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Simon Burns's speech to the Royal College of Surgeons of Edinburgh's conference “In Safe Hands: Reducing Errors in the Operating Team”
Wednesday 8 December

  • Last modified date:
    11 January 2011


Introduction

Thank you, Margaret [Dangoor, President, Patient Safety Section, Royal Society of Medicine]. 

Nothing any of us do at any time is wholly without risk.  From the moment we get out of bed in the morning to the moment we fall back into it at night, we are constantly calculating, mitigating and managing risk, consciously or not.  And beyond making sure we don’t get hit by a bus on the way to work, we – and in particular, you – all manage risk in our professional lives too.
 
The ever-more effective management of that risk is vital to the future of the Health Service. 

This government has one overriding goal for the NHS – for it to produce outcomes that are among the best in the world.  Simple to say – hard to deliver – impossible without an absolute commitment to patient safety.

To achieve it, we need to learn.  We need to be open to the experiences and lessons of others, from within the NHS and far beyond it, from the UK and around the world.  For there is nothing, I repeat, nothing that is as important as ensuring patient safety.  When other objectives conflict with safety, safety must be the priority.

The National Health Service is an organisation of staggering complexity and size.  It employs the talents of well over one million people who see, treat and care for one million others every 36 hours.  It is just not possible for every single procedure, every single intervention for every single patient to go precisely as planned. 

There is not a system in the world that has managed to eliminate risk.  It is impossible because of the innate fallibility of human beings.  But if we cannot eliminate those risks, we must do everything we can to minimise them.  And when something does go wrong, we must learn from it and prevent it from happening again.  The question is how best to do this?
The events at Mid Staffordshire Hospital are a pertinent reminder.  Events which led to poor quality care going unnoticed, unreported and unacted upon – where sadly, an inexcusable attitude toward patient safety contributed to the tragic deaths of too many patients.

The traditional NHS culture

Whatever the specific reasons why things went so badly wrong at Mid Staffordshire, I believe there is a wider issue about the way in which the NHS is run that undermines patient safety.

From its birth, more than 60 years ago, the NHS has been managed very much from the top-down.  In recent years, this has been magnified by a seemingly endless stream of process driven targets that, however well meaning, have created a system focussed on process and not on people – a system that can undermine a doctor’s own professional judgement, forcing them to put ticking boxes over and above doing what they knows is right.

There is always a temptation to react to something going wrong with an extra set of rules and regulations.  In any specific instance, this is perfectly sensible.  But over time, as these rules build up, they can act a barrier to patient safety rather than its guarantor.

Never Events

There are, of course, certain things that should never happen to a patient in NHS care.  Things we should never tolerate.  We are currently looking at expanding the list of these lines in the sand, so-called “never events” – incidents such as wrong site surgery or the transfusion of the wrong blood type – from 8 to around 22. 

If such a ‘never event’ happens, it is a clear indication that something has gone very wrong.  Not only in the specific circumstances of the incident, but that the wider systems and procedures in place within the organisation are inadequate.

A new way

If our goal is outcomes among the best in the world...

If we demand the highest levels of patient safety...

Can we achieve this only by continuing to add to the rule book and by expanding still further the bureaucracy that polices it? 

Or should we take a different approach?

One that places more value on personal responsibility, transparency and accountability? 

One that focuses on the clinical evidence of what works, here and around the world?
I believe we can only achieve the highest levels of safety and quality by liberating doctors, surgeons and other healthcare professionals to do their jobs to the best of their ability and make them accountable for the outcomes of their care. 

By creating a culture of openness that places patient safety above all other things. 

By trusting that people can do a better job than “the system” ever could. 

Let me give you two examples.  One, the result of the general rules based approach.  Another the result of placing our trust in openness, evidence and the professionalism of the people of the NHS.

Two reports were published last month.  One, the Dr Foster Hospital Guide, argued that although there have been improvements overall, there were still high levels of “adverse medical events” combined with the widespread under-reporting of such incidents and too many hospitals with death-rates higher than one would expect. 

Contrast this to another report released last month.  According to a study by the European Association for Cardiothoracic Surgery, patients undergoing heart surgery in England have a greater chance of survival than in almost any other European country.  In the past 5 years, death rates have halved and are now 25% lower than the European average. 

This quite stunning improvement was not down to a government target.  It was the direct result of the collection, analysis and publication of outcome data by cardiac professionals.  It was their idea, their lead and it is they who should be lauded for the results.

If you take responsibility for patient safety out of the hands of professionals – from people – and place our trust instead in rules and regulations – in pieces of paper – then we run the very real risk of undermining patient safety.

This government’s approach is to trust the professionals, to empower people and to insist on a culture of openness and transparency to drive improvement.

Whistle Blowing

Now, transparency is not easy.  Especially when things aren’t as they should be.  It can be difficult to speak out when you see bad practice.  Too often, it is easier to just keep your head down and hope that the problem will go away.  It almost never does. 

Probably the biggest reason why people feel so nervous about coming forward is their perception that if they do they’ll be persecuted for it.  A culture of blame is a poisonous thing.  And it is incompatible with a desire to learn from mistakes and to deliver better patient care.

Staff should feel comfortable voicing concerns and know that they will be taken seriously. 

We want to amend the NHS Constitution to highlight enshrine these whistle blowing rights for staff, to expect them to act on any suspicions and to commit employers to support staff who raise concerns. 

Negotiating with the unions, we want to amend the terms and conditions of service for NHS staff to include a contractual right to raise concerns in the public interest.

We are issuing unequivocal guidance to NHS organisations that all of their contracts should cover staff whistleblowing rights.

And we will issue new guidance to the NHS to help them support those who raise concerns.

I want to do away with any remaining culture of fear, bullying and secrecy, and to do so as quickly as possible. 

Surgical checklist

Hand in hand with openness must go a commitment to implementing what the evidence shows us improves clinical safety.  One excellent example, and one that you will all be familiar with, is the World Health Organisation’s “surgical safety checklist”.

The WHO estimates that every year, around half a million people die needlessly on the operating table.  Their surgical checklist, inspired by the aviation industry – a sort of pre-, during- and post-flight check – has now been implemented in all NHS organisations. 

A recent study in the Netherlands demonstrated how the same list there has reduced deaths by almost half and complications by more than a third.

Now some may take umbrage at being made to make such basic checks, but I believe the BMJ had it right when they said the following in an editorial last year.

It said, “Try asking your neighbour – ‘If we were going to operate on you, would it be a good idea to take a few minutes to ensure all the operating theatre team knows the plan and we have the correct equipment? – the answer is predictable.”

European Working Time Directive

A recent survey of NHS Trusts in England by the Royal College of Surgeons of England highlighted the impact of the Working Time Directive on the NHS.  They estimate that NHS Trusts in England spent more than three quarters of a billion pounds last year on locums.  That’s almost double what was spent three years ago.

We are committed to reduce the amount of money we spend on agency and locum staff.  None of us want to return to the bad old days of doctors too tired to work safely, but we need to be flexible. 

People should be able to choose the hours they work.  The Coalition Agreement commits the government to limiting the application of the Working Time Directive.  People already have the right to opt-out of the agreement and work up to a maximum of 56 hours a week if they so wish.  We will support anyone who wants to exercise this right.

At the same time, we are taking the Working Time Directive back to the EU.  We want to keep people’s right to opt-out of the agreement but also give ourselves, not least in health, the flexibility we currently lack.

Reform and Finance

But it’s not only safety that we wish to place in the hands of professionals.  In July, we outlined our plans to reform the NHS in England.  In the coming years, there will be a wholesale devolution of power from Westminster to the front line of healthcare.  For those who may be unfamiliar with these plans, allow me to set out the main points.

First, we will hand responsibility for the design and commissioning of local health services to GP Consortia, working with their colleagues across primary, community and secondary care. 

Second, all hospitals and NHS organisations must achieve “Foundation Trust” status, giving them the freedom and responsibility to organise themselves as best they can, free from the shackles of central government. 

Third, we will create the largest and most vibrant social market in the world by allowing any willing provider to compete to provide patients with the very highest levels of care.

And fourth, we will give power directly to patients to choose their GP and – with the support of their doctor – the choice of where, when, how and by whom they are treated. 

Patients will become an active participant in their own care, not just a passive recipient of it. 

To make all of this happen, we will spark an information revolution.  We will publish as much data as we can in a way that is accessible and easy to understand.  Not only will this give patients the information they need to make informed choices, it will tell health professionals how they are doing in relation to their peers – as cardiac surgeons have done – and it will give all sorts of organisations the ability to study and scrutinise the day to day performance of every part of the NHS. 

These reforms will place the Health Service in England under a more brilliant and disinfecting spotlight than ever in its history.  And they will place patient safety as the single most important aspect of every decision made within the NHS.

Why now is the right time

One thing that that will be obvious to you all is the economic backdrop to any NHS reforms wherever you happen to be in the United Kingdom.  Above all else, this government is determined to restore order to our public finances.  Despite our commitment to continued, significant investment in the NHS, we will still need to find massive efficiency savings – up to £20 billion – from within the NHS budget to continue to meet demand.

£20 billion pounds of savings, every single penny of which will be ploughed back into NHS front line services.

Some say that, with these financial pressures, now is not the time to embark on a programme of significant reform.  That to seek huge savings at the same time as changing the way we run NHS will create real and unnecessary risks to patient safety. 

But if we do not reform, meeting the financial challenge will be impossible. 

If we do not reform, doctors will continue to work with one hand tied behind their back. 

If we do not reform and replace politically-driven process targets with the pursuit of improved outcomes, patient safety will suffer.
I believe that you are far more capable of improving patient safety than any number of pieces of paper from Whitehall telling you how to do your job. 

It is not the people of the NHS who are at fault, it is the system.  And the only way to really improve patient safety, is to reform that system and to put our trust in the professionals.

Thank you.

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