After Francis: safety, safety culture and next steps

18 September 2013

John Illingworth

The House of Commons Health Committee today published its report, After Francis: making a difference. The report offers further insights and reflections on some of the most critical and contentious areas of debate triggered by what happened at Mid Staffordshire: minimum staffing levels, a duty of candour and regulatory regimes.

But in line with what we are hearing time and again, it all comes back to this thing called 'culture'. Stephen Dorrell, Chair of the Committee, is quoted as saying:

'Robert Francis made 290 recommendations in his report, but in truth they boil down to just one – that the culture of "doing the system’s business" is pervasive in parts of the NHS and has to change.'

If we've learnt anything from recent failures in healthcare, it's that there are lots of things – complex things – working alongside and opposed to each other that make up the culture of an organisation, or a ward, or an entire system.

At a recent roundtable we hosted, we heard that culture could be described as 'what people do when nobody’s looking'. If that's the case, then it will be nigh on impossible for the Care Quality Commission (CQC) to inspect for an organisation’s culture, which was also supported in the Committee’s report.

We also heard at our roundtable that safety culture assessment tools provide a practical device for stimulating conversations and surfacing safety concerns, but that ‘the temptation to impose the use of these tools for performance measurement or compliance purposes must be avoided.’

So what are we to do? Well, rather than trying to boil down the many complex factors that might lead to 'another Mid Staffs' to a single recommendation, we should tackle some of the issues we know have a bearing on staff behaviour and, ultimately, the experience and outcomes for patients.

First, encouraging staff to report incidents is a critical component of a safety culture. Making monitoring of patient safety practice and data a core responsibility of the CQC mustn't allow local care providers to see their responsibility for this diminished. Of course the CQC should have access to all available intelligence to target its inspections, but the likely consequence of the reporting system being managed by the regulator is that opportunities for learning from it become limited and centralised, not infinite and locally owned.

Second, it's pleasing to see the Committee reference the approach taken by Salford Royal NHS Foundation Trust. Here, wards make information on nurse staffing levels publically available on a daily basis. This approach is the sign of an organisation that's confident in its decisions about what 'safe' means, and is honest with patients when it is not able to meet their (and their own) expectations. It would be wonderful to see this done everywhere.

Third, it is promising to see the Committee recognise that 'measures designed to strengthen a culture of candour in the NHS should require openness about the full range of outcomes achieved, not just about where things go wrong.'

Here at the Health Foundation we would take this principle further: that any efforts to assess the safety of an organisation are not complete if they are dominated by only assessing things that have gone wrong.

Safety and safety culture are much more about having reliable processes to ensure things go right: where real time information is constantly fed back to those responsible to delivering care, where risks are anticipated and prepared for and where information from a wide range of sources is integrated and acted upon. These make up the dimensions of a framework for measuring and monitoring safety developed by Charles Vincent and colleagues at Imperial College London, commissioned by the Health Foundation.

We have tested the application of this framework with three NHS trusts across the UK. An interesting comment we received in the feedback was 'where does culture fit into this?' Rather like my observations on the Health Committee report, culture is the product of many things that can be addressed, rather than something in its own right which cannot.

John is a Policy Manager at the Health Foundation.

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