After my first wife died during a routine operation in 2005 I had many things to contend with. But in common with most people who’ve lost someone at a young age, I wanted to try and understand what had happened. Yes, I had the independent report and the Inquest, but I wanted to find out more about healthcare, especially culture, training, human factors and patient safety.
Over time I grew a list of people in healthcare who were passionate about these areas, yet despite a growing interest in patient safety, human factors were seemingly something of minor academic interest. But there were clinicians who got it, who were passionate because they really understood it, often through witnessing disasters around them (and occasionally involving them). And there was some amazing research that had been gathered, often at the cutting edge of medical practice.
These people didn’t have much of a voice because organisational boundaries, and more often a simple lack of access, meant there was little awareness of each other. Aviation had been there as well. So in 2007 I approached the Department of Health and said: ‘I’m going to pull together all these people into a room to look at what each other is doing. I wondered if you’d help out by giving us a room?’
When we first met there was much discussion about teamwork problems leading to safety issues – a narrow focus made worse by my own perspective. Slowly, over the coming years we got some money, started to gather the research and articles and put them together on a website, and had some very constructive discussions about the breadth of human factors. Naturally I’d associated human factors as being part of patient safety, but I’ve come to realise that what understanding human factors really does is improve reliability and efficiency – safety is a by-product. The NHS really needs reliability and efficiency. And the clinicians and patients want safety as well.
In 2010 we recognised that we had to start working with people at the top. Professor Sir Bruce Keogh, Medical Director (now of the newly formed NHS Commissioning Board) seemed a willing audience. He’d witnessed a growing awareness in heart surgery of the dangers of ‘acceptance of a degree of harm’ as being normal, and wanted to change things. After a couple of meetings he agreed to form the Department of Health Human Factors Reference Group to look at how we embed human factors in the NHS. We were asked to report back in March 2012.
Actually, we did more than that. As we looked into certain issues it started to help influence policy making, both within the planned Commissioning Board, but also with bodies such as the GMC and NMC. The Reference Group reported back in March as planned, but immediately Sir Bruce asked us to make the final report an interim one, as it was clear we’d laid some good foundations which could be successfully followed up.
So what’s happened since? Ummm…
In broad terms the report has been recognised for what it’s achieved and its recommendations. And as the year slips into autumn Sir Stephen Moss, Chair of the Reference Group, will present to the National Quality Board. But Sir Stephen and I, as well as others, have a couple of concerns.
Firstly, I’m particularly cautious of that old question often asked at the top of the NHS: ‘What’s the one thing we could do that would make the difference or gives us the biggest bang for our bucks?’ I hate that question because, to my mind, it misses the point. Culture change isn’t about doing one thing – it’s about doing lots of little things consistently and with purpose (whilst maintaining coordination).
Secondly, we’re concerned that we’ll be seen as talking about a minority interest. The National Quality Board will say ‘nice presentation, now let’s get on with the real business of improving efficiency and saving money’. But of course, this is about the real business.
It’s about the real business of running a national health service where patients leave better than they started (where possible) and the healthcare provided delivers reliable outcomes for all (which currently often seems pot luck, despite some amazing people). That’s why we’ve emphasised the excellent people involved in the Reference Group; we had tremendous support from the major people and organisations. Human factors is no longer just about a few enthusiasts. The science is recognised and mainstream.
For the NHS there is a spectre lurking on the horizon: Mid Staffs and the Francis Inquiry, which we now expect to report back late October. I’ve no doubt that Robert Francis has slowly come to recognise that what Mid Staffs delivered to its patients was exactly what the national system was designed to do, the ‘law of unintended consequences’ came together in an appalling way.
While we wait on the outcome of our meeting with the National Quality Board, I shall leave you to download and review our report. It identifies how we’ve started to build the foundations of a national strategy on human factors in healthcare, as well as a range of recommendations to build the detail of that strategy. This requires coordination, science from human factors specialists and an ability to remain on the edge of the system, not afraid to challenge.
One of the people involved with the Reference Group is Professor Rhona Flin from the University of Aberdeen. She’s done some amazing work alongside her colleagues on human factors in safety critical industries. She mentioned recently that she’s been very busy because, following the disaster in the Gulf of Mexico in which culture and human factors had a central role, the oil industry is approaching this area with renewed vigour. Maybe in a few months the NHS will be knocking on Rhona’s door as well?
Martin is a pilot and the founder and current Chair of the Clinical Human Factors Group.