A 'no blame' culture may be useful but is not an end in itself. Frank Burns argues that evidence of real progress is needed.

A 'no blame' culture may be useful but is not an end in itself. Frank Burns argues that evidence of real progress is needed.

Every year, a million NHS patients, 10 per cent of all admitted, are involved in safety incidents.

The scale of the patient safety problem was first highlighted by chief medical officer Professor Sir Liam Donaldson in his 2000 report An Organisation with a Memory. The National Patient Safety Agency was established soon after, with a remit to set up a national reporting system. This would allow national trends to be analysed and advice to be fed back to health services.

In 2005, the National Audit Office praised the agency for the reporting system and the safety culture it had helped create. However, it found little analysis of the lessons learned and few signs of any action.

The issue has been championed at a high level. In his foreword to Safety First - the Department of Health response to the NAO - Sir Liam said: 'Safety does not have the priority it needs at the top of all our healthcare organisations.'

In last summer's Healthcare Commission report on the Clostridium difficile outbreak at Stoke Mandeville Hospital in Buckinghamshire, chair Professor Sir Ian Kennedy said: 'Safety cannot ever be allowed to play second fiddle to other objectives that may emerge from time to time.'

The Healthcare Commission is consulting on its priorities for the 2007-08 healthcheck ratings in which it intends to give a greater focus to safety issues. (On closer examination, this appears to be largely confined to controlling MRSA and C difficile infections.)

All this is in stark contrast to a signal lack of emphasis given to. patient safety in the 2007-08 operating framework published in December last year. Apart from the targets to reduce MRSA and C difficile, improving patient safety is not one of the top four priorities for 2007-08. There are no targets set in relation to reducing fatalities linked to safety incidents. It seems that, when it comes to the first real use of financial penalties for poor provider performance, treating too many patients or failing on the 18-week access target is clearly a more important national priority than preventing harm to patients.

In the first three months of 2006-07, the NPSA recorded 600 fatalities linked to safety incidents and 2,000 severe outcomes short of death. Even these figures understate the true position, given the recent NAO finding that only 25 per cent of GPs participate in the NPSA reporting process. This suggests that, in the six years since Sir Liam produced his landmark report, there have been more than 10,000 patient deaths linked in some way to safety incidents in the NHS and a staggering 50,000 patients have suffered severe harm.

Anyone who is any doubt about the scale, range and damage caused to patients by avoidable errors should take a look at the range of recent safety alerts issued by the NPSA covering radiology reports and medication - the fact that three patients were killed from 2001-04 by being given oral medication intravenously perfectly illustrates the barely credible nature of some of the errors made.

The wrong test?

The conclusion must be that, seven years on from Organisation with a Memory, the NHS has not put in place an effective process for improving patient safety. This begs the question: is the 'reporting', 'analysing' and 'learning' model which underpins the national strategy right?

The test of success is not whether staff feel confident enough to treat mistakes and near misses as a learning experience. The test is whether or not the NHS is improving the safety of patients.

Taking the NHS as a whole, there is no evidence that we are making progress at a pace appropriate to the scale of death and harm.

Incidentally, there is no way we could have this evidence anyway, as there are no targets against which progress can be measured.

It is difficult to dispute the importance of a 'no blame' approach to creating a healthy learning culture. Is it unreasonable to suggest that a key component of strong, appropriate management is respect for individual accountability?

Can there be any doubt that NHS organisations have an obligation to hold people - however illustrious and senior - to account when their personal failings have resulted in harm or near harm to patients? This must be especially so where failings repeat errors, mistakes or carelessness that have been the subject of previous guidance.

The NHS may even, over the years, have conditioned itself to regard accidental harm to patients from safety incidents as a normal part of the risk in the treatment of illness, even a common side-effect.

The absence of good evidence that the NHS is learning lessons quickly enough suggests that the reporting/ learning approach needs to be firmly backed up with robust managerial action on individual failings.

The Healthcare Commission has cited evidence from the 2006 staff survey that things may be improving. This is based on the finding that 40 per cent of staff in acute trusts reported seeing a serious safety incident or near misses in a 12-month period compared with 44 per cent in the previous year.

A more telling statistic from the same survey reveals that only 50 per cent of staff in acute trusts feel their trust takes effective action to prevent recurrence of errors - and this worrying statistic shows no improvement over the 2005 survey.

Arguably, a better measure will be the next set of NPSA statistics (due to be published at the end of this month) on the actual number and nature of incidents reported.

There is no good evidence so far that the NHS is learning the lessons of nationwide experience quickly enough and this suggests that the reporting/learning approach to patient safety needs to be firmly backed up with robust managerial action being taken (where the facts allow) in regard to individual failings and deficiencies among clinical and other staff.

Ultimately, the most important opinions on whether the NHS is getting to grips with safety are those of patients. In the past, patients and their families were astonishingly tolerant of mishaps, excusing the service on the grounds that conscientious, underpaid and overworked staff were doing their best. Many still have this attitude.

But many now expect a major public service which consumes nearly£90bn of public funds to guarantee their safety - at least in relation to mistakes and errors - even if it cannot promise perfect organisation, infallible clinical judgement or exemplary customer service.

Betrayal of trust

Among the most harrowing experiences of any hospital chief executives are meetings with the families of patients whose treatment has gone badly wrong through organisational or personal failings.

These discussions rarely revolve around the finer points of the 'no blame' culture and the strengths of a learning organisation. A far simpler question is inevitably put to the chief executive: 'You are in charge of this hospital! How can you possibly allow this sort of thing to go on?'

This question is often accompanied by an eruption of anger that is not a reflection of the personality of the people concerned but of the despair and betrayal they feel. The cause of their anger is invariably the contrast between their initial faith that any hospital would be 100 per cent focused on the safety of patients, and the complacency and carelessness they encountered in reality.

It is true that these angry people want to know 'lessons will be learned' for the benefit of other patients. They also increasingly want the staff and managers involved to accept responsibility, be held to account and be disciplined where this is warranted.

The NHS is right to pursue the policy of embedding a positive safety culture in all organisations. However, unless significant progress can be demonstrated over the next year or so in reducing the level and seriousness of safety incidents, a collapse in public confidence may force politicians to take a more draconian approach.

Signs that this is already happening can be seen in the more assertive tactics being adopted by coroners, the police and the Health and Safety Executive. Even the DoH recently resorted to threats of high-level retribution when it lost patience over repeated errors and associated fatalities in the administration of intravenous/intrathecal chemotherapy.

It will be a great shame - in both senses of the word - if it takes fear of legal retribution to galvanise the NHS into effective action on this.

What should be driving this issue higher up the agenda is a determination by trust boards to properly fulfil their statutory obligations to guarantee the safety of patients. Any trust that has not put the attainment of level 3 accreditation from the NHS Litigation Authority clinical negligence scheme for trusts in its top three priorities is not taking the issue seriously enough. Achievement of the standards to gain this level of clinical negligence scheme for trusts accreditation involves a much more searching - and independent - examination of a trust's risk-management processes than will be provided by even the new improved Healthcare Commission self-assessment process.

Ultimately, real progress in improving safety will require much greater determination on the part of the vast numbers of dedicated and conscientious clinical staff right across the NHS. They will not want to see their efforts to deliver excellent care undermined by flawed processes and careless colleagues. -

Frank Burns is former chief executive of Wirral Hospitals trust and healthcare adviser to Weightmans Solicitors. E-mail frank.burns@weightmans.com