Patients, public, professionals - we’re all citizens with a stake in the system

This month marks the 25th anniversary of Piper Alpha, considered by many to be the worst offshore oil disaster of all time after an explosion left 167 people dead and destroyed its North Sea platform. The subsequent Cullen Inquiry led to over 100 recommendations for changes in safety practices, accepted in full by an industry deeply shaken by the tragedy.

This story will be familiar to many of us, as will the comparisons drawn between other safety critical industries and the NHS on their approach to minimising risk and building a safety culture.

The opportunities and limitations of comparison and cross-learning is well-trodden territory. However, as the NHS grapples with the fallout of the Francis Inquiry, it remains a timely reminder of what can, and should, be achieved. And I wouldn’t be the first person to reflect on whether in years to come we will see Francis as a tipping point.

It’s by no means certain. As many are quick to point out, there have been plenty of reports about poor care and recommendations on what the NHS should do about it. But these reports seem to come and go without having a deep and lasting impact.

However in reflecting on the events of 1988 and with the benefit of hindsight from those involved, there is an interesting lesson to be drawn about what can happen when perspectives are misaligned and engagement is lacking.

A significant safety incident often reveals a mismatch between different perspectives and interpretations of people’s surroundings and responsibilities. It can be painfully apparent at the crisis moment: there are gaps and misunderstandings, warnings have gone unheeded and safety has not been fully examined from every point of view.

So far, so Francis.

Yet it is also worth reflecting on the fact that this misalignment occurs even when those working within an industry are primarily exposed to risk – the pilot goes down with the plane, so to speak – and might therefore be considered to have a significant personal incentive to manage it effectively, as well as a professional responsibility.

However healthcare is an industry in which risk is largely assumed by the receivers of care, often under circumstances where there is a real imbalance of knowledge and power. Worse still, the very people at greatest risk are excluded from the process of managing it.

With the best will in the world, professionals cannot always see things as they appear to people using services. This may be because the risks are only apparent to the person in the hospital bed, not standing next to it. It may be that perception of harm is informed by individual priorities and self-knowledge.

However there are also occasions when professionals cease to perceive or chose to ignore unsafe practices and put people at risk. At which point we should also acknowledge that while they may ultimately face professional sanctions, it is individuals and families who live with the real consequences of harm.

Unless we start to fully engage people in a proper debate about safety and use their insights to identify and manage risk, we will not move forward.

But this isn’t easy and won’t be achieved by more of the same. The experience of engagement for many could best be described as being brought ‘to’ services: brought to their meetings to speak their language about their priorities, with services then expressing dismay that only certain groups of people are able and prepared to do that.

I draw a caricature but I’m sure it will strike a chord with many.

Instead we need a revolution in engagement. First and foremost we need to stop talking about the 'three Ps'. Patients are often portrayed as supplicants, the public are seen as disconnected from the interests of ‘real patients’ and ‘professional’ is a role, not an actual person.

In reality we work together as individuals, communities and experts to create health. So I’d suggest that we start seeing all of us as citizens with a stake in the system, not labels and boxes. As citizens we all have an absolute right to be involved in this debate – we use, work for, pay for and vote for this service collectively.

What is ‘safe’ and how to achieve it must be a collaborative process between us all which, as a first principle, must be based on openness and transparency. Citizens have every right to know and have an opinion about what happens in public services, and that includes how safe they are.

Ruthe is Public Services Programme Manager at Age UK.