How can healthcare get it so right and so wrong? Part 2

In my blog last week, I talked about the example of Kettering Hospital, who identified 43 ‘care delivery problems’ of which 6 had a direct impact on the death of a patient. Well done to Kettering for conducting an SUI and identifying multiple issues, but then they’ve refused to make the report anonymously available to the public. And I want to know: what do our leaders think of that?

Like it or not, the whole system of healthcare delivery in the UK depends on leaders to inspire a better way of doing business. People talk about inspirational leadership being ‘distributed’ across the NHS, often at local levels, but surely a leader must be in a position to view the whole picture? At the top of the NHS (and I include royal colleges and other professional bodies), there has been a loss of credible leadership – in fact it’s been decimated. Those with credibility are lone voices in a sea of mediocrity, too many other leaders are ‘moving deckchairs on the Titanic’.

A colleague observed that healthcare is very conditioned to ‘look up’ (the reforms haven't changed that) and that most management, professional behaviour and language remain firmly hierarchical.

Leadership is therefore critical. In the age of modern automated cockpits, it was once said that the most commonly heard phrase from pilots was ‘what’s it doing now?’ Perhaps in the NHS the most common phrase from frontline staff is ‘what are the leaders doing now?’

Provider trusts who have remained relatively stable are crying out for leadership at the top – leadership which adds value to their local effort, alignment of national policy, help to focus on what matters, reinforcement of the key messages about the safety culture, resilience, learning etc. Not targets or dictats, but simply leadership.

Without it the system is not a system.

The hard concrete or glue that this system needs to build on is knowledge and science – patient safety, human factors, improvement, measurement etc. Without this to stick the system together it’s just random interventions reinvented. And the leaders need experts in these fields to support them. It goes without saying that the centre of the NHS remains probably the only safety critical organisation in the world that doesn't employ any human factors experts.

When a large group of people were invited recently to a meeting set up by the patient safety leads at NHS England – to discuss setting up the new patient safety collaboratives – I know a number attended with a real sense of energy and excitement about building on the past with the prospect of working in a context of serious and public senior leadership commitment (which perhaps had previously been lacking). However, many of those same people left frustrated and disillusioned that the NHS was doing what it does so well: always starting from scratch rather than deeply learning from the past and from other analogous industries. 

Lately the NHS has been trying to ‘deeply learn’ from US healthcare. It’s often based past work on research from the Institute for Healthcare Improvement (IHI) but, for all its value, in my view the IHI has been overly focussed on individual interventions. This, whilst saving lives, still doesn’t help change the culture in UK healthcare which is perhaps more centrally influenced than other healthcare systems.

So what can we look forward to? My concern is that it will probably be a rehash of random interventions and bundles, very laudable but hardly embracing a commitment (as stated by the National Quality Board's Concordat) to build on human factors to help create a resilient way of delivering care in the coming years. The Concordat already offers a framework of actions, but it now needs an operational plan of who will do what by when.

It’s a shame that provider trusts have to make improvements in safety and quality without inspiration from the centre. But then again, there are some amazing things going on at the frontline. A few weeks ago I spent a morning with over 100 frontline staff at a hospital in the Midlands. A morning where they took the lead, describing what they were doing to do to improve performance and reduce harm through understanding incidents, never events and human factors. A morning where the stars of the show weren't managers or people from outside businesses, but clinicians who we're looking at how they could do their jobs better, easier, safer and much more successfully.

A senior person in the NHS said this to me: ‘Human factors IS the solution. The problem is not disease-specific or harm-specific, it is in the way we work together, the way the team behaves, the way we communicate, the way we share information and handover, the way we observe, detect and respond. Everyone understanding and using the principles and knowledge that human factors brings is the solution – the solution is not to focus on pressure ulcers. By focusing on human factors the pressure ulcer problem is addressed, so is every other unsafe practice or care. For some reason it is seen as too simple as to be the solution!’

The NHS has the potential to use the system to bring about such improvement on a greater scale, something that’s very hard in places like the US. Sadly, it’s not doing that.

Martin is a pilot and the founder and current Chair of the Clinical Human Factors Group, www.twitter.com/MartinBromiley