This was published under the 2010 to 2015 Conservative and Liberal Democrat coalition government
Rt Hon Jeremy Hunt MP United Kingdom Secretary of State for Health Virginia Mason Hospital, Seattle
Let me start by saying what a huge pleasure it is to be here in Seattle, and how grateful I am to Gary Kaplan and Virginia Mason for hosting us today.
This hospital is one of those remarkable and special places that faced deep tragedy and yet somehow turned things round to achieve something extraordinary. Under Gary’s inspired leadership you are now rightly regarded as one of the safest hospitals in the world.
Which is why I wanted to come here to see it for myself.
The same transformation happened on much larger scale in a number of safety critical industries. Those names now familiar to us all – Bhopal, Chernobyl, Three Mile Island, Piper Alpha, Exxon Valdez – have become bywords in their industries as turning points which heralded a profound change in culture.
Yet strangely the healthcare sector itself has not collectively embraced that change.
Too often it has been a byword for an endeavour where avoidable safety failings end up being accepted as unavoidable. “These things happen” and “we did everything we could” seem to be acceptable responses, even though they would be intolerable in other contexts.
This makes your achievements here at Virginia Mason even more impressive.
Here the tragic death of Mrs Mary McClinton ten years ago – and its impact on her family, her doctors, the hospital and the wider community – became a turning point. Your resolve in choosing to learn and change as a response is an inspiration for healthcare professionals the world over. Just as in aviation or automobile manufacturing, when something goes wrong, you “stop the line”. And as a result much harm has been avoided and many lives saved.
We too, in the UK National Health Service, face our own turning point.
The appalling cruelty and neglect that happened between 2005 and 2009 at Mid Staffordshire hospital – and failings in care subsequently uncovered at other hospitals – have profoundly shocked our nation.
Just as Mrs McClinton’s death was a turning point for this one hospital, I want to make Mid Staffs a turning point for an entire health economy.
Not for one second do I underestimate the challenge of delivering change in 260 hospital Trusts employing 1.3 million staff across the system. But I believe we can do it.
As Professor Don Berwick - who wrote an outstanding report on improving safety in the NHS last year – said, in a unified system you have the ability to make systematic change on a national scale.
We also have something else: the extraordinary dedication of the NHS staff I meet every week, who have shown in the last year a profound commitment to learning the lessons of Mid Staffs and making our care world-class in its safety, effectiveness and compassion.
And we have good foundations to build on too, with impressive improvements already made in areas like cardiac surgery, hospital infections and the safe use of medicines.
What Price Safety?
“Fine words” say the sceptics, “but where’s the money? With all the pressures we face, it is simply not affordable to raise safety standards in way you ask”.
Nothing could be more wrong.
Wrong ethically, because it can never be right to condone a system in which patients suffer harm unnecessarily.
But wrong economically too.
Because our starting point must be to recognise that unsafe care ends up being more - not less - expensive, particularly if you look at the costs to the healthcare system as a whole.
Every year the NHS spends around £1.3 bn on litigation claims, money that could and should be spent on frontline staff. At a hospital level the figures are even more startling: in recent years North Cumbria paid £3.6m to just one individual. Bromley paid £7m to another. Tameside paid a staggering £44m in compensation over just four years.
System-wide, the financial impact is much greater than simply litigation awards. Whether in England, the US, Canada, France or Germany we know about one in ten patients experience harm when they are in hospital. For England one study found that this added three million bed days a year at a cost of £1 billion, with consequential costs adding a further billion pounds – and according to that same study around half of that harm is preventable.
The best hospitals deliver safe care on tight budgets not because the two contradict each other – but because gripping safety is an essential part of gripping budgets.
At Salford Royal, they estimate they have saved £5m per annum and 25,000 hospital bed days by the introduction of safer care. Here in Virginia Mason, I understand that you have saved as much as $15m through your improvements to patient safety.
More than a financial cost
Money matters, of course, but look at the impact on staff – and above all patients and their families.
There can be no greater breach of the trust between clinician and patient than when a patient is harmed unnecessarily. There may be a profit motive in no-fault manufacturing but there is a moral motive for zero-harm healthcare. And we should welcome that – because that is what healthcare is: the privilege of helping human beings at their most vulnerable, the noble purpose that motivates doctors and nurses the world over.
And the effect on frontline healthcare workers is profound if unsafe care is not checked.
Not only does it take up huge amounts of clinical time when mistakes have to be corrected and hospital stays prolonged. It has – as I have seen for myself - a devastating effect on staff morale and self-confidence. Avoidable harm does more than damage institutional reputations - it is a violation of the values and ideals that unite everyone in the provision of health.
Financially, reputationally and morally unsafe care carries a price – a price we cannot and should not pay.
Sign up to Safety Movement
So today, I sign up to safety.
I want today to mark the start of a new movement within the NHS in which each and every part of our remarkable healthcare system signs up to safety, heart and soul, board to ward.
Professor Berwick said the heart of safe care is a culture of learning.
So the engine room of this new movement will be a new national network housed in NHS England, a collaboration of all NHS organisations and local patients, who share, learn and improve ideas for reducing harm and saving lives.
The first 12 vanguard hospitals signed up to the movement this week. Within the next few months I will write to every NHS organisation in England, inviting them to join and sign up to safety. I hope over time that every hospital in England will rise to the challenge and join the campaign.
Every hospital Trust that chooses to join will commit to a new ambition: to reduce avoidable harm by a half, reduce the costs of harm by one half, and in doing so contribute to saving up to 6,000 lives nationally over the next three years.
I have asked NHS England, Monitor and the Trust Development Authority to work together to put in place support for hospitals to develop their plans to do this. They will provide advice to ensure that each plan takes full account of the international evidence as to what measures have the most impact. For those hospitals that sign up, The Chief Inspector of Hospitals will include progress against these plans as important evidence to inform the inspection and ratings regime. They will also be reviewed by the NHS Litigation Authority, which indemnifies trusts against law suits, and, when approved, they will reduce the premiums paid by all hospitals successfully implementing them.
Starting this year, the campaign will recruit 5,000 safety champions as local change agents and experts - safety ambassadors, safety agitators, safety evangelists - a grassroots safety insurgency across England which will seek out harm, confront it and help to fix it.
We will go beyond institutions to seek to sign as many staff in the NHS as we can to the safety campaign. Just as more than 500,000 people this month made individual pledges to improve care for patients on NHS Change Day, the movement will seek to harness that great well of values and expertise in the NHS to a common endeavour on safety.
Members of the campaign, which will be formally launched in June, will be supported by a new team, Safety Action For England, consisting of senior clinicians, managers and patients with a proven track record in tackling unsafe care - people frontline staff will respect, listen to and work with. They will ensure fast, flexible and intensive support when the line needs to be stopped and a lesson needs to be learned in England.
A whole system will be wired together so that where unsafe practice is detected at one end of the country, the lesson is learned at the other end as well.
An Open Culture
Critical to the success of this movement will be a culture of openness and transparency.
Again, though, “easy to say”.
Because being open when something is going wrong demands change. It challenges established practices to which people are attached. It shakes up the consensus that develops in some places that poor care is normal – the “normalisation of cruelty” as I have called it.
Openness acknowledges problems, studies them and fixes them. It doesn’t shrug. It “stops the line”.
So we must start by acknowledging that the NHS has not always done the right thing by people who speak out about poor care. Relatives like Julie Bailey and James Titcombe, campaigning after the loss of a loved one. Whistle-blowers like Helene Donnelly and Kay Sheldon. And politicians like Ann Clywd and Andrew Davies who have spoken out about poor care in Wales. Never should speaking out be confused with a lack of commitment to NHS values or “running down the NHS”. The highest form of commitment to our NHS is surely the courage to speak out against the system when the system gets it wrong.
So we have already taken a number of important steps to nurture an open and transparent culture.
First, I have implemented a series of measures to help staff speak up when they have concerns about poor care. I have banned “gagging clauses” in severance agreements when staff leave their employers, which prevent them from talking about harm to patients. There will be a new duty of candour in professional codes, making clear the need for all doctors and nurses to come clean quickly when things go wrong – and to encourage a blame-free culture, agreement that early candour should act as a clear mitigating factor in any investigation of misconduct.
I am also introducing a new statutory duty of candour on organisations, giving them a clear legal duty to tell patients when they have been harmed. Today I can announce the start of a consultation to include all significant harm - death, serious and moderate harm - in the new duty, as recommended by Professor Norman Williams, President of the Royal College of Surgeons and Sir David Dalton, Chief Executive of Salford Royal NHS Foundation Trust. This will help to make English NHS hospitals amongst the most open and transparent in the world and mark the start of a transformation in our safety culture.
Legislation, however, is not enough. We also need to equip staff with the skills and confidence to speak up. So today I am announcing two important additional measures. First, I have asked Health Education England to work with brave whistleblower Helene Donnelly to ensure that raising concerns about patient care and safety becomes part of mandatory training requirements for all NHS staff – her current role at Staffordshire and Stoke on Trent Partnership Trust, incidentally, is a model for what the new cohort of safety ambassadors should aspire to. And secondly, we will also ensure that the new Care Certificate we are introducing for healthcare assistants includes training on how to raise concerns about poor patient care.
Safety in Numbers
To support that drive for openness, we have overhauled our national regulator, the Care Quality Commission, to underline its independence and reinstate thorough and expert inspection of hospitals to ensure the quality of their care. The safety and culture of a hospital will be critical subjects of the scrutiny, as will complaints handling, incident reporting, falls, pressure sores, staffing levels and so forth.
The inspectors are also listening to staff and patients and the board to get a proper feel for a place - and make an expert judgment about whether its leaders really are alert to safety and keen to learn when things go wrong.
I suspect Virginia Mason would be assessed by our regulators as “outstanding”.
Whilst I suspect it, I think you know it - because you have the numbers to prove it. Once we have our culture in the right place, the next thing we reach for is the data. It allows us to manage improvement. It allows us to ring alarm bells. And it provides evidence to patients that they can place their trust in us when they are at their most vulnerable.
So for many organisations, the first step will be to collect safety data more reliably. And as that happens, the level of reported harm will increase. Not because avoidable harm is actually increasing – but because it is being properly reported for the first time. Indeed, halving avoidable harm may mean doubling reported harm.
I am pleased that Professor Sir Bruce Keogh is currently working with senior clinicians across the system to develop an indicator so that we can properly understand whether particular reporting levels indicate the right reporting culture in an organisation.
And from June a dedicated section of the NHS Choices website - “How Safe is my Hospital” - will allow the public to compare hospitals in England on a range of safety indicators. For safe staffing, from this June it will be at ward level, every month, allowing the public to check the wards used by their own loved-ones.
They will also be able to check incident reporting levels, MRSA and C difficile rates, pressure ulcers, falls, and compliance with patient safety alerts. Here, the power of peer pressure should spur hospitals to ever higher standards of safety and patient care.
But I intend to go further still. We need to ensure that unsafe care has nowhere to hide.
We need a much more reliable measure of actual harm that allows proper comparisons. So NHS England are developing a new system based on external reviews of the case notes of where people have died or experienced harm. Together with new independent Medical Examiners, this will give us, for the first time, a more reliable national average of avoidable hospital deaths and a more effective “smoke alarm”, triggering closer scrutiny of the outliers.
Let me finish on an optimistic note. Because progress on safety has not gone unnoticed.
In our latest annual survey of public opinion on the NHS, public confidence dipped a little: unsurprising in the wake of the Mid Staffs scandal. But 77% of the public agreed with the statement: “if I was ill I would feel safe in an NHS hospital”, the highest level ever recorded. And 73% agreed that people are treated with dignity and respect in the NHS, again the highest ever.
We still have further to go, but this is real progress and a sign of what can be achieved if we really focus our efforts.
Today, 12 hospitals in England have ‘Signed up to Safety’. They are the pioneers. Throughout this year, the movement will be signing up more champions, more hospitals and more staff.
So let us make today the moment we stopped the line on wasteful and unsafe care in the NHS and reaffirmed our conviction in everything it stands for. Let today mark the moment when we resolved the NHS should not only be the fairest healthcare system in the world, but also the safest.