Today marks a year since the publication of the Francis report. And on the face of it, much appears to have happened. The Care Quality Commission (CQC) has developed a new approach to regulation and inspection, NHS England has published clinical outcomes across ten new specialities, and a major new patient safety collaborative programme is well under development.

But in the same period we’ve also seen the police launch a formal inquiry into Colchester Hospital following reports that staff were bullied into changing cancer waiting time data, Monitor double the number of its interventions into NHS trusts and the chair of the CQC warn of a ‘dysfunctional’ rift between NHS managers and clinical staff which is putting the safety of patients at risk.

So what does this tell us? It tells us that progress has been made on developing some centrally-driven initiatives to improve safety. It also suggests that there inevitably remains a challenge around culture.

It is no surprise that progress on culture is not immediately evident. Not only is it a difficult thing to lay your hands on, the public inquiry itself was focused on ‘the role of the commissioning, supervisory and regulatory bodies’ – the first Inquiry in 2010 focused on the care delivered to patients at Mid Staffordshire – and these levers are not the way to positively influence culture. So while the government and NHS England play a pivotal role in creating the right environment for change, it is down to people on the ground to make the changes deemed necessary.

Our analysis suggests that only 44 of the 290 recommendations from the second inquiry – that’s around 15% – are solely within the remit of NHS organisations to do something about, and only an additional 7 can be addressed by staff at the front line.

In his report on patient safety, Don Berwick talked about the NHS embodying the goal of ‘constant learning’ as the means to achieve real improvements in patient safety and safety culture. We think this could manifest itself in immediate action by NHS organisations, whether it involves executive teams creating an environment in which mistakes can be openly discussed without fear of reprisal, or frontline professionals changing their practice as they better understand the hazards in their services.

The Health Foundation has developed a programme to enable health professionals to identify proactively the risks in a particular service before they lead to harms in patients. This has involved the teams producing a ‘safety case’, where evidence is collected from a wide range of sources to demonstrate that risk controls have been put in place and that there is a process for monitoring the system’s ongoing safety. They are used in other safety critical industries, and often form the basis for a ‘claim’ about the level of safety being achieved, often boiled down to a '1 in X chance of failure'.

In further discussions about how this approach could be applied in healthcare, a question that keeps coming up is whether we are ready for the difficult questions that such an approach surfaces. In other words, ‘can we handle the truth?’ Are NHS trust boards open to hearing about the ‘risks’ associated with their services? Will regulators react positively to issues being proactively raised by organisations? Is the media willing to unearth the improvements made as a result of safety issues, as well as the problems caused by them? And is there an appetite amongst the public for this kind of information relating to their healthcare?

The answer to the first three questions may be ‘yes, but it depends’. But I think the answer to the fourth could well be simply ‘yes’. If there is one thing that irks the public more than the occurrence of poor care, it is the tolerance and concealment of poor care. And this brings us back to the ‘C’ word: culture. We believe that the process of proactively identifying risks and being open about them would radically change the culture of safety. Healthcare is a risky business, but now is the time to be candid about it if we’re going to make any progress against the issues identified in the Francis Inquiry.

This blog was first published on the Guardian Healthcare Network.

John is a Policy Manager at the Health Foundation.

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