System safety and the Francis Inquiry

A few weeks ago every Boeing 787 ‘Dreamliner’ around the world was grounded on safety concerns. As the NHS gears up for the imminent release of the Francis Inquiry report, the Dreamliner holds important hidden lessons for how the NHS needs to identify and learn from safety issues that span the healthcare system.

It started with a fire. Cleaners smelt smoke and mechanics saw flames: a state-of-the-art lithium ion battery was burning under the aircraft’s floor. Fortunately the plane was already on the tarmac. The fire was extinguished and a major investigation began. A few days later a second Dreamliner made an emergency landing after detecting odd battery readings and an unusual smell. Soon after, the global fleet was grounded.

While this crisis unfolds for Boeing, the NHS faces its own moment of reckoning. On Wednesday the Francis report will finally be published after two and a half years examining the regulatory, supervisory and commissioning systems that contributed to appalling failures of care at Stafford Hospital.

The Francis report is widely expected to identify failures across the entire healthcare system, spanning all the way from policymakers, commissioners and regulators to those on the organisational front lines. The recommendations are expected to be equally broad ranging.

The contrasts between the response to the Dreamliner and the response to Mid Staffordshire are striking and deeply instructive. They provide clear lessons that could dramatically improve how the NHS addresses risks that span the entire healthcare system. In particular, they provide a near-perfect demonstration of the ‘orange wire test’ posed by Sir Liam Donaldson (the WHO Envoy for Patient Safety) in an article for the Lancet, which examined how healthcare could respond to widespread safety issues as effectively as the aviation industry.

The most obvious contrasts here are the most superficial. The speed and scale of the aviation industry’s response to the Dreamliner was impressive, for sure. And the seemingly trivial outcomes of the trigger events may be surprising to many outside aviation. There were no deaths. No one was harmed. I believe that healthcare will, one day, achieve rapid and precautionary responses like this too.

But for the moment there are deeper and more fundamental lessons to be learnt. These focus on the basic mechanisms that healthcare relies on to drive safety improvement. They point to a considerable gap in the healthcare system's ability to identify and address system-wide risks.

The grounding of the Dreamliner is unusual but the activities that surround it are not. Every aviation accident and serious incident is investigated by an independent air safety investigator. These investigations routinely examine the entire aviation system – from regulatory activity to organisational culture, and from equipment manufacturers to service providers.

These investigations have three purposes: to understand the causes of failure, to recommend ways that the system should be improved, and to hold all relevant organisations publicly accountable for making those improvements.

As we approach the conclusion of the Francis Inquiry, these institutional structures that drive aviation safety improvement are particularly instructive for healthcare.

Like the Francis Inquiry, national air safety investigators are entirely independent and stand apart from the system they investigate. But unlike the Francis Inquiry, they are permanent and normal features of that system. Their routine, system-wide investigations have contributed to dramatic improvements in air safety. Last year there were nearly 40 million commercial airline flights and only 21 fatal accidents.

Critically, these safety investigators are not regulators. They therefore have no stake in current regulatory agendas or activities. Neither are they tainted by financial, policy or operational decisions. They simply investigate causes, identify lessons, recommend improvements, and hold others to public account. They do this impartially, regularly, rapidly and without seeking to assign blame.

So comparing the responses to the Dreamliner and to Mid Staffordshire reveals a simple but startling and – for me – deeply troubling insight. The NHS has no way of routinely investigating and learning from system-wide failures. When it comes to systemic risks that span the entire healthcare system, the NHS is flying blind.

This doesn’t mean that the NHS fails to investigate safety and quality issues. On the contrary, thousands of important investigations are conducted each year by healthcare providers, commissioners, regulators and professional bodies.

But the current mechanisms for investigating and improving safety across the system are limited. None have a mandate to examine all aspects of the healthcare system as an integrated whole. And many of them are coordinated by organisations that may themselves be the unwitting source of systemic risks in supervision, regulation, commissioning and the like.

Because of this, the NHS has had to rely on rare, one-off, lengthy and highly charged public inquiries to belatedly learn the lessons of systemic failures like Mid Staffordshire, or Bristol before that.

The Francis report will no doubt be a powerful source of insight and a trigger for system-wide improvements, demonstrating the unique power and value of public inquiries. But it will also throw the gaps in healthcare’s safety oversight and improvement systems into sharp relief.

It is over a hundred years since the first independent air safety investigation was conducted in the UK. It is now time to establish a permanent and truly independent safety and quality investigator in healthcare to do the same.

Carl is a Health Foundation Improvement Science Fellow at Imperial College London, www.twitter.com/CarlMacrae