Inquiries alone will not tackle failures of care

Public inquiries are extraordinary vehicles for shining a bright light into the darkest recesses of the NHS. The Francis report maps out in incredible detail the systemic failures that contributed to the failings at Mid Staffordshire Foundation Trust. As was widely suspected, these failures span the entire healthcare system, from top to bottom.

Unfortunately, public inquiries are extraordinary in other ways too. They are rare, lengthy, one-off and expensive, and focus mainly on re-engineering the stable door years after the horse has bolted – and, in this case, after the whole stable block has been redesigned.

Terrible failures of care began to accumulate at Stafford Hospital eight years ago, yet only in the past few months has the NHS been presented with the full picture, along with 290 recommendations for improvement.

This prolonged cycle of disaster, inquiry and reform poses a troubling and urgent question – is there a better way? Can risks that span the entire healthcare system be uncovered and addressed quicker than this? Can the NHS get better at identifying and learning from systemic failures? One potential solution may be found by simply looking skyward.

On a cold and foggy morning back in January, Londoners woke to the shocking news that a helicopter had crashed onto a busy street in Vauxhall, killing two and injuring several more. Soon after, news headlines announced that an inquiry would be held into the safety and regulation of the airspace above London.

System-wide investigation

What was not reported was that this form of system-wide investigation is entirely routine within the aviation industry. After any air accident or serious incident the entire aviation system is examined – from individual behaviours and organisational cultures to regulatory structures and financial pressures – in order to identify the causal factors and recommend improvements across the whole system.

‘The NHS might develop its own capacity to routinely identify and address risks emerging across the entire healthcare system’

The aviation system has achieved extraordinary levels of safety in large part because of this routine, independent, detailed and systematic investigation of failures. Last year was the safest on record: there were around 40 million commercial airline flights around the world but only 21 fatal accidents.

The contrast with healthcare is striking. The NHS has no comparable mechanism to independently and routinely investigate risks that reach across the entire healthcare system. This is despite the huge number of deaths and serious injuries that result from safety lapses each year across the NHS – on many estimates causing equivalent levels of harm to several helicopters crashing onto Vauxhall every single day.

Investigations into safety and quality issues are of course commonplace in the NHS. Thousands are conducted each year by healthcare providers, commissioners, regulators and professional bodies. But these investigations each see only a small and partial piece of the puzzle, and are often coordinated by organisations responsible for designing, regulating or commissioning the healthcare services that are being investigated.

To address systemic failures that span the entire healthcare system – such as those uncovered at Mid Staffordshire, and Bristol before that – the NHS currently relies on the extraordinary vehicle of holding a one-off, prolonged public inquiry.

A serious gap

This points to a serious gap in the healthcare system as a whole: it is unable to routinely examine and improve itself. When it comes to understanding and addressing risks that span the entire healthcare system, the NHS is largely flying blind.

‘Our healthcare system needs to learn how to diagnose and treat itself, rather than having to wait for the next painful cycle of disaster’

The activities and functions of specialist safety investigators in other industries hold important insights for healthcare. They offer powerful lessons for how the NHS might develop its own capacity to routinely identify and address risks emerging across the entire healthcare system. Safety investigations in the aviation industry, for example, are conducted by a national air safety investigator – in the UK, the Air Accidents Investigation Branch based at Farnborough.

The core strength of the UK’s aviation safety investigator is that it is entirely independent of the system it investigates. It understands the system but stands apart from it, providing an impartial, balanced and critical voice.

Crucially, it is not a regulator and so has no stake in the current regulatory, financial or operational system. It analyses the system’s failures, highlights its weaknesses, recommends ways to improve and makes people accountable for delivering those improvements. Its authority derives entirely from its independence, its expertise and its public voice.

Inquiries are not enough

As the immediate implications of the Francis inquiry report are digested – and as government ministers begin planning the next inquiry at Morecambe Bay – we need to fundamentally rethink how the NHS investigates and learns from systemic failure.

Public inquiries serve a special and important purpose but they are not enough. The NHS needs to develop its own capacity to conduct routine, independent and authoritative investigations into risks that span the entire healthcare system. These investigations should provide regular and practical recommendations for systemic improvement. And organisations right across the NHS must be held accountable for making those improvements, from top to bottom.

It is more than a century since the first independent air accident investigation was conducted in the UK. As the NHS considers its collective response to the Francis inquiry report, it seems an appropriate time to follow suit. Our healthcare system needs to learn how to diagnose and treat itself, rather than having to wait for the next painful cycle of disaster, inquiry and reform.

Carl Macrae is a senior research fellow in improvement science at the Centre for Patient Safety and Service Quality, Imperial College London