184 and counting…

Achieving cultural change will take more than a list of initiatives.

In his statement to parliament on Wednesday (9 March), the Secretary of State for Health remarked that there are two important ingredients for culture change in the NHS: “openness and transparency about where problems exist, and a true learning culture to put them right.”

To meet the first part of this ambition, the Secretary of State announced a number of new measures, including:

• A ‘learning from mistakes league’ to rank organisations according to their reporting culture
• Trusts to publish estimates of their own avoidable mortality rates.

There is plenty to say about these two measures, but that can be left for another time. A broader observation is that the government is clearly banking on data transparency as the primary driver for improving safety.

Making information public feels intrinsically like the right thing to do. However, there has been no articulation from the government of exactly how this will help to achieve the desired result. As we stated in a previous briefing:

“…is it [public reporting of data] intended to drive public choice of care providers? Or to develop a competitive spirit between professionals? Or to embarrass staff into action? Or a combination of all three? Without a clear theory as to how data reporting will foster improvement, there is a risk that it will become an end in itself.”

Will those organisations at the bottom of the ‘learning from mistakes league’ respond in a way that defies their current standing, simply because the table was published? After all, the data used to formulate the table has long been in the public domain through the NHS Staff Survey and the National Reporting and Learning System.

Listening to René Amalberti speak at the Patient Safety Global Action Summit this week, we’ve learnt that industries like nuclear power and aviation haven’t achieved culture change by introducing discreet policy initiatives; instead, they have been a consequence of more systemic change and as part of a long-term approach.

We suggested some ideas for a long-term approach for safety improvement in our learning report in November. We are already putting some of these into practice through our funded work – whether that is using the patient as the weather-vein for safe care, developing a health economy-wide picture of safety, or developing a compendium of safety interventions appropriate to different situations.

Putting things right

Further measures announced this week are seeking to meet the second part of the Secretary of State’s ambition (to create “a true learning culture”).

• A legal ‘safe space’ for staff cooperating with the new Healthcare Safety Investigation Branch’s (HSIB) investigations into serious adverse events
• A new independent medical examiner process (likely to be a doctor in another part of the same trust) to review all deaths in hospital
• Trusts to each publish an openness and transparency charter to set out how staff will be treated following an adverse event.

The HSIB and independent medical examiner are two measures that have been a long time coming (since the Shipman Inquiry in the case of the latter). The senior leaders of trusts will have to make sense of these requirements, explain them to staff and patients, and dedicate resource to support their implementation.

It takes an organisation with confidence to assess how each such measure fits within their own strategy for quality and safety. As one trust told us in our 2015 report, Building the foundations for improvement:

‘There’s any number of things which ping into your inbox, but [there] is that real focused intent on the journey so that you don’t get distracted by the latest thing that might be in vogue.’

Research and analysis by Professor Sheila Leatherman and colleagues at the Health Foundation, due to be published next month, suggests that between June 2011 (when the parliamentary progress of the Health and Social Care Bill was paused) and December 2015, the government initiated 179 policy interventions intended to improve quality, nearly two thirds of which were focused on patient safety.

While it is heartening to see such concerted effort to improve quality and safety, they continue to be launched in reaction to events rather than as part of a long-term plan. There is a real risk that uncoordinated tactics – in the absence of a clear strategy – means even laudable initiatives may not have the effect intended, or could even tip an already fragile service over the edge.

Going on this week’s announcements, we’d better update the number of policy interventions to 184. And counting.