Culture is the foundation of patient safety

Robert Francis mentioned at the Commons health select committee the CEO of a nuclear power company who went out of his way to thank people who gave him bad safety news.

It reminded me of a friend who is an officer in the US navy. He works in naval reactors and they do not wear uniforms. It is a signal to any sailor with anything to say about nuclear safety that rank is not a problem. Safety is always the first item on the agenda.

My point is that whatever your sector, culture is recognised as the foundation of safety. And culture is managed. It is analysed, thought about and modified.

Nuclear engineers, airline pilots and chemical engineers have their targets, ambitions, goals. But they also know that human factors are real, tangible and there to be managed. They know some cultures are more prone to blowing people up than others. 

The culture of the NHS is not inherently safe, responsive or open. To become so it needs to be actively managed in that direction. There’s nothing wrong with pace-setting managers or deeply expert clinicians, but not everyone should be of one ilk or the other.

Unbalanced culture

Leadership teams need a balance of skills and styles, but most organisations do not actively manage the assembly of that balance. Usually they get as far as looking for a range of experience.

Rarely do you look at an organisation and say it has a true mix of styles, backgrounds, motives and points of view, or see how the organisational values are the ones needed to deliver its goals.

‘Each individual, organisation’s leaders and profession will need to reflect and act in a way which signals a new focus on the patient’

And that for me is the deep issue behind the scandal at Mid Staffordshire. The culture of the hospital was not balanced. One view dominated, clinicians acquiesced and patients were ignored.

No one was demonstrating what the culture to drive great patient outcomes looked like. No one was managing the culture in that direction. It wasn’t that they were chasing targets − it was that chasing targets became the culture.

The prime goal of the NHS is for the money available to deliver the best possible outcomes for the population. The secondary goal is to shape the NHS to meet the needs of the future population in a way which is sustainable.

New transparency

To achieve this will need a form transparency we have never known. It needs parity of esteem between the patient voice, the clinical voice and the manager. This parity will need to be local with individual patient representatives, individual clinicians and local managers all in the room together improving services.

It will also need to be national, with the collective patient voice, the clinical professions and the system leaders in another room with all three views contending to form the right collective solutions.

It is partly the role of the NHS Commissioning Board to set the tone. But if the broader NHS is to change, each individual, each organisation’s leaders and each profession will need to reflect and act in a way which clearly signals a new focus on the patient and their needs. The challenge is where to start.

In cancer we think we have developed the first domino. After five years of thinking, developing, testing and improving, the National Cancer Survivorship Initiative is about to say to commissioners that if you only do one thing, commission the Recovery Package. There is more they could and should do, but this will give them the head start and allow them to drive patient outcomes. And it is both simple and consistent with other conditions.

‘It is on the ground that the new patient-centred NHS will need to appear if we are to snatch some good from Mid Staffs’

Commission an electronic holistic needs assessment with associated care plan, a treatment summary record and high-quality cancer care review, and a health and well-being clinic − all as a package.

Stop commissioning routine follow-up appointments for any service which has not risk stratified most patients into supported self-management.

Effectively what they are doing is commissioning a proper understanding of patient need and proper communication between acute and primary care − while saving money.

The real battleground

I predict three forms of resistance: lots of people choosing not to believe the evidence; clinicians being reluctant to change engrained habits; and commissioners fearing patient needs they don’t know how to address.

Apply the test of Francis, of course, and these fade away. Evidence from patients is evidence from patients. The expectation the new NHS has of its clinicians is to constantly improve their service. Unaddressed problems come back later to bite commissioners expensively.

This incremental, consistent improvement is for me the real battleground of the Francis report. The secretary of state, the commissioning board, Monitor and NICE can all do their bit. But it is on the ground that the new patient-centred NHS will need to appear if we are to snatch some good from the immeasurable suffering at Mid Staffordshire.

Ciarán Devane is chief executive of Macmillan Cancer Support