On Thursday Health Secretary Jeremy Hunt will announce ambitious plans to improve safety and transparency within the NHS – to help build a safer service for patients seven days a week at the first ministerial-level Global Patient Safety Summit.
Speaking at the Summit, Jeremy Hunt will set out a range of new measures including an independent Healthcare Safety Investigation Branch and legal protection for anyone giving information following a hospital mistake.
These ‘safe spaces’ will protect those co-operating with investigations in a move to help clinicians to speak up and bring new openness to the NHS’ response to tragic mistakes. Families will get the full truth faster, staff the support and protection to speak out and the NHS will become better at learning when things go wrong and acting upon it.
Jeremy Hunt will also announce that from April 2018, expert medical examiners will independently review and confirm the cause of all deaths, as originally recommended by the Shipman Inquiry, and subsequently by Robert Francis following the events of Mid Staffs. If any death needs to be investigated and if there is cause for concern, appropriate action will be taken.
The current system has largely remained unchanged for over 50 years and leads to significant variations in the number of deaths that are investigated so reform is overdue. These changes will ensure complete peace of mind for the public and their loved ones so that if things go wrong, they are identified and further investigation facilitated.
Health Secretary Jeremy Hunt said:
A huge amount of progress has been made in improving our safety culture following the tragic events at Mid Staffs but to deliver a safer NHS for patients, seven days a week we need to unshackle ourselves from a quick-fix blame culture and acknowledge that sometimes bad mistakes can be made by good people.
It is a scandal that every week there are potentially 150 avoidable deaths in our hospitals and it is up to us all to make the need for whistleblowing and secrecy a thing of the past as we reform the NHS and its values and move from blaming to learning.
Today we take a step forward to building a new era of openness and the safest healthcare system in the world.
As part of the package, NHS Improvement will publish the first annual ‘Learning from Mistakes League’. Drawing on a range of data this will identify the level of openness and transparency in NHS provider organisations for the first time:
- This year’s League shows that 120 organisations were rated as outstanding or good
- 78 had significant concerns and 32 had a poor reporting culture
As part of his drive for a safer NHS seven days a week, the Health Secretary will also announce:
- Changes to guidance by the General Medical Council and Nursing and Midwifery Council so that when NHS staff are honest about mistakes and apologise, a professional tribunal gives them credit for that, just as failing to do so is likely to incur a serious sanction;
- NHS Improvement will ask all Trusts to publish a Charter for Openness and Transparency so staff can have clear expectations of how they will be treated if they witness clinical errors;
- NHS England will work with the Royal College of Physicians to develop a standardised method for reviewing the records of patients who have died in hospital; and
- England will become the first country in the world to publish estimates by every hospital trust of their own – non-comparable – avoidable mortality rates.
The two-day Global Patient Safety Summit will bring together Health Ministers, senior delegates and expert clinicians from across the world including Margaret Chan, Director General of the World Health Organisation.
James Titcombe, Morecambe Bay parent and National Adviser on Patient Safety, Culture and Quality, said:
Time and time again, we hear the promise that ‘lessons will be learned’ following reports about systemic failures and individual stories of avoidable harm and loss in the NHS. Yet, far too often, the same mistakes are repeated and meaningful learning and lasting change simply doesn’t happen.
If we are going to transform this, it’s clear that we need to do something different. Events at Mid Staffs and Morecambe Bay serve to highlight the devastating consequences of a culture that failures to learn.
These announcements are about saying ‘never again’ - the measures announced are major steps that will help move the NHS towards the kind of true learning culture that other high risk industries take for granted.
Martin Bromiley, chair of the Clinical Human Factors Group, said:
To be high performing in today’s highly complex safety critical industries we need to be open to learning, open to people speaking up who disagree with us, and curious. A learning culture isn’t a nice thing, it’s essential but if people can’t be honest because of fear, we can’t learn.
The principles outlined of a just culture which supports learning are exactly the principles that other high performing safety critical industries aspire to if they are to improve safety.
Healthcare has a long way to go but these measures are the first step of a critical journey. We mustn’t tolerate gross negligence or willful acts, but likewise we need to recognise that the vast majority of clinicians come to work to do their very best, yet often are prevented from doing so by the very system they work within.
Notes to Editors
- The government has made much progress in improving the safety culture in hospitals and across the health system following the report of Sir Robert Francis into the tragedy of what happened at Mid Staffs.
- According to the Health Foundation the proportion of people suffering from four of the most common hospital harms has fallen by around a third in the last three years with MRSA bloodstream infections falling by more than half during that period.
- The Government has also introduced a new and much tougher peer-led inspection regime which has led to 27 hospitals being put into special measures and the law has changed to introduce a statutory duty of candour when thing go wrong. Every trust has been asked to appoint independent Freedom to Speak up Guardians so clinicians can relay concerns to someone other than their line manager.
- The new independent Healthcare Safety Investigation Branch has been asked by the Health Secretary to consider focusing initially on maternity and neonatal mortality investigations before rolling out to other areas of clinical activity. It is intended to make a major contribution to the government’s ambition to halve still births, neonatal injury and death and maternal death rates but it will not be limited to maternity.
- Medical examiners will be experienced doctors, capable of ensuring that the medical certificate of cause of death is completed fully and will answer any questions families have about the cause of death, including clarification of medical terms. All deaths will be scrutinised in a proportionate way to deliver assurances and safeguards to the bereaved prior to burial or cremation. The new system will also allow easier identification of trends, unusual patterns and local clinical governance issues, making malpractice easier to detect.
- Coroners will still be responsible for investigating suspicious deaths
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