Patient safety: no room for complacency

Health secretary Matt Hancock addresses the Patient Safety Learning Conference at The King's Fund, London

Thanks for having me today.

Anyone who has had family members needing care knows what it feels like to sit and wonder whether or not someone you love is going to be OK. You take it for granted that the care you receive will be safe, but sadly we know that’s not always the case.

Ensuring patients are safe underpins everything we do. I’ve set out my early priorities – workforce, technology and prevention.

Patient safety is the golden thread that runs through all of them.

I’m fresh off the night shift with the fantastic staff at Derriford Hospital in Plymouth so forgive me if I look a bit tired!

The compassionate and good-humoured nurses, doctors, managers and paramedics I met all told me the same thing: they focus relentlessly on patient safety.

They said they need safe systems around them. Opportunities to learn from mistakes are crucial. And a culture where staff are empowered to speak out when things go wrong.

In my first few days in the job, I agreed with Dr Aidan Fowler, the new NHS Director of Patient Safety, that the new national patient safety strategy will mean safety is cemented into our long-term plan for the NHS.

I want to pay heartfelt tribute to Jeremy Hunt, who led this agenda and drove it for so many years. Be in no doubt: we will drive it for years and years to come.

We’ve made huge progress over the last few years. The CQC is internationally recognised for its inspection regime – driving up standards across the NHS and improving care for patients.

Patient Safety Learning have put forward a very positive set of proposals. Dr Fowler will soon set out an exciting and powerful vision for patient safety over the next decade. Every patient – whether in hospital, at home, in a GP surgery – expects compassionate, effective and safe care.

To achieve that, we need to improve learning, we need to better shout about the work that the best trusts are doing, and the NHS must be as open and transparent as we can.

Commitment to learning

There are many figures I could quote – numbers of errors, adverse events. But in some ways they hide the real issue – which is the impact on people and families.

I won’t ever forget, James, the hot summer day you came into my office in the department overlooking Parliament and told me the sad, sad story of Joshua. We cried together, because nothing can bring Joshua back. And in so many ways the huge progress on patient safety is his legacy. James, I pay tribute to your work, to this series of conferences, and to your publication today which is a blueprint for the change we need to see.

We’ve heard today of the things we can all learn from those tragic events at Morecambe Bay. We’ve also heard of the emerging lessons from the first few HSIB investigations.

These lessons are vital. We must learn from them in our quest to make the NHS the safest healthcare system in the world. And we must apply those lessons to the whole health and care system.

Safety is not just about telling people to do better. Patient safety is about accountability, not blame. It’s an irony that to build a safer system we need less of a blame culture.

Instead, we need transparency and accountability in a positive culture, where people can have the confidence to be self-critical, because only then will we get the continuous improvement. And we need to improve the systems and processes that support staff. All with the goal of minimising human error.

The Learning from Deaths programme has been a major step. It means trusts better understand where care needs to improve. And it says trusts must have proper arrangements for learning from deaths of patients including, crucially, supporting and engaging with families.

And from April, medical examiners will significantly overhaul the way we learn from the care given to patients who die. They will confirm the cause of all deaths that don’t need to be investigated by a coroner. Bereaved families will be better involved and offered more opportunities to raise concerns so we can ensure that we learn from mistakes and more families don’t have to go through the agony of unnecessarily losing a loved one.

At a national level, the Healthcare Safety Investigation Branch is a world first. It uses independent professional investigators to get to the root cause of some of the most serious patient safety incidents.

But I still want to go further. We will set up a new independent body to conduct investigations.

We have published our Health Services Safety Investigation Bill in draft, and I want to hear your views on how it should work.

And I want to ensure Professor Tim Briggs’s excellent work on ‘Getting It Right First Time’ helps us spread best practice on patient safety across the NHS.

The National Clinical Improvement Programme is emulating this approach at a consultant level. I was really impressed to see there’s a way for doctors to be totally upfront, sharing their individual clinical outcomes so they can learn from each other.

I also know that there’s often a case of information overload. Multiple patient safety alerts about a huge range of issues, meaning it’s hard to prioritise which matters the most.

So Aidan Fowler will head up a group of experts who will help you understand the clear actions that need to be taken, protecting patients from the most serious risks.

Opportunities of technology in health

Finally, we must harness the power of data and technology. IT issues can lead to patients being given poor care because systems don’t communicate. Ultimately lives can be lost.

We need to use cutting-edge technology to deliver safe, high quality and patient-centred care. And we need to use transparent open data to be able to spot anomalies that might indicate systemic failures. We’re moving towards full roll-out of electronic prescribing and medicines administration in secondary care to extend inter-operability and reduce medication-related error.

Our new Patient Safety Incident Management System will improve how we capture and spread the insight that we can gain from incident reporting in the NHS, harnessing the new opportunities for analysis that machine learning can offer, to ensure our safety intelligence remains cutting edge.

And we must – we must – improve the way we spot sepsis and save lives starting with our new ‘suspicion of sepsis dashboard’. Sepsis is such a devastating condition and I’ve been so incredibly moved listening to stories from families who have lost loved ones. We must do all we can to stop it.

The new dashboard will measure the number of patients who come to hospital with serious infections, and give quick information so doctors can see which of those infections cause patients to deteriorate very quickly and help them understand which treatments are most effective, and how to intervene quickly.

In the future, all this data will be used to help analyse which infections most often lead to sepsis. It is yet another example of how technology has the potential to improve patient care in the NHS when we can get the systems to talk to each other. And I’d like to thank the clinicians and experts at Imperial who have helped develop it. It is the next step in the NHS’s fight against sepsis. But we need to go further.

No complacency

Improving patient safety is a determined and unwavering commitment for us all. We must constantly strive to listen to patients and their families and listen to staff so that we can learn from mistakes, be innovative and continually improve.

We need a culture of humility, openness and learning. There is no room for complacency.

I want every one of those staff who care for patients to be able to work safely and deliver safe care. I want patients and their families to have total confidence in the care they receive. I want the NHS to rise to the challenge of being the safest health system in the world.

That is our goal. We can achieve it. And I look forward to working with all of you to get there.


From:
Department of Health and Social Care
The Rt Hon Matt Hancock MP

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