In the UK, the NHS is a defining institution, and the House of Commons is frequently preoccupied with failed patient safety management as a national issue. All over the world, health systems are improving patient safety by learning from other safety critical industries, particularly from aviation. American surgeon, Atul Gawande, campaigned successfully for the World Health Organisation operating theatre checklist, and his brief book, The Checklist Manifesto, has become something of a bible amongst UK health professionals. Key to the modern philosophy is being ready to learn from mistakes. However, the culture in healthcare is still denial and to find blame, rather than to admit mistakes and so be able to learn from them.
It is not often that a Select Committee inquiry leads to major policy change, but here is a notable victory for the Select Committee system. This autumn has seen the launch of a new statutory body in England to investigate clinical incidents in healthcare, the Health Services Safety Investigation Body (HSSIB). A new Act of Parliament gives it statutory independence and special powers to investigate the causes of clinical failures without blame, and to make recommendations for healthcare safety improvements. It is modelled on the Air Accident Investigation Branch (AAIB), the UK’s world leading aviation safety investigation body. In future, HSSIB will hear aggrieved patients and relatives, as well as clinicians who are concerned that they have made an error. HSSIB has no power to judge or punish. Nor will it allow what people say to HSSIB to be used in court against them. HSSIB is a world first. Other countries have been carefully following the UK’s pioneering work on this.
Back in 2015, after a huge public inquiry into the scandalous breakdown of care at the Mid Staffordshire Hospital, the then UK health secretary, Jeremy Hunt, was candid with the Public Administration Select Committee. How many serious incidents per year? “About 30,000 every year, of which 10,000 are severe harm or death.” He also said there was massive under-reporting of avoidable deaths in the NHS. “How well do you assess that the NHS and your Department is doing this now?” he was asked, and he responded, “I do not think we have cracked the problem at all.”
A new Act of Parliament gives it statutory independence and special powers to investigate the causes of clinical failures without blame, and to make recommendations for healthcare safety improvements.
The following month, the Committee reported to the House of Commons that the quality of most investigations into clinical incidents fell far short of what patients, their families and NHS staff are entitled to expect – “no systematic and independent process for investigating incidents and learning from the most serious clinical failures. No single person or organisation is responsible and accountable for the quality of clinical investigations or for ensuring that lessons learned drive improvement in safety across the NHS.”
The Committee recommended that the government should bring forward proposals, and legislation, to establish a national independent patient safety investigation body. To his credit, before we finished drafting our report, Jeremy Hunt had announced to the House of Commons that the government was adopting this policy. There followed a year-long consultation and many meetings of a consultative group of people involved with safety management and accident investigation, including with representatives of victims and the bereaved.
The government then established a ‘shadow HSIB’, which has done its best to develop expertise and capacity, and has started to cut its teeth on investigations, but it could never function as the statutory HSSIB now will. It lacked independence, the necessary powers to require the NHS to give it access to information and people, and the crucial ‘safe space’ for whistle-blowers and others to speak freely.
People make mistakes. The interesting thing to learn is why, and how to avoid the same mistake in future. Solutions can be very simple, like colour coding different intravenous drips, which has saved 1000s of lives.
People make mistakes. The interesting thing to learn is why, and how to avoid the same mistake in future.
HSSIB will operate outside the rest of the healthcare system. It has the power to investigate anything that it considers to be in the interests of patient safety, including any regulator like the NHS inspectorate, the Care Quality Commission, or professional bodies like the National Midwifery Council.
HSSIB’s most controversial special power is the ‘safe space’ – the ability to receive information and personal accounts of incidents, which are protected from disclosure, even in Court. The government has strived to promote a no-blame culture in the NHS. It introduced the ‘freedom to speak up guardians,’ a ‘duty of candour’ on NHS clinicians and staff. HSSIB will provide meaningful protection for people speaking up. There will be no more cases like Dr Bawa-Garba, a junior obstetrician who spoke freely, and then was wrongly convicted for manslaughter and struck off by the GMC for doing no more than telling the truth of her error. She was reinstated, but only after a battle. The causes of the infant death were systemic, not down to a single culpable personal failure.
HSSIB is an entirely additional, permanent capability in healthcare devoted solely to promoting patient safety. It is not a regulator, or a prosecutor, or an advocate for anyone or anything other than for patient safety.
The provision in the national accounts for medical negligence cases is over £80 billion. HSSIB will pay for itself again and again if it saves only a small fraction of that.