There has been a lot of talk in the NHS about moving from blame to a learning culture but are we really achieving this? A change in culture and investment in human factor awareness is needed, believe Minesh Khashu and Ben Tipney
Earlier this year, health secretary Jeremy Hunt responded to reports about avoidable deaths in UK hospitals by calling it “the biggest scandal in global healthcare”. He is quoted by The Guardian as estimating the figure to be as high as 1,000 per month.
‘Even reducing avoidable harm by just 10 per cent would save the NHS in excess of £200m/year’
Even if the actual figure was 10 per cent of this, it is still too high. Moreover, there is far more avoidable harm that doesn’t result in death and is in many ways just as costly. It is difficult to quantify the cost of emotional trauma to families of patients who have lost their lives or suffered irreparable harm.
Also, the “cost” to the professionals involved in the incident is not well understood.
For the point of this discussion, if we focus on only the financial implications, the numbers are staggering. The NHS Litigation Authority allocates in the region of £2.5bn per annum to cover the costs of avoidable harm, with individual cases sometimes exceeding £20m.
Is this sustainable within an NHS, already creaking under the strain? Even reducing avoidable harm by just 10 per cent would save the NHS in excess of £200m per year.
What can we do to reduce this avoidable harm? Is it simply a case of more consultants working over weekends as suggested by Mr Hunt?
The tragic death of Elaine Bromiley in 2005, following what should have been a routine sinus operation, well exemplifies the problem. When one peels back the layers of this incident, the root causes are failures in communication, leadership, situation awareness, assertiveness and task prioritisation. These fall under the domain of human factors.
Ms Bromiley’s husband Martin, an experienced airline pilot, has worked tirelessly to raise awareness of human factors in healthcare, including setting up in 2007 the Clinical Human Factors Group, with the aim of improving the awareness and understanding of healthcare professionals about human factors and thereby improving patient safety. Key to his inspirational work during the past 10 years has been the focus on learning rather than blame.
‘There is a lot of talk but very little action’
There has been a lot of talk in the NHS about moving from blame to a learning culture but are we really achieving this? There is a lot of talk but very little action. We need fundamental shifts in culture and significant investment across the healthcare industry in human factors awareness.
What impact does the media have on the ability of the NHS as an organisation to create that paradigm shift away from blame? What responsibility do we have as a society to reposition our attitudes and expectations of perfection on healthcare professionals to make way for a more transparent system and in the long term, nurture a safer culture for the system that we rely on to look after us when we are in need? Is there supportive leadership from our politicians on this issue?
On the curriculum
Unlike the aviation industry, human factors are not yet part of any mandated healthcare training or medical curriculum. It is worth noting that between 1995, when the Civil Aviation Authority mandated crew resource management training across the industry, and last year, serious incident rates have reduced significantly despite global increases in air traffic.
In 2013, the National Quality Board released a concordat about human factors in healthcare, which was signed by the majority of the regulatory bodies in the industry, and this has been followed up by the General Medical Council publishing a draft document for consultation regarding non-technical competencies for doctors.
These are positive steps, but will not, in themselves, go far enough in driving change at the appropriate scale and in the required timeframe. Setting standards for professionals to meet is important, but what is also required is investment in sufficient training to develop and sustain the skills necessary to meet those standards.
‘We need to create the appropriate culture to foster the pertinent behaviours within teams and organisations’
If we presume that the NHS has “woken up” to human factors and their importance in reducing avoidable harm, is there a strategic plan for the NHS during the next 5-10 years for ensuring that all professionals are sufficiently trained and skilled in this area?
How do we practically and efficiently provide this training to all frontline professionals in the NHS?
We have heard very little about this aspect of minimising avoidable harm. Apart from healthcare professionals and people interested in safety and quality improvement, colleagues from the media as well as the political domain (across party lines) need to support this work.
We are well aware that for this to be a sustained improvement, we need to create the appropriate culture to foster the pertinent behaviours within teams and organisations. Culture, unlike what grows in a petri dish in a lab over a few days, takes years to grow and nurture.
We need a clear, well defined strategy and timeline in this regard. Over to you Mr Hunt.
Minesh Khashu is consultant neonatologist and professor of perinatal health, and Ben Tipney is a human factors training consultant