Jeremy Hunt's announcement last week on ways to improve the learning culture within the NHS and in turn minimise clinical mistakes, prompted me to revisit a presentation I have been using for the last eleven years. In it, I talk about previous Governments' efforts to improve clinical safety from the centre and highlight no less than six different initiatives that have been published to do exactly that; move from a blaming culture to that of learning lessons and improving safety.
For the cynical among us, or potentially those that have long memories, it begs the question, so what? Will this really change anything?
Having been a consultant liver transplant surgeon for twenty years, I have had the honour to work alongside some of the best clinical staff in the country, who work tirelessly with their colleagues to diagnose, treat and care for their patients in what is an increasingly challenging environment. What prevents them from embracing the recommendations Jeremy Hunt talks about, isn’t a lack of understanding or empathy for who they care for. It’s fundamentally down to culture and an inherent fear of blame and (misallocated) culpability.
The way the NHS is currently structured isn’t conducive to the open and transparent environment Jeremy Hunt has set out in his announcement. This is evident from the experiences of whistle-blowers involved in the Francis Inquiry. I read an article only a few weeks ago about how one year on, these people have not yet found comparable reemployment in the NHS and they still feel isolated from the employer they served for so many years. Similarly, it is hard not to look at what Jeremy Hunt announced this week and see the similarities with recommendations from the Francis Report which have yet to be implemented.
Jeremy Hunt and his predecessors are therefore right to point out the need for great change, but let’s look at what can be done from within first.
Change from within
The change we all agree is needed can come from leadership, outcomes reporting and measurement, and incentives.
Failure should be an opportunity to learn and improve. This ‘black box thinking’ could become a way of life in the NHS - as it has done in other sectors such as aviation and the nuclear industry - but it requires leadership, not from Government but from the Board of a health care organisation. Someone on the Board (the Medical Director would be most suitable) should have direct responsibility for embedding this state of mind into the organisation and should be held to account, as they would with any other duty. There should also be internal mechanisms that help staff on the ground adopt this new way of thinking. Patient safety outcomes need to incorporated into everyday management mechanisms - a dashboard on clinical safety for example should be available for all staff to see and use, the same way a ward management system would be used. This information should also be fed into remuneration rewards for staff - sending a clear signal of the importance of this role for everyone involved in service delivery.
In the current climate, it's not uncommon to read about CEOs and COOs of NHS Trusts facing financial challenges and it's therefore somewhat understandable that they have concerns in guaranteeing throughput when resources are limited. But if they have to do more for less, the answer is not to do less. It's to transform the ways of working to be able to do more. Particularly when one of the manifestations of doing more for less is clinical safety.
Technology can and does mitigate this threat. ePrescribing is a prime example of how the use of technology can resolve poor medicine management. Isle of Wight NHS Trust’s recent introduction of a fully automated prescription drug allocation process for example, has resulted in an 83% reduction in missed doses and a decreased length of stay for the patient.
Now is the time for 'black box thinking'
We have a Government that has clearly recognised the need for a step-change in the way the NHS perceives and utilises clinical errors, as well as the impact it can have not only on the patient but staff, and the NHS as a whole.
We also have a Health Secretary that understands the value of digital technology in helping the NHS meet the continuing demands on services, within an ever tightening cost envelope.
And so, whilst I am someone that’s had an extensive career working in the NHS and with it comes a long memory, I don’t consider myself one of the cynics.
Hunt has the potential impetus to support the NHS in becoming an organisation of ‘black box thinkers’. He also has a vison for a paperless NHS. Together they can revolutionise the way we treat and care for our communities, and in turn future proof the health of our nation.
In a few weeks' time, Jeremy Hunt will become the longest serving Health Secretary on record. I don’t think I know of anyone that would disagree when I say, Jeremy Hunt, this should be your legacy.