Progress in creating the independent patient safety investigation function, by Dr Mike Durkin, Director of Patient Safety, NHS England.
An independent patient safety investigation function, in my view, is a rare opportunity to address some of the failings which we know exist in the NHS. It will help us to improve safety across the system and continue our efforts to create an NHS based on continuous learning and openness.
To achieve this it is clear we need to do things better. At both a national and local level investigations need to be of a consistent high standard and they need to be done swiftly, smartly, robustly, inclusively, objectively and transparently. At the moment that isn’t always the case.
What we’ve been doing
This summer, we established an expert advisory group (EAG) to advise on the scope and principles of what will become the new ‘independent patient safety investigation service’. The EAG has been meeting since the summer and I am personally very grateful for the time and energy its members have committed. The group is not doing this alone and is keen to collect and test the views of others. It will use these views to shape its thinking and, consequently, the new investigation function.
Earlier this month, members of the EAG and the team charged with supporting the development of the function attended the Patient First Conference in London. At the conference we listened to frontline staff such as nurses, doctors and quality managers, as well as patient leaders. It came across loud and clear that:
- we need to address the culture of blame and fear
- the process needs to be open and transparent to inspire trust
- we need to have patient involvement and good communications at every stage
We also heard that we should:
- prioritise things that affect the whole system
- provide help and support with best practice for staff
- share system-wide learning by operating without fear or favour
When a mistake is made there is sometimes the view taken that the hospital or practice within which we work needs protection. When that happens we have forgotten that it’s our patients to whom we owe the truth about what had happened.
You can see a snapshot of our findings from the conference in the visual minutes.
Last week, we also held our first workshop with patient representatives and family members of those personally affected by problems with NHS care. By listening and learning from the experiences of people with first-hand experience (in some cases where they had tragically lost a loved one) we have taken away vital insights that we will use to shape our proposals. I was personally struck by the honesty and bravery with which those who attended discussed what are hard things to share, and I am very grateful to all those that came for their time and efforts. One of the real take-home messages from me was the need for us to strike the balance between being compassionate and listening with care as well as making sure the investigation function has ‘teeth’.
Some of the other important things we heard were around:
- the need to keep patients and families up-to-date at every stage, making it clear what they could expect, and when
- the need for patients and their families to be clear on what the function will do and how it will work
- the need for thorough investigations and sharing of information
One of the questions raised with me since the event is about the Secretary of State’s announced intention to ask the new safety investigation function, once established, to consider a particular focus on maternity cases for its first year. Read more about this.
We are going to be continuing to listen and we are keen to encourage as many people as possible to complete our questionnaire. The results really will shape our thinking, so please do take the time if you can.
We will be analysing and sharing feedback in the coming weeks. We will work hard to continue feeding back what we have heard and keep the channels of communication open for further views and discussion. I know the EAG and everyone we have spoken to are keen to do the same.