From a blame culture to a learning culture
Health Secretary addresses the Global Patient Safety Summit on improving safety standards in healthcare.
Every year an estimated 1 million patients die in hospitals across the world because of avoidable clinical mistakes.
It is difficult to confirm the exact number because of variability in reporting standards, but if it is of this scale it sits along hypertensive heart disease and road deaths as one of the top causes of death in the world today.
In the US they estimate it at up to 100,000 preventable deaths annually and in England the Hogan, Darzi and Black analysis says that 3.6% of hospital deaths have a 50% or more chance of being avoidable – that’s potentially 150 avoidable deaths every single week. Holland and New Zealand make similar estimates.
So today is historic.
Distinguished guests, health ministers from across the world, Director General Chan from the World Health Organisation thank you for attending this first ever ministerial-level Global Patient Safety Summit. A special welcome to my friend and colleague the German Health Minister Hermann Grohe with whom I am jointly hosting the summit and who will organise a follow up summit in Berlin in a year’s time. And a warm thank you to the many people who have travelled long distances to be here as we aim to make a decisive step towards improving standards of safety in healthcare.
In 1990 a bright 24-year old medical school graduate started his first job in medicine. He was a pre-registration house officer looking forward to a glowing career in surgery.
In his first month he was attending to a 16-year old boy undergoing palliative chemotherapy. The boy needed two different injections, one intravenously and a second by lumbar puncture into the spine.
The intravenous drug was highly toxic – indeed fatal - if administered to the spine. But it arrived on the ward in a nearly identical syringe to the other injection. Both syringes were handed to the young doctor for the lumbar puncture procedure and both injected into the patient’s spine.
As soon as the doctor realised what had happened, frantic efforts were made to flush out the toxic drug from the boy’s spine. But it was to no avail and tragically he died a week later.
So what happened next?
You might think the most important priority would be to learn from what went wrong and make sure the mistake was never repeated. But instead the doctor was prosecuted and convicted for manslaughter. He and a colleague were given suspended jail terms.
In this case the convictions were eventually overturned at the Court of Appeal. But the real crime was missed: as the legal process rumbled on, exactly the same error was made in another NHS hospital and another patient died because our system was more interested in blaming than learning.
The blame culture doesn’t just create fear for doctors. It causes heartbreak for patients and their families as I discovered when I met the parents of 3-year old Jonnie Meek.
Jonnie tragically died unexpectedly in hospital in 2014. His parents found their grief at losing Jonnie compounded several times over by the immense difficulty in establishing what exactly happened. An independent report found: ‘Two different [hospital] trusts… Both responded in the same closed, unhelpful manner…[Jonnie’s parents] on the outside, unable to find a way in to ask simple questions. [NHS employees] blocked by fear…expectation of blame lead[ing] to defensive behaviours.’
We are now working with Jonnie’s family to seek an order for a second inquest.
But it shouldn’t need an inquest to find out the truth. Instead we need to ask what is blocking the development of a supportive, learning culture we need to make our hospitals as safe as they should be.
Too much avoidable harm and death
In England we have made much progress in improving our safety culture following the Francis Report into the tragedy of what happened at Mid Staffs.
According to the Heath Foundation the proportion of patients being harmed in the NHS dropped by over a third (34%) in the last 3 years. MRSA bloodstream infections have fallen by over half in the last 5 years. We have introduced a new and much tougher peer-led inspection regime which has led to 27 hospitals being put into special measures, 11 of whom have now come out. The law has changed placing on all hospital trusts a statutory duty of candour to patients and their families when things go wrong. The government was elected on a firm commitment to make NHS care safer across all 7 days of the week and we are making good progress.
But today I want to talk about the profound culture change necessary if we are to complete this journey: the change from a blame culture to a learning culture.
A learning culture not a blame culture
In his book Black Box Thinking, Matthew Syed, whom we will hear from later, talks about how that same blame culture used to exist in the airline industry.
He tells the tragic story of United Airlines flight 173, where 10 people died in a crash that happened in December 1978. The pilot, Captain Malburn McBroom, was trying to rectify a potentially dangerous problem with the landing gear but failed to notice that the plane was dangerously low on fuel. When he was forced to crash land the plane, he did so with extraordinary skill saving the lives of over 150 passengers. But because of his mistake – not noticing the low fuel levels, he got tied up in a 7-year long court case, came close to suicide, lost his pilot’s licence, and ultimately died a broken man.
But that tragedy had a surprisingly positive ending.
Because it became the moment the airline industry realised that if it was going to reduce airline fatalities, it needed to change its culture. They realised that ‘human factors’, rather than technical or equipment failure had been at the heart of the problem. Anyone could have failed to notice low fuel levels when they were trying to fix the landing gear. Why didn’t other crew members spot the problem and speak out? The issue was not that particular person, but what could have happened to any person in the same situation.
As a result the airlines transformed their training programmes. They mandated reforms that required pilots to attend group sessions with engineers and attendants to discuss communication, teamwork and workload management. Captains were required to encourage feedback, and crew members were required to speak up boldly.
And the result? There were dramatic - and immediate - reductions in the number of airline fatalities. The number of deaths overall halved over 30 years - at the same time as air travel increased nine fold. 10 people died in the United 173 crash, but experts are unanimous that the learning that resulted has saved thousands more.
Now healthcare is of course very different to aviation.
When someone dies in an airline accident you know there has been a mistake - whereas with over 1,000 deaths every year in the average hospital it is not always so clear. And while modern airplanes are undoubtedly highly complex, they are nowhere near as complex as the human body.
But the airline industry did change its culture. And so can we.
How? In my speech to the Kings Fund last year I talked of the 3 stages necessary.
The first step is intelligent transparency.
Intelligent transparency leads to action - and that means we need to understand the scale of the problem not just nationally but where we actually work.
So following a request to NHS hospitals by Dr Mike Durkin, NHS National Director of Patient Safety, the NHS in England will this month become the first country to publish estimates by every hospital trust of their own annual number of avoidable deaths. Methodologies vary, so the numbers can’t be compared, but it is a major step forward for every hospital trust to make their own estimate of avoidable mortality and be open about what they find.
What you can compare, however, is the quality of reporting culture. Just how easy is it for people on the frontline to speak about things that have gone wrong? Do hospitals listen to doctors raising genuine concerns or do they punish them as we saw happened to Dr Raj Mattu and other whistleblowers? So we yesterday published a table that grades the openness and honesty of reporting cultures in our hospitals. Chief Inspector of Hospitals Sir Mike Richards and NHS Safety Director Dr Mike Durkin have looked at a range of indicators including staff survey measures of how supported frontline staff feel if they raise safety concerns, whether staff feel able to contribute towards improvements at work, and how effectively a trust uses the national reporting and learning system. On the basis of these indicators every trust has been graded as having an outstanding or good reporting culture - or requiring improvement.
Once we have validated both sets of data, the CQC will include them in a new annual report on the state of hospital quality which will be published from this year.
The world’s largest learning organisation
Transparency is the first stage, but the second stage is to use intelligent transparency to turn the NHS into what I have long wanted it to be: the world’s largest learning organisation.
There is of course a huge amount of learning that goes on every day in our NHS. One study found that doctors take 158 clinical decisions every day and we should never diminish their efforts to extract every possible piece of learning from their daily work.
The government too, has played its part by introducing the new CQC inspection regime; legislating for the statutory duty of candour; making progress - not always smoothly - towards a 7-day NHS; we have asked every trust to appoint independent freedom to speak up guardians so clinicians can relay concerns to someone other than their line manager; we have launched the Sign up to Safety campaign and recently the campaign to halve the number of stillbirths and neonatal deaths.
But if we are really to tackle potentially avoidable deaths, we need culture change from the inside as well as exhortation from the outside. A true learning culture has to come from the heart.
And this means a fundamental rethink of our concept of accountability.
Time and time again when I responded on behalf of the government to tragedies at Mid Staffs, Morecambe Bay, Winterbourne View, Southern Health and other places I heard relatives who had suffered cry out in frustration that no one had been ‘held accountable.’
But to blame failures in care on doctors and nurses trying to do their best is to miss the point that bad mistakes can be made by good people. What is often overlooked is proper study of the environment and systems in which mistakes happen and to understand what went wrong and encouragement to spread any lessons learned. Accountability to future patients as well as to the person sitting in front of you.
The rush to blame may look decisive. It may seem like professionals are being held accountable. In fact, the opposite can happen. By pinning the blame on individuals, we sometimes duck the bigger challenge of identifying the problems that often lurk in complex systems and which are often the true cause of avoidable harm.
Organisational leadership is vital if we are to change this - and we can see world class organisations inside and outside healthcare have a very different approach. They have the boldness to probe more deeply, thus learning precious lessons. They see a medication error as an opportunity to make labelling clearer, a mistake in an operating theatre as a chance to improve teamwork and communication, just as airlines did after the crash of United 173.
Which is why we need a new mindset to permeate the entire ethos of the NHS, where blame is never the default option. Justice must never be denied if a professional is malevolent or grossly negligent. But the driving force must be the desire to improve care and reduce harm - fired by an insatiable curiosity to pursue improvement in every sphere of activity. This is what I mean by the world’s largest learning organisation.
And when we give patients an honest account of what happened alongside an apology, what is the impact? Countless academic studies have shown there is less litigation, less money spent on lawyers and more rapid closure, even when there have been the most terrible tragedies.
Some say that is all very well, but with hospitals in deficit what happens if you can’t afford to implement the lessons you learn about how to improve the standards of care?
Even after the significant rise in the NHS budget announced at the autumn statement, the resources to tackle these deep-rooted issues are finite. But as Sir Mike Richards and many others have pointed out, it is quite wrong to make out there is a choice between safe care or balanced budgets because the evidence shows that hospitals with better care usually have better balance sheets as well.
Of course there are times when safer care requires more resources, but unsafe care is even more expensive - in fact we know from the 2014 Frontier Economics report it costs the NHS up to £2.5 billion a year due to longer hospital stays, repeat visits and expensive litigation.
A compensation culture costs money - £1.4 billion of the NHS budget - but it also costs lives by creating a culture of defensive medicine which means avoidable harm remains stubbornly higher than it should be because we make it so hard for frontline clinicians to speak openly and honestly about how to learn from mistakes.
That means a profound change in culture.
The recommendations from Sir Robert Francis’s Freedom to Speak Up review have not yet taken effect and there are still too many stories of whistleblowers being bullied or hounded out of their jobs.
We must go further.
Just as the Carter process announced last month will harness the power of transparency to improve our use of resources, so today I want to harness that same power to bring down the rate of avoidable deaths by turning the NHS into a true learning organisation.
Following the commitment I made to Parliament at the time of the Morecambe Bay investigation, we will from 1 April set up our first ever independent Healthcare Safety Investigation Branch. Modelled on the Air Accident Investigation Branch that has been so successful in the airline industry, it will undertake timely, no-blame investigations.
Harvard Professor Dr. Lucian Leape has said that ‘the single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes’. So just as the Air Accident Investigation Branch gives a legal ‘safe space’ which protects those cooperating with its inquiries, we will bring forward measures to give similar legal protection to those who speak honestly to HSIB investigators so that the principle of a ‘safe space’ is at the heart of what the Healthcare Safety Investigation Branch does.
Affected patients or their families will need to be involved as part of the safe space protection. And while the findings of investigations will be made public, the details will not be disclosable without a court order or an overriding public interest, with courts being required to take note of the impact on safety of any disclosures they order. This legal change will help start a new era of openness in our response to tragic mistakes: families will get the truth faster; doctors will get support and protection to speak out; and the NHS as a whole will become much better at learning when things go wrong. What patients and families who suffer what they want more than anything is a guarantee that no-one else will have to re-live their agony. This new legal protection will help us promise them ‘never again’.
I have asked the new organisation to consider focusing initially on maternity and neonatal mortality investigations to give us time to examine and understand its effect before rolling it out to other areas of clinical activity. By doing this I hope it will make a major contribution to our new ambition to halve still births, neonatal injury and death and maternal death rates where we still rank unfavourably to many other high income countries.
But this work won’t just be limited to maternity. And as we create the legally safe space for learning that has long benefited the airline industry, we will in the words of NHS National Director of Patient Safety Dr Mike Durkin be taking ’the biggest single step in a generation to foster a positive learning culture that will support NHS hospitals to become safer for patients.’
I can also announce some other important steps to help foster a true learning culture.
The GMC and NMC guidance is now clear - where doctors, nurses or midwives admit what has gone wrong and apologise, the professional tribunal should give them credit for that, just as failing to do so is likely to incur a serious sanction. As in the airlines, doctors, nurses and other health professionals need to know that they will get credit for being open and honest and the government is committed to legal reform that would allow professional regulators more flexibility to resolve cases without stressful tribunals, where professionals have admitted their mistake.
NHS Improvement will ask for this to be reflected in all hospital disciplinary procedures and ask all trusts to publish a Charter for Openness and Transparency so staff can have clear expectations about how they will be treated if they witness clinical errors.
From April 2018, we will be introducing the system of medical examiners recommended in the Francis Report. This will bring a profound change in our ability to learn from unexpected or avoidable deaths, with every death either investigated by a coroner or scrutinised by a second independent doctor. Grieving relatives will be at the heart of the process and have a chance to flag any concerns about the quality of care and cause of death with an independent doctor.
NHS England is also working with the Royal College of Physicians to develop and roll-out across the NHS a standardised method for reviewing the records of patients who have died in hospital.
The objective of these changes is to make it unnecessary for anyone ever to feel they have to ‘blow the whistle’ on poor care. But as we make this transition, it is vital that we offer whistleblowers protection wherever they are in the NHS so if we discover that there are any gaps in the law protecting them, we will act to close them.
Distinguished guests, Karl Popper said true ignorance is not the absence of knowledge but the refusal to acquire it. So now is the time to use the power of intelligent transparency to make sure that we really do turn our healthcare systems into learning organisations - and offer our patients the the safe high quality they deserve.