Jeremy Hunt, secretary of state for health, is embroiled in battles with junior doctors, GPs, and consultants over contracts and patient safety. He thinks that he will improve safety by reducing excess weekend deaths. The doctors think that he’s endangering patient safety through obliging them to work unsafely. Ironically, he’s the first secretary of state since the founding of the NHS to put patient safety at the top of his agenda. Earlier this month he launched a global movement on patient safety and announced developments intended to improve patient safety.
Neglect of patient safety
The sad truth is that patient safety was not an issue at all in the first 50 years of the NHS. This was true of all other health systems as well, and it’s still not an issue for many. But evidence grew that being admitted to hospital is considerably more dangerous than bungee jumping with around 10% of patients suffering harm and around 150 patients a week in England dying deaths in hospital that could have been avoided. The US Institute of Medicine finally put safety on the agenda with its 1999 report “To Err is Human,” and England’s report, the curiously named “An Organisation with a Memory,” followed in 2000. The then chief medical officer, Liam Donaldson, chaired the report and has become a world leader on patient safety.
One consequence was that England set up a national reporting system for safety issues, and there have been 12.3 million reports, creating the biggest database in the world on patient safety. But this is estimated to be only about 5% of total incidents, and there is big variation in reporting rates among hospitals. About a fifth of the reports are falls.
Because such a small proportion of errors is reported and because of the variation in reporting rates nothing can be concluded about the safety of hospitals, but it is possible using the reports and other data to produce what the NHS has called a “learning from mistakes league.” There are four rankings, and 77 trusts (of 230), mostly hospitals, have scored “significant concerns” and 31 “poor reporting culture.” Once “validated” these results will be published every year.
This is part of creating what Hunt calls “a learning culture not a blame culture.” This aim will, I fear, cause hoots of disbelief among doctors, who feel that they are being blamed for failures in the NHS. I believe that Hunt is serious, but his aims and intentions are running a long way ahead of his capacity to relate to the broad church of doctors and convince them of his seriousness.
In his speech at Lancaster House earlier this month he described how the airline industry made the difficult transition from a blame to learning culture.
In 1978 Captain Malburn McBroom skilfully crash landed a plane after trying to rectify problems with the landing gear but failing to notice that fuel levels were dangerously low. He was destroyed by the subsequent court case, but the case led the industry to understand the importance of “human factors” in safety. Nobody spoke up when McBroom crashed the plane, but the industry worked to create a culture where people are not only comfortable with speaking up but know well the importance of doing so.
The change in culture was associated over 30 years with a halving in deaths while air travel increased nine fold.
Hunt recognises that we have to be cautious in extrapolating from air travel to healthcare, but another innovation that has been important in air travel—the introduction of the Air Accident Investigation Branch—is to be copied, with the introduction from April of the Healthcare Safety Investigation Branch. It will provide a legal “safe space” in which to undertake no-blame investigations, with the emphasis on learning to improve patient safety. Patients and their relatives will be part of the process. The branch will begin its work in maternity and neonatal care.
Then from April 2018 every death will be either investigated by a doctor or scrutinised by an independent doctor with the aim of avoiding unexpected or avoidable deaths.
A three day festival of health safety
Hunt’s speech was delivered on the third of three days of meetings on patient safety orchestrated by Imperial College’s Centre for Health Policy, which also published two reports on patient safety—“NRLS [National Reporting and Learning System] Research and Development” and “Patient Safety 2030.” I facilitated the first day, attended the third day, and facilitated a final small session in which global leaders in safety shared thoughts on what the priorities should be for research into patient safety.
I came away with several observations on patient safety:
• There should be quicker and easier ways to report safety incidents, and Imperial has developed a system. One of the problems with the current system is that there is no feedback, yet feedback is essential for learning. The Imperial system provides some immediate feedback, but we need to develop ways to provide more specific feedback.
• In a few years’ time we will no longer need reporting: incidents will be automatically picked up from electronic records.
• Currently we know little about safety in primary and community care, and this gap must be closed. Nursing homes and social care should be included.
• Patients must be much more involved in safety, and be able to report incidents and participate in the learning that must follow.
• Most harm results not from the “never events” like operating on the wrong patient, although these still occur in large numbers, but from multiple small errors in patients with multiple conditions.
• Talking about “quality and safety” is like talking about “fruit and apples,” said Don Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement. Safety cannot be divorced from quality.
• Antimicrobial resistance is a global problem of patient safety, said Sally Davies, chief medical officer for England.
• People have two broad answers to the question “How do we achieve success?” said Mathew Syed, author of Black Box Thinking: one group answer “talent and brilliance” and the others answers “learning from mistakes.” The first group have been dominant in the West, and one consequence was that little was learnt between the demise of the Greeks and the Renaissance—because people respected the masters like Plato and Aristotle and didn’t question their teachings. Science is about learning from mistakes, but healthcare has had a reverence for “talent and brilliance.” So did the airline industry, but it changed. Healthcare needs to change too. “Eminence is a problem in our profession,” said Margaret Chan, director general of WHO.
• There is a widespread belief that improving patient safety will reduce costs, but more evidence is needed.
• It’s essential, emphasised Chan and others, to “walk the talk”: any blaming by politicians will rapidly undermine a commitment to a no blame culture. Hunt needs to improve his relations with doctors if he is to achieve a no blame culture.
Richard Smith was the editor of The BMJ until 2004.
Competing interest: RS facilitated the first of the three days’ meetings and a short meeting on research priorities at the very end. He was not expecting to be paid, but he was told he would be paid after he had completed the facilitation.