Just banter’ is used an excuse to diminish and ‘play down’. ‘Just a joke’ or ‘I was just’ is heard too often and this hidden ‘just culture’ feeds into the prevailing culture of NHS organisations and what staff on the ground, and in turn what their patients experience on a daily basis. Often these incidents or behaviours can be sadly dismissed as ‘woke concerns’

Describing people or roles is equally as damaging – whether it be used to justify asking someone to do something deemed beneath the person asking it or denying them opportunities such as teaching based on their role or status e.g. ‘just a staff grade’ or ‘just a junior doctor’, these phrases have crept into the NHS lexicon far too often over many years. Often people have had bad experiences themselves in their own training and think this justifies behaving in the same way as it’s ‘just a junior doctor’ and therefore it doesn’t matter. That’s nothing to say of the use of ‘just’ to speak about our valuable nursing, AHP and management colleagues as well as the other thousands of non-clinical support staff – cleaners, porters and others all working within the NHS.

The BMA have recently changed the terminology for what have traditionally been called ‘junior doctors’ or doctors in training. These doctors are now referred to as ‘resident doctors’. Whilst the reasons for this are many – to reflect the experience and skillset of these important group of doctors which makes up nearly 25% of all doctors in the UK and to mirror the terminology in the US and Spain to name but a few, part of this will be no doubt to change the narrative from both employers and the public as to how these doctors are perceived. They are not ‘just junior doctors’ – they are the future of the NHS, often with many years of experience in the latter years of their postgraduate training. Renaming or not, treating them as ‘just a resident’ does a disservice to the NHS and the various national workforce policies which exist – without basic respect and recognition, the rebranding is meaningless

The lost tribe of SAS (Specialty and Specialist) doctors and locally employed doctors (with locally employed doctors growing at the fastest compared to other groups. From 2019 to 2023, there was a 75%, increase, from 21,000 to 36,831 licensed doctors) have long suffered in this field. They have been viewed as ‘second rate’ for too long and now, in the workforce crisis we find ourselves in, is their time to rise and take their rightful place alongside resident and consultant doctors with fulfilling and supportive careers. Sadly the current reality is that whether the word ‘just’ is said or not, it exists silently every single day for thousands of SAS and LED doctors in their daily practice. Over time, this takes its toll on morale and wellbeing.

It’s time we take heed of the original Professor Sir John Williams’s report – where each organisation within the NHS should be one of learning and openness. We need to learn to treat other better and with more respect, regardless of role. At the end of every ‘just’ comment, is a person.

Author

James Hadlow

James is Associate Medical Director – Remote and Rural Strategy at East Kent Hospitals University NHS Foundation Trust where he works a joint policy/strategy and clinical role as an anaesthetist. He has previously been a Darzi Fellow and has worked as Senior Strategy and Policy Lead at NHS England as well as previously being a member of the All Party Parliamentary Group for AI for Citizen Participation. He has written previously for New Statesman and has experience in medical education and research. He holds PG Certs in Clinical Leadership and Clinical Education.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.