Myriad concepts and values underpin patient safety agendas nationally and globally and can be seen in government, regulatory and professional bodies' reports and publications. Putting the patient first, being open, honest, trustworthy, just, and professionally competent, are just some of the concepts seen.
A just NHS culture
In a speech on 6 February 2019, Secretary of State for Health and Social Care, Matt Hancock, stated that we trust nurses and doctors more than any other profession (Department of Health and Social Care (DHSC) and Hancock, 2019). He spoke about the importance of a ‘just culture’ in the NHS and openness, honesty and trustworthiness. He related these concepts to NHS patient safety and leadership in a wide-ranging presentation.
The speech addressed strengthening NHS leadership and the newly published Kark report on the Fit and Proper Person Test (Kark and Russell, 2019). Independent medical examiners were also discussed. Hancock also spoke about a number of patient safety crises:
‘As Health Secretary, I'm sorry to those families in Gosport, Liverpool Community Hospital, Mid Staffs and everyone else who has been let down. But I'm not here today to point fingers and blame people. Instead, we must learn the right lessons about creating a caring, compassionate culture, about protecting and renewing the bond of trust between the public and the NHS—our nation's most loved and respected institution.’
Clinical negligence
Hancock also spoke about clinical negligence and what happens when mistakes are made in patient care and treatment. He accepted that we all make mistakes and that we should all strive to avoid them:
‘But the fact of a mistake isn't the biggest problem. It's how we respond to them and how we learn from them, that's what's most important. And we must never let our fear of the consequences, stop us from doing the right thing.’
Living our values
Hancock mentioned an important statement of operational values that one trust he had visited has drawn up. The Princess Alexandra Hospital NHS Trust in Harlow, Essex, has developed a behaviour values charter (2019). He praised this as an excellent example of demonstrating openness, honesty and trustworthiness. This Trust's behaviour charter sets the scene for patients and their families on the behaviours and values they can expect staff to demonstrate. It is a public declaration of intent by the Trust and lists its core values explicitly. Staff should be:
These values are further defined in terms of what the Trust and each staff member will do, how they will do it and what they will not do. It is a very simple and powerful statement of values and is well designed and constructed. It will serve as an excellent model and template that all trusts could usefully adopt and develop.
Ideas behind the label matter
Concepts and values can be interpreted and applied in many ways. Defining a ‘just culture’, ‘transparency’, or ‘accountability’ will result in lots of discussion and conclusions being drawn. Debating these and other ethical and legal terms will help develop an NHS patient safety culture, and staff can begin to internalise and own these concepts in a practical way.
When discussing ethical and other concepts, it is not necessarily the label that matters but the ideas that surround it. I always try to look for some common understanding of the ideas behind the label to see what is trying to be achieved. This issue was most recently identified by the Care Quality Commission (CQC) (2018) in relation to the need for a common NHS understanding of the concept of patient safety:
‘To truly have a safe NHS, all who work in it need to share a basic knowledge and understanding of what we mean by patient safety and be educated in some basic, common principles. Other industries share a common understanding of safety regardless of the role they are in. This is something the NHS needs to achieve. Taking this approach will help to move to a culture where it is accepted that error can happen and that systems need to be planned with this understanding. Recognising the fallibility of individuals and the inherent risk in providing health care is essential to create a just culture.’
Litigation levels
In his speech, Hancock said the chief executive of the Princess Alexandra Hospital NHS Trust found that the number of clinical negligence claims has not increased since it introduced this new values charter (Princess Alexandra Hospital NHS Trust, 2019). Hancock said the chief executive believes:
‘When people feel like they've been treated with honesty and candour, they're less likely to resort to legal action.’
This is a moral issue and Hancock also sees it as a financial issue. He states that compensation payouts have quadrupled from half a billion to £2 billion a year over the past decade and feels that this is unacceptable and clearly unsustainable:
‘If we don't do something about the growing number, and value, of clinical negligence claims, it threatens to swallow up the record £20.5 billion a year we're putting into the NHS and derail our Long Term Plan to transform the health service. And that infuriates me, because it's an injustice for taxpayers and our hardworking NHS staff.’
Don't forget the patient
Hancock makes an important point, but we should not forget patients who have been negligently injured by those who were meant to care for them. Yes, the money paid out could have been put into frontline health services, but justice demands that negligently injured patients receive compensation for the damages suffered. The law directs that they should be put, so far as money can do this, in the position that they would have been in had the negligence not occurred. In talking about, ‘injustices’, patients should not be forgotten.
Hancock said that under the new patient safety agenda being planned, patient safety should be improved because there will be:
Don't demonise the lawyers
Hancock's aims for a new patient safety strategy are commendable but his comment about ‘less taxpayers’ money going to lawyers' is a cause for concern. Lawyers are a neutral force; they are, as members of highly regulated professions, not spuriously suing the NHS in the hope of financial gain. Patients have come to them because they have been injured by healthcare staff—those who were meant to care for them. The lawyer does not have to take the case on, and will need to be satisfied on several important matters before they commit to taking the case.
Nursing and medical negligence cases can often be very complicated and require expert witnesses, which adds to costs. Causation—what caused or materially contributed to the damage the patient claims they have suffered—is often a key issue that can add complexity. This is a specialist area of legal practice and a case involving a small financial value claim can raise issues that are just as complex as one with a high monetary value claim.
Rather than just saying that we need to avoid giving money to lawyers, it would be better to say that we need to avoid negligently harming patients so that patients are not forced to seek professional legal advice to pursue their right for monetary compensation.
The fact that patients can access justice and have competent legal representation is a social good. As a society we should not be prejudicing their right to seek justice.
Hancock also spoke about work with the Healthcare Safety Investigation Branch and NHS Improvement to give more support to families when things go wrong:
‘A new family engagement model will ensure relatives play an integral part in any investigation, that their concerns, and their complaints, are listened to and acted on. Nobody should feel like they're being fobbed off or a nuisance. We must give families all the information in an open and transparent way. And ensure they're treated with sensitivity and compassion before, during and after any investigation.’
Whistleblowers
Hancock spoke about the need to encourage whistleblowers. They are, he said, doing the NHS a great service but, sadly, they are often ignored, bullied and forced out of work:
‘Making someone choose between the job they love and speaking the truth to keep patients safe, is morally abhorrent and operationally foolish. It's an injustice I am determined to end.’
He spoke about changing the way the NHS system views whistleblowers. They should not be seen as part of the problem but as part of the solution. The key is to embed a ‘learn not blame’ culture in every part of the NHS to ensure that staff who save lives by whistleblowing are protected. Hancock links this need to create the right culture with getting the right NHS leadership. He described the culture as:
‘A culture of learn not blame. Saying sorry when we get it wrong, earning the public's trust, never taking it for granted.’
Hancock concluded his speech by saying that there is no one solution to patient safety and that it is a series of steps, a path of continuous learning and improvement.
Conclusion
Hancock's speech on patient safety is to be welcomed. He sets out the challenges that must be met for the NHS to develop an ingrained patient safety culture. There is a clear sense of direction and the work carried out on values by trusts such as the Princess Alexandra Hospital NHS Trust add extra velocity to the drive for NHS patient safety culture development.