• Chief hospital inspector highlights staff hierarchies as risk to safety
  • Ted Baker says NHS should learn about safety from aviation and energy industries
  • Call for safety systems to acknowledge ”humans make mistakes”

Hierarchies within the NHS workforce are a “real bar” to patient safety, the chief inspector of hospitals has warned.

Professor Ted Baker, of the Care Quality Commission, said his organisation has had many reports of junior staff feeling unable to challenge senior clinicians, which has led to never events and patient harm.

Speaking at a conference run by GS1 UK Healthcare, he also said some clinicians have an “elastic” attitude towards safety when under pressure, which does not exist in other industries.

It comes four months after he told HSJ there was a “cultural disconnect” between frontline NHS staff who experience the high-risk reality of healthcare every day and the false belief of many others in the service that it was intrinsically safe.

Professor Baker said trusts’ overall performance has improved in the last few years, with the majority of hospitals now rated “good” or “outstanding”.

However, he added that 40 per cent of services are rated “requires improvement” or “inadequate” for safety, with that figure “not moving as it should”.

Addressing the safety culture in the NHS, Professor Baker said: “Hierarchy and inter-professional relationships are a real bar to safety because people feel they can’t challenge.”

He cited an example at an unnamed trust where a junior doctor had misplaced a nasogastric tube in a patient who subsequently died, with no challenge from nursing staff despite them being fully trained in the procedure.

“In so many of these [never] events we hear that a junior member knows what’s happening, but feels they can’t challenge,” Professor Baker said.

“It’s not that simple to say ‘you must challenge’ because…the culture in which they work does not support them taking the right action.

He added: “For too long we’ve taken the view that the way for patient safety is for people not to make mistakes – but we have to understand that people make mistakes all the time and we need to design patient safety around that understanding.”

“We need a fundamental change in culture in the frontline to allow staff to take the right action.”

Professor Baker shared some insight from a meeting arranged by the CQC between NHS clinicians and safety experts from other industries including aviation, nuclear, and oil.

He said: “The clinicians expressed how difficult it was to be busy and if they don’t get an operation going they get into trouble – yet one British Airways captain said he would be in trouble if he doesn’t leave his stand on time but he would never move that plane until he knows it’s safe.”

“So, there’s a sense of how two organisations think differently about risk, and those that are risk-aware have got this right.

“They recognise that from the word go that priority is patient safety. It’s non-negotiable and it’s not something that’s elastic when under pressure – yet some people in healthcare still have that view.”

Talking about training, Professor Baker said clinical staff have told the CQC they have little time for safety training while grappling with increasing demand, and that the “many patient safety alerts…feel like a bureaucratic exercise rather than something to really focus on to improve patient safety”.

“Those other industries say safety is the first thing they teach, and staff learn about how humans make mistakes…and that hierarchies within teams are extremely dangerous,” he said.

“We don’t have that in healthcare – we accept hierarchies and expect them to be there, and you often see that those are the things that get in the way of safety.

“The fact that you’re a clinician doesn’t mean you’re an expert on safety. There’s an assumption that’s the case but actually that’s about understanding human factors…and hierarchies and how they get in the way of safety, and that’s often not present in healthcare organisations.

The answer is to “change the culture”, Professor Baker concluded.

“We have to recognise that everyone needs to be part of safety, and they need to have an understanding of it.

“It must have humility to it. We have to start recognising that we’re all fallible and errors are going to occur.

“An error is seen as a failure, but actually if we accept errors as part of everything we do and something we learn from then we’re in a position where we can have much more productive involvement with families when things go wrong.”