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The Francis report - reflections from abroad

Morten Pytte
Morten Pytte
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Patient safety is a global concern as healthcare organisations still struggle to deliver safe care. Similar to the UK, a significant number of patients in Norway, where I work, are harmed while receiving care.

Unlike the UK, the awareness of patient safety as a concern is relatively new in Norway where the government initiated campaign to improve patient safety only launched in 2011. Unfortunately there is no silver bullet to safe care.

Public inquiries provide us with valuable information and recommendations and may make a difference if acted upon, while other safety critical industries may suggest the path to improved safety. However, Norway has no tradition of public inquiries regarding healthcare, thus it was with great interest that I read the Francis report on the Mid Staffordshire NHS Foundation Trust inquiry published last week.

The report reminds us that healthcare still has a long way to go to deliver safe and high quality care, listing horrifying cases of patient experiences that you would not expect to find in our societies. Although the patient cases are specific to Mid Staffordshire, and may or may not happen in other places, the lessons to be learned and the recommendations made by the report will apply to healthcare organisations across the nation as well as abroad. Unfortunately the report did not make many headlines outside the UK.

The Francis report is thorough and provides an extensive amount of evidence followed by a list of as many as 290 specific recommendations. The executive summary alone is 115 pages. To me the main message is that major changes in culture and attitude among policy makers, healthcare managers and professionals need to happen in order to place the patient’s needs in the centre of all activities. After all, they are the service users.

Twelve years have passed since the report on the Bristol Royal Infirmary Inquiry was published. The report included 200 recommendations with the aim of ‘producing an NHS in which patients’ needs are at the centre, and in which systems are in place to ensure safe care and to maintain and improve the quality of care’. This and other inquiries have been well received with a favourable reception of the recommendations. However, the progress of implementing the recommendations may in some cases have been slow or non-existent, as pointed out by the Francis report.

Will the Francis report be another missed opportunity to improve safety and quality of care?

Policy makers, hospital managers and healthcare professionals in England and beyond have a golden opportunity to embrace the Francis report to identify opportunities for improvement. I am happy to see that the report acknowledges the challenge of implementing the recommendations, but the opportunity to engage all employees may be missed in the ‘top down’ approach. Staff involvement will be vital to achieving the goal of patient centred, safe care.

How have other safety critical industries used public inquiries to improve safety? In 1988 the Piper Alpha oil rig in the British sector of the North Sea exploded, killing 167 platform workers. The accident triggered a public inquiry that led to a step change in how safety is handled offshore; moving from pure prescriptive regulation (‘top down’) to a combination of prescriptive and performance based safety regulations (combined ‘top down’ and ‘bottom up’).

In a performance based approach, the organisation is responsible for demonstrating that it is operating safely. This approach includes the mapping of processes, involving stakeholders throughout the organisation to proactively identify and take ownership of risk, and to establish and maintain barriers to mitigate risk. In this approach to safety, healthcare professionals and managers get a common understanding of the major risks to patient.

In healthcare we need to realise that safety does not just happen or follow from professional expertise. Neither can safety be implemented with top down pronouncements. Safety has to evolve from within the organisation – bottom up and top down. The performance based approach to safety may be one way forward to ensure that the Francis report does not become another missed opportunity to improve patient safety and quality of care.

Morten Pytte is an anaesthetist by training and the Programme Director of the Healthcare Programme in DNV Research & Innovation located in Norway, www.twitter.com/MortenPytte





 
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Comments
To encourage safety to evolve within an organisation, a culture needs to develop.
Question: Who is going to co-ordinate this?
William B.Rouse, in his paper "Healthcare as a Complex Adaptive System: Implications for Design and Management,offers the thought that:

"Management of complex adaptive systems requires leadership, rather than power,incentives and inhibitors rather than command and control."

I would wholeheartedly endorse this. A leader has values and integrity, which the followers try to emulate. By having a leaderless system, we are virtually rudderless. We have no power to influence what happens next.

He goes on to suggest:
"We need to analyze and design the systemic nature of healthcare delivery and not continue to let it evolve and see whether one idea works or not."

I suggest we need people who are brave and daring. People like the Anaesthetist I knew, who stated simply:
"I am not prepared to see any more patients die from avoidable causes." Around this simple statement, she gathered followers. And with the followers, she developed a model.

This simple mantra became a way of training others, which is not too difficult or complex to understand. It's a bit like the Glasgow Coma Scale: everyone was able to do it, but the level of intervention depended on the level of capability.

It took courage, resilience and determination to fight within the system against the numerous faults that could be identified. But unless we find enough people to raise the standard, and create followers,we are whistling in the wind.

Do you know how to provide information to the Francis investigation?
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