How do we ensure failure on this scale never happens again?

Elaine Maxwell, Assistant Director for Patient Safety at the Health Foundation, gives us her thoughts on some of the key themes emerging from the Francis Inquiry report and how this links to the Health Foundation’s ongoing work to improve the safety of healthcare.

The Francis report made grim, if not unexpected, reading for anyone interested in the NHS. The 290 recommendations are still being read and considered by government and it will be some time before we truly see how the report will influence policy and practice within the wider health service. In the meantime, we, along with many others, are looking at ways to help the NHS ensure that failure on this scale never happens again.

What has been shocking is the wide range of factors that contributed to the failures in care at Mid Staffordshire NHS Foundation Trust. As well as the concerns about the practice of individual healthcare professionals identified in Robert Francis’ first report, there were clearly system-wide failures that failed to protect vulnerable patients. This means that improvement is needed in a number of different areas. For us, accountability and measurement emerge as particularly important themes.

Openness, transparency and candour throughout the system

We need to be thinking about accountability on three levels:

• accountability to patients and their families
• accountability for professional standards (through professional registration and revalidation)
• accountability to the public (through the two healthcare service regulators, the Care Quality Commission and Monitor).

At the Health Foundation, we believe that first and foremost, the NHS should be accountable to patients and their families. Users of healthcare services need to be in control of their care and the other two areas of accountability should reflect this person centred approach.

Part of being accountable to patients is being open when things go wrong and it will be important to ensure that a duty of candour is carefully implemented and embedded in culturally and at all levels of the system. This will need to be well thought through to make sure that there are no unanticipated consequences. We are considering how to contribute to the development of an approach that achieves both candour and an open learning culture.

Accurate, useful and relevant information about safety

Measurement is a critical component to understanding whether care is being provided in a way that protects and promotes patient safety. The Francis report underlines why new approaches are needed. At Mid Staffordshire NHS Foundation Trust there was plenty of data available but a lack of consensus on how to interpret it.

This confusion led, at many levels, to the side stepping of responsibility for acting on the data. More time was spent trying to explain away high Hospital Standardised Mortality Ratios (HSMR) than exploring what was happening in practice. The fact that discussion about HSMRs took place in isolation and was not set in the context of wider available data (including complaints to the Trust or results of the staff survey) also made it easier to question the data.

Using safety cases offers a more proactive approach to safety management. This technique, which we are continuing to test in our Safer Clinical Systems programme, combines data from different sources to provide an overview of safety. This is explained in more detail in our article on safety cases this month. 

What next?

We believe that there now needs to be a debate about how patient safety is defined and measured. As well as simply counting harms we need to develop ways to predict how safe care will be tomorrow, while also understanding how safe it was yesterday.

This will be a major focus of our patient safety work in 2013. We have published Lining up: how is harm measured? which looks at lessons from our Lining Up research project – an investigation into interventions to reduce central line infections. The report describes findings that have important implications for measurement of performance, and using measurement to improve quality and ensure patient safety.

We will be publishing a new report by Professor Charles Vincent and his colleagues this spring which we hope will stimulate a vibrant debate about how safety is defined and measured. 

We will host a number of roundtable events and publish blogs discussing the issues raised, culminating in a measurement summit in October 2013. Following this we will publish our recommendation for a comprehensive framework for the measurement of patient safety, a powerful tool that will help to prevent failures in healthcare on the scale described in the Francis report.

Find out more

• Tools, resources and debate on the Health Foundation website designed to help you respond proactively to the Francis Inquiry report