Noel Plumridge on why safety is just a ritual

Fix the seat belt, twiddle the ventilation nozzle and reach for some reading material.

If you have not read last October's Healthcare Commission report on the C difficile outbreaks at Maidstone and Tunbridge Wells trust, I urge you to. It is the story of what happens when lack of organisational stability, preoccupation with targets and widespread personal insecurity undermine effective corporate governance. It is a telling indictment of the NHS management culture.

The board at Maidstone said, unambiguously, that its top priority was patients' safety. It formally declared itself compliant with core national standards for infection control. But it did not know what was happening. Its information was often incomplete or inaccurate, leaving non-executives at a disadvantage in being able to scrutinise and challenge.

Besides, no one at Maidstone was looking for C difficile infections. In 2005 an outbreak involving 150 patients went unnoticed. The MRSA rate was being monitored, but it had a national performance target. At national level the belief was the MRSA target could be a marker for other hospital acquired infections, but once a measure becomes an overt target, its usefulness as a broader indicator shrinks. The message becomes simple: hit the target.

Systems and procedures were in place, but the trust's attention was elsewhere. The commission said: "The trust struggled with a number of objectives which they regarded as imperative. These occupied senior managers' time and compromised the control of infection and hence the safety of patients". The ritual of appointing an infection prevention and control director was fulfilled, but this person "had no real understanding of the role".

When it came to infection control, the Maidstone board, like the proverbial swimmer in the Mediterranean, was merely going through the motions.

But wait. Before we can leave the ground, there is a familiar requirement: a demonstration of the safety features of this aircraft. Several passengers look up, mainly because it seems polite to give the two women offering the show some moral support. Most don't bother. We hear how to fasten our seat belts. See to our own oxygen masks before our children's. Not wear stiletto heels on the escape chutes. Not to inflate life jackets inside the aircraft. Use the life jacket light and whistle.

Now we can go. The two women walk down the cabin, checking we understood about seat belts. We all did. We have flown before.

British aircraft safety routines and risk management are superb. They have to be; at 35,000 feet you do not always get a second chance. Many of the hospital based initiatives pioneered by the National Patient Safety Agency, including the concept of blame-free error reporting, have their origins in the aviation industry.

Demonstrating the safety features of the aircraft is essentially ritual. Most of us know how to use a seat belt. The likelihood of a stricken plane safely landing on water and its stiletto-free passengers calmly sliding into the briny to await rescue is slim. Especially between Southampton and Leeds, a flight entirely over land. But so familiar are the messages that, in the event of a crisis, we would know what to do. It is why sergeant majors drill military recruits. It is what the NHS hand-washing campaign is all about.

In the NHS the risk factors associated with financial failure are well known. Many were present at Maidstone. A relatively recent merger, followed by regular structural change. High senior manager turnover. A reactive management style. No culture of challenge at board level. The distraction of a big building project. And, finally, denial when the reality, long acknowledged at the sharp end, starts to impinge in the boardroom.

But there is no such thing as financial failure, just failure. Faced with the complex and sometimes contradictory challenges of hospital management, the urge to simplify is natural. It is tempting to focus on what, for the present, seems crucial - financial balance perhaps, or maybe the 18-week target - and impose "robust" monitoring of a small set of performance indicators.

This too is a form of ritual behaviour. The NHS is familiar with it; it encourages dishonest reporting and blinkered management. Good corporate governance exists partly to control this tendency and ensure the organisation addresses its full range of responsibilities.

What happened at Maidstone was ultimately a failure of corporate governance. This is what makes the commission's report compelling.

It would be wonderful if a prescribed sequence of actions slavishly followed would keep us safe from risks. But I am sure Flybe also has a panoply of risk management techniques in place to ensure the plane does not end up in the Humber.

A former NHS colleague insists every airline passenger has a duty to drink champagne in the departure lounge, as the little bubbles help the aircraft get off the ground. I suspect it is more to do with the engines, the people who maintain them and the procedures that ensure they do. That is effective governance.

National Patient Safety Campaign director Stephen Ramsden noted on hsj.co.uk that this year's operating framework, which defines NHS priorities, does not feature improving patient safety, though it does mention cleanliness and infection control. He urges boards to devote appropriate time to patient safety and commit to putting safe care higher up the scale of priorities than meeting national targets. He's right.