The Being Fair Tool: From Skeptic to Convert

When the Being Fair tool launched in May 2025, I'll be honest, my first reaction was scepticism. The old Just Culture Guide always irritated me because it started with the assumption someone had done something wrong, and at first glance, this felt the same. But after using it in practice and working with others to apply it? I've changed my mind. This tool is genuinely helpful, if you use it right. The key difference from the old Just Culture Guide is that this tool starts by assuming it's a systems issue and only continues if there's genuine evidence it might not be. The old guide started by looking for individual culpability first.

What It Is: A Quick Reminder

The Being Fair tool was launched in May this year by NHS England, after consultation, as an update and replacement to the Just Culture Guide.

It opens with a clear statement: "Patient safety incidents are usually signs of systemic issues, and action singling out individuals is rarely appropriate." You can recognise the PSIRF language throughout the tool.

It starts with Sydney Dekker's restorative questions:

• Who is hurt?

• What do they need?

• Whose responsibility is it to meet that need?

Which is exactly where we should be starting for all our compassionate engagement and involvement work.

The tool then works through a series of questions, consistently nudging us back towards systems-based approaches. I've included a link to the tool below, and won't repeat the questions here, instead I've included some thoughts on using the tool.

1. The Foundation: A Genuine Systems-Based Investigation

The Being Fair tool is only as good as the systems investigation that precedes/follows it. If your learning response is superficial or still blaming the individual, this tool won't save you—it'll just add another layer of process to a flawed approach.

Red flag: If your "systems investigation" concludes that the main issue was the individual's actions with a brief nod to "communication could be better," and recommends "individual training", we probably need to do some work on our investigations first (always happy to help with that!)

2. HR Partnership: Get Everyone on Board First

This isn't a tool to introduce during a crisis. Our workforce colleagues need to understand systems thinking and be committed to this approach before an issue arises. We don't want to be introducing this during a situation that has arisen last thing on a Friday.

If you haven't already, try and get workforce teams aware of PSIRF and this tool. You could walk through case studies together. Make sure everyone understands that this tool's purpose is to redirect most cases back to systems thinking, not to find creative ways to discipline staff.

3. Timing: Speed Matters

When an incident happens, there can be a knee-jerk reaction to leap straight into professional standards processes. By the time someone thinks to use the Being Fair tool four months later, staff may already be signed off sick, trust has eroded, and the work to restore has just become a lot harder.

4. Culture Programmes: Join the Dots

Many organisations have culture programmes of work ongoing or commencing at the moment. Are these teams aware of the Being Fair tool? Are they building it into any education around culture in the organisation?

5. Freedom to Speak Up: A Natural Alliance

Your FTSU Guardians are perfectly positioned to advocate for use of this tool when they're supporting staff involved in incidents. Are they aware of it? Are they empowered to encourage its use when responding to concerns being raised with them?

When Would You Actually Use This Tool? Scenarios Where It Works Well:

Scenario 1: During an MDT Systems Review, it emerges that a practitioner repeatedly ignored clear safety protocols despite multiple reminders from the team around them.

Scenario 2: A learning response reveals that a staff member falsified records.

Scenario 3: During investigation of a medication error, evidence suggests a practitioner was working while impaired by substances (either prescribed or otherwise).

Scenario that doesn't need the tool:

Scenario 4: A junior doctor makes a prescribing error in a busy department where they experience frequent interruptions, unclear protocols about who should be supervising, and a new electronic prescribing system that's been poorly implemented. Ideally we can immediately recognise that this is a systems issue. If you choose to use the tool in this scenario, and there's no harm in doing so, you'll answer the first question about the substitution test and realise that yes, any junior doctor in these circumstances would likely have made the same error. The tool will redirect you back to systems thinking where you should have been all along.

A link to the tool is here: NHS England » Being fair tool: Supporting staff following a patient safety incident

My conclusion: The Being Fair tool isn't perfect, and it won't fix a broken safety culture on its own. But what it does do, when used properly, is provide a structured, evidence-based pathway that consistently redirects us back to systems thinking whilst highlighting and protecting the rare situations where individual conduct genuinely needs addressing.

The biggest shift from the Just Culture Guide isn't just the reversed order of questions, it's the underlying assumption. This tool starts by believing in your staff and in the complexity of healthcare systems. It assumes that when things go wrong, it's usually because the system failed, not because someone came to work to do a bad job.

Use it early. Use it jointly. Use it with the genuine commitment to follow where it leads, which, most of the time, you will be back to examining and improving your systems.

And if you find your teams using this tool frequently? That might be a signal that something else is going wrong. The Being Fair tool should be rarely used, because most of the time, you should be stopping at "this is a systems issue" long before you ever pick up the tool.

I'd love to hear from you if you've used the tool and found it helpful.