The Chinese word for ‘crisis’ can be translated as both ‘danger’ and ‘opportunity’. But when it comes to crises in the NHS – like at Southern Health, Morecambe Bay or Mid Staffordshire – the dangers are well documented, but the opportunities are often missed. Sure, each crisis is often accompanied by a blizzard of policy initiatives, but on the ground little seems to change.
That’s why the government’s intention to set up a new Healthcare Safety Investigation Branch (HSIB), to investigate those safety issues with the most potential for learning, should be good news. Done properly, it has the potential to bring about lasting culture change. But whether it delivers on this promise hinges on its ability – led by the new Chief Investigator, Mr Keith Conradi – to build trust, both in itself and right across the system.
The creation of the HSIB
The journey to the establishment of the HSIB began in 2014, when an article by Health Foundation fellows Carl Macrae and Charles Vincent described ‘a smorgasbord of approaches to investigate and address systemic safety issues at various levels of the healthcare system with little apparent consistency, logic or strategy underlying their design or execution.’
The article prompted an Inquiry by the Public Administration Select Committee. The Committee concluded that ‘the processes for investigating and learning from incidents are complicated, take far too long and are preoccupied with blame or avoiding financial liability’. It recommended that the government set up an independent investigation unit in the NHS, modelled on the airline industry.
Then in May 2016, an Expert Advisory Group published a report to advise how the HSIB should operate. It made clear that the primary objective of the HSIB is to investigate systemic safety issues in order ‘to improve systems and prevent future harm, not to apportion blame or liability.’
This is a bold step forward. Never before has a health care system established an independent investigator like this, despite being commonplace in other industries (for example, the Air Accident Investigation Board recently celebrated its 100th birthday).
What will success look like for the HSIB?
If the new body ends up being judged on whether it brings about lasting culture change in the NHS, is it likely to succeed? After all, the HSIB is a body – in fact a branch within a body – with an expected budget of around 0.3% of what the NHS spends each year on litigation claims alone. And it will be seen by some as just another body, prodding change from outside.
But opportunities like this don’t come along very often: the chance to genuinely galvanise the system around a commitment to learn from failure.
So what does the new Chief Investigator have to do to realise this bold ambition? For me, there are three priorities, which actually boil down to one – to build trust:
- To build trust among patients by making them an active and equal partner in every investigation. Patients, carers and families who have suffered harm are not just the victims, but the holders of valuable intelligence – intelligence which should be seen as the ‘black box’ to every safety incident.
- To build trust among those working in the NHS by making them part of the solution, not the problem. The HSIB should train local staff in the latest techniques so that they can carry out their own high quality investigations (given the HSIB will only have the resources to conduct around 30 investigations itself each year).
- To build trust among the wider system by establishing the HSIB as separate to the rest of the NHS. The HSIB needs the independence to make recommendations to any part of the system, which may include recommendations to the regulator itself. The Public Administration and Constitutional Affairs Committee recently described the government’s decision to host the branch within NHS Improvement as ‘disappointing and unacceptable’.
Done right, the HSIB presents the opportunity to make improvements to patient safety at an unprecedented scale; done wrong, then this will be another opportunity out of a crisis well and truly missed.
John Illingworth is an Improvement Fellow at the Health Foundation