Westminster Patient Safety Symposium.

With these words, Sir Jeremy Hunt MP opened the first ever Patient Safety Symposium in the House of Commons. It’s an unarguable statement, and an indictment of our current situation that it needs to be said out loud. The symposium is the fruit of the All-Party Parliamentary Group on patient safety, set up jointly by CHFG, AvMA and Patient Safety Watch. Speakers included CHFG trustees Charles Vincent and Tom Reader, and CHFG ambassadors Richard Duggins and Susanna Stanford, while sessions were chaired by our founder Martin Bromiley, and COO Dawn Benson. Here’s our distilled version of the main themes of the event.

War of Independence

NHS England CEO Jim Mackey warned of ‘false binaries’, where organisations feel obliged to choose between safety and financial management, arguing that these must always be connected, to murmurs of approval. Another view is that they should be separated – the Civil Aviation Authority is responsible for safety, while cheerfully indifferent to the financial wellbeing of any individual carrier or airport. And in aviation, as RCN boss Nicola Ranger pointed out, ‘safety is a given’, rather than the optional extra it is in healthcare.  Maybe NHS organisations have been marking their own homework for too long? There is legislation governing how many animals a dog-walker can look after, but no binding limits on nursing ratios. Maybe expedient safety decisions are made because there’s nothing to stop them?

Meanwhile, concerns were raised about the one genuinely independent safety body, HSSIB, as it prepares to be swallowed whole by the Care Quality Commission, a move described by Charles Vincent as ‘madness’. The ‘safe space’ that HSSIB has created depends entirely on the fragile trust of staff and patients in its independence. Reassurance on this point came from the floor via CQC Chief Inspector of Hospitals Toli Onon, who explained that HSSIB was merely being ‘hosted’ within the CQC. Which is not as reassuring as it sounds. Mike Durkin reminded us that we are global leaders in safety investigations and safety research, but we are by no means leaders in safety. His was a thoughtful speech brought crashing down by the unprovoked use of the word ‘improviasts’ to describe those campaigning for safety. Sorry Mike, that’s not in the dictionary, and we hope it never will be.

Take the load off

Another signal coming through loud and clear was system overload: we’re not doing too little ‘safety’ work, we’re doing far too much. The sheer volume of recommendations is overwhelming the ability to respond. The instinct is always to add tasks and procedures, and never to remove them. ‘Safety clutter’ is everywhere: for example the double-checking of medication, which takes time, doesn’t work, and has effective alternatives. Charles Vincent pointed out that there are 126 organisations with a regulatory influence in the NHS, and that a routine hip replacement involves 75 different procedures to follow in the first 24 hours. There is an urgent need for regulatory streamlining. The preponderance of local solutions – or “one-off bodges” to quote Mary Dixon-Woods – leads to ridiculous levels of wheel-reinvention. And so we end up with 147 different obstetric early warning scores across the NHS.

Staff safety is patient safety

Richard Duggins gave a sobering insight into his work with staff suffering burnout, arguing powerfully that workforce wellbeing is inextricably linked to patient safety. His story of the nurse having panic attacks in the car park, who asks ‘what have I done wrong?’ will linger with many. 56% of staff admit coming to work when not well enough, something known to double the risk of unsafe care. And burnout isn’t about individual fragility, it’s a system problem, requiring a system solution. Shaun Gallagher presented GMC research showing that one-fifth of doctors are at risk of burnout, and a quarter had a stress absence in the preceding year. These are unsustainable figures, and it is hard to see how progress can be made in safety until they change.

Patient experience is data, and it is being systematically ignored.

AvMA CEO Paul Whiteing complained that patient concerns are dismissed as subjective or emotional, or anecdotal, and never treated as data – a point echoed by Nadine Montgomery and Susanna Stanford. Countless episodes of harm can be traced back to a single failure to listen. Tom Reader pointed to the wealth of untapped feedback from patients. The complaints system was sent a quarter of a billion words by patients in the last year, data that needs to be harnessed to pick up on early warning signs of failure.

Jono Broad  warned that we are “not yet turning listening into action”, though it sounds like we are not yet listening at all. He invoked Chestertons’ Fence  as he urged us to reject the Dash report, which he said was uninterested in why the safety organisations were set up in the first place.

Preaching to the Choir?

The room was certainly full of like-minded safety enthusiasts, but it wasn’t all group-think. Mary Dixon-Woods’s remarks about transgressive behaviour, with the assertion that ‘bad apples’ do in fact exist, and no-blame culture can allow them to escape scrutiny, divided opinion. A culture conspicuously bent on weeding out wrong ‘uns  is hardly conducive to honest and open reporting of errors. However, the day had begun with the breaking news from Great Ormond Street, revealing the catalogue of harm caused by a single poorly-performing surgeon, showing that this is a problem we have yet to get to grips with. And although the guest list was a proper Who’s Who of the patient safety world, Members of Parliament were disappointingly thin on the ground. Notable exceptions were Lizzi Collinge, the Member for Morecambe, and Bernard Jenkin, who took copious notes and made important contributions from the floor.

We heard a lot more about problems than solutions, but it still felt like an enormous step forward. Above all it felt holistic: we started to combine the different perspectives to see how the pieces of the patient safety jigsaw fit together. Onwards and upwards.