The silent scandal of patient safety

If we are to improve the silent scandal of patient safety across the NHS we need a new culture of openness, transparency and accountability.

This was published under the 2010 to 2015 Conservative and Liberal Democrat coalition government

The Rt Hon Jeremy Hunt MP

Florence Nightingale said, “The very first requirement in a hospital is that it should do the sick no harm.”

The many dedicated doctors and nurses I have met as Health Secretary would all agree.

Thanks to their commitment, the Commonwealth Fund consistently rates safety in the NHS ahead of France, Germany, Sweden, Norway and the US.

But is it as good as it should be? Julie Bailey, James Titcombe and other brave campaigners who have lost their loved ones know the answer to that question is unequivocally “No.”

In the wake of Mid Staffs, Morecambe Bay and many other shocking lapses in care, we must ask ourselves whether we, along with other countries, have become so numbed to the inevitability of patient harm that we accept the unacceptable.

That grim fatalism about the statistics has blunted the anger that we should feel about every single individual we let down, anger that should be the fuel of an uncompromising determination to put things right.

It is time for a major rethink.

Never events that are not “never”

The NHS sees getting on for 3 million people every week.

On the basis of the statistics we have (about which more later), around 0.4% of those ended up with incidents of harm. 0.003% ended with a person’s death.

This is a tiny proportion of the total number of people treated. But even those figures amount to nearly half a million people harmed unnecessarily every year. And 3,000 people who lost their lives last year - not despite our best efforts, but because of failures in our efforts. That’s more than 8 patients dying needlessly every single day in our wards and operating theatres.

Like the woman who tragically died because her notes were mixed up with someone else, so she ended up with 8 different doctors prescribing 25 different drugs - including many for a condition she didn’t have.

Or the woman who died shortly after being prescribed penicillin by a GP, even though the GP had been told she was allergic to it.

Or the 95 year old lady who starved to death because her drip was not fitted properly and over an entire week - the last week of her life - nobody checked to see if it was working.

All stories I have received in the last couple of months in my postbag.

I will never forget the first time I met Professor Norman Williams, President of the Royal College of Surgeons. I was a rather green Health Secretary with no medical background. At that meeting, he told me about something I had never heard of before – the concept of “never events,” events so totally unacceptable and patently avoidable that they should simply never happen.

So I looked up the figures.

In 2011/12, there were 326 never events - although international studies suggest there is likely to be significant under-reporting. But the ones we know about include 161 people with foreign objects left in their bodies, like swabs or surgical instruments; 70 people suffering wrong site surgery, where the wrong part of the body or even the wrong patient was operated on; and 41 people given incorrect implants or prostheses.

Put another way - every other day we leave a foreign object in someone’s body, every week we operate on the wrong part of someone’s body, and every fortnight we insert the wrong implant.

This is the silent scandal of our NHS.

As James Titcombe, who lost his 9 day old son Joshua at Furness General Hospital, said this week: “We need it to change. We need that culture to change. Patient safety should be the number one priority, and organisations that work within regulation need to be aligned with that principle.”

A new culture

So let me start today by paying tribute to the many NHS leaders who for many years have been fighting hard to turn the tide.

People like Sir Liam Donaldson, who started the debate on patient safety long before it was on other people’s radars. We have made huge strides thanks to him and continue to build on his legacy.

Or Professor Sir Bruce Keogh and Professor Ben Bridgewater, who pioneered the publication of heart surgery survival rates - which have seen a dramatic reduction on mortality levels so they are now some of the lowest in Europe.

Or David Dalton, Chief Executive of Salford Royal, whose commitment has made his hospital one of the safest in the country, reducing cardiac arrests by 59% since 2008.

And Professor Norman Williams, who I mentioned earlier, who has taken a principled stand on the publishing of surgical survival data despite the understandable nervousness of many of his members.

Their commitment, and those of many others, is inspiring. But it is time to make that commitment the norm and not the exception in our NHS.

Which means a different culture and different leadership: where senior consultants and managers in our hospitals always give unremitting and uncompromising support to frontline staff to help them resolve safety concerns.

Where the system never trumps the individual and where volume never trumps quality.

A culture of openness

So how do we achieve this? Today I want to propose five areas where we need to make progress.

Firstly, we need to foster an open and transparent culture where problems are always aired and never swept under the carpet.

It is important to recognise that even the best motivated people do make mistakes. Indeed, we need to nurture innovation and risk taking if we are going to continue to be proud that some of our doctors and hospitals are the very best in the world.

That means being up-front that whilst we aspire to zero harm, we will never deliver zero harm - just as the airline industry can never deliver zero crashes.

But there is a difference between controlled risk, taken with the consent of patients, and avoidable lapses in clinical procedures or care. So we need to foster a culture where appropriate ambition is encouraged - but where avoidable errors and injuries from care are constantly revealed and reduced.

Part of this is about the right leadership from their employers, who must set an example when it comes to creating a culture of openness.

So as part of our response to Francis, we are introducing a new Duty of Candour on all providers to be open and transparent with patients when things go wrong. Indeed, it will be a criminal offence for any provider to provide false or misleading data.

But part of it is about leadership by clinicians too. I welcome the high bar set by the Royal College of Anaesthetists this week in their new accreditation programme. I also strongly support the stance taken by the Royal College of Surgeons on the publication of surgical outcomes data as we start to publish them more comprehensively than anywhere in the world over the next few months.

The effect on publishing overall success rates has been dramatic for heart surgery, and I know the overwhelming majority of surgeons support it for their discipline.

Of course it takes time to get the risk adjustment right, alongside proper analysis of the data to reflect the role of both individuals and multi-disciplinary teams. But when we know the data is robust it is only right that the public should know if a surgeon chooses to withhold his or her performance data - and people can draw their own conclusions.

Our best weapon: NHS frontline staff

The second area we need to focus on involves harnessing our very best weapon: frontline NHS staff.

Professor Don Berwick, one of the world’s foremost experts on patient safety, is currently advising us on how to create the right safety culture in the NHS. I don’t want to pre-empt what he and his committee say. But one of Don’s great insights is that in order to succeed, we need to harness the passion, dedication and commitment to safety that already exists in those who work in the NHS.

Patient safety must never be treated as an alien concept that has to be imposed on our doctors and nurses – rather, we must ask ourselves whether we have created structures and processes that make it hard for them to do what their instincts and commitment to patients tell them. Our system - and its leaders - must encourage rather than discourage them from doing the right thing.

That means a big focus by Boards on staff engagement around safety issues. It means teamwork, breaking down hierarchies and the substantive use of the NHS staff survey to track whether the right attitudes to safety are being nurtured in a hospital culture. It means everyone from chair to cleaner focused on where improvements can be made.

Because the evidence is overwhelming – staff who are better engaged are better motivated to go on to provide better care to their patients. So harnessing their natural desire to do the best for their patients - and why else do you join the NHS? - is the only way we will truly transform the culture.

Strengthening accountability in the doctor/patient relationship

The third area where we need to make progress involves strengthening the doctor/patient relationship.

Last month, I gave a speech about how there should be an accountable clinician – preferably a GP – responsible for every frail, elderly patient outside of hospital. I said it concerned me that whilst there was a consultant responsible for them inside hospitals, it was not always clear who was responsible for them when they are discharged.

The concept of an accountable clinician is well-understood in most hospitals. But with the advent of multi-disciplinary teams, valuable though they are, we must not allow it to become blurred. However superb the team, the buck always needs to stop with someone. And the patient has every right to know who that person is.

I believe we should return to having the name of the responsible consultant and responsible nurse written above every patient’s bed. This happens in a number of Trusts already and I am delighted that UCLH and Kings in London have agreed to introduce it.

But it does not happen everywhere.

So I’m delighted that Professor Terence Stephenson, President of the Academy of Royal Colleges, as well as a UCLH consultant, has agreed to lead a seminar with the professions, regulators and employers to discuss how best this can be taken forward in the NHS.

System incentives

Next we need to ensure that our commissioning, regulatory and inspection systems give adequate weight to patient safety issues.

From later this year, the new Chief Inspector of Hospitals, Professor Sir Mike Richards, will start a process of deep dive inspections that will give an expert peer-review insight into all aspects of how each of our NHS Trusts operate, with patient safety being one of the five core domains he will consider.

This week, the CQC published a draft framework for the new inspections. I am pleased it has a strong emphasis on safety. Put simply, it will not be possible for a hospital to be assessed as ‘outstanding’ if it doesn’t go the extra mile on safety.

But I want to go further. So I have asked Sir Mike to publish a six- monthly statement on the state of patient safety in the NHS. As a culture of transparency takes hold, the reported number of safety breaches is likely to increase rather than decrease. Sir Mike’s report will give us a vital independent perspective as to whether the actual likelihood of a harm-free experience is increasing or declining. We also need to ensure the same focus is maintained in the way services are commissioned. I am pleased that safety is central to the NHS Mandate, and indeed with the progress that has been made in reducing MRSA and CDiff infections.

But I am today asking NHS England what can be done through the commissioning process to improve the transparency of reporting - particularly of never events. I will ask them to build on the important progress made with the Safety Thermometer, which measures the prevalence of harm-free care. And I will discuss with them what more can be done to further reduce the incidence of safety breaches through the contracts signed by CCGs.

In the end, the success of this programme will depend on the right incentives and consequences both for hospitals and inside hospitals - and NHS England will have a critical role in making this happen.

Understanding measurement: the goal of harm-free patient care

The final area where we need to make progress is a better understanding of how proper measurement works – not only things that do happen that harm patient safety, but also the things that don’t – the often harder-to-measure errors of omission.

Every Board member and every ward manager needs to be able to answer the question – “how safe is my hospital or how safe is my ward?”

Ultimately what matters most to patients is not the reported number of incidents, or whether that reported number is going up or down, but the actual likelihood of a harm-free experience where you do not get an infection, a pressure ulcer, have a fall or a VTE. That is a figure that is unlikely to be uniform across a hospital, so accurately tracking safety across different wards and specialties is essential. I want our NHS to be the first healthcare system in the world to publish the relative likelihood of a harm-free patient experience across every hospital in the country. And in doing so we will be embracing a transparency revolution more ambitious than anywhere else in the world.

All of which will be underpinned by other changes made possible by technology. By 2018 or possibly sooner, all medical records will be electronic and, with consent, sharable across the whole health and care system. Notes will be available when and where they are needed. Prescriptions will be automatically cross-checked against a patient’s other medication to flag up conflicts. And clinical audit will be made possible on a scale and pace never seen before.

Reasons for optimism

Talking about safety breaches is always difficult. But I want to finish on a note of optimism. There is huge pressure in the NHS right now. On broadly the same budget, we are doing 400,000 more operations than at the time of the last election. So it would be easy to argue that with increased throughput more mistakes are inevitable.

But when you look at the evidence, the reverse is true. MRSA infections, for example, have halved over the last three years across the system.

And in individual Trusts, there have been some even more spectacular successes.

Like at the Royal United Hospital Bath where, through a structured programme of safety improvement, they have halved adverse events in the last two years.

Or in the South West, where a concerted regional effort has seen Hospital Standardised Mortality Rates fall by 20% over the last three and a half years.

Or at Salford Royal, where their focus on patient safety since 2008 has seen MRSA down 96% and C-diff down 90%, with a 46% reduction in Grade 2 pressure ulcers in the last year alone.

Yes, still, the NHS fails too many times. But it also holds the keys to becoming the world’s safest health system - not just by today’s standards but by the standards we all aspire to.

Through a culture of openness and candour which sees more data published than any other health economy in the world.

Through an inspection regime that will drive hospitals to put the patient first and foremost in everything they do, with a responsible consultant and a senior nurse accountable for every single patient.

Through better measurement and reporting of the extent of harm free care in our hospitals. But most of all, through by creating a new culture which engages and listens better to frontline staff so they help us to design systems that prioritise safety whatever the pressures.

The lesson of recent tragedies is that the NHS must never again be silent about patient safety - because it matters too much.

It matters to each one of the million people who have given their professional lives to the NHS.

And it matters to each one of the millions of patients they care for every year.

A change of this magnitude will not be instant, nor will it be easy.

But it is possible. And our NHS should aspire to nothing less.

Published 21 June 2013