At long last, a public acknowledgement that being honest and open about medical mistakes that cause pain and suffering is not only humane but ultimately saves millions of pounds.
Jeremy Hunt, the chair of the Health and Social Care Committee (HSCC), commenting on a report commissioned by the committee into the safety of maternity services on the BBC Today programme (6 July), said that the ‘culture of blame’ that persisted throughout the NHS, in spite of numerous initiatives to promote transparency, was “stopping staff admitting mistakes and lessons being learned”. He then went on to say that the cost of ensuring maternity units were properly staffed would be in the region of £250m – 300m. On the face of it, this seems an enormous figure until you look at the total NHS compensation bill, which amounted to £2.3bn alone for 2019/2020 (of which maternity claims accounted for 40%).
Why does a culture of blame persist?
Mr. Hunt noted in his interview that if the NHS was to adopt a similar no-blame compensation scheme like Sweden, with lessons being learned and implemented to stop the same mistake being repeated, around 1000 babies’ lives a year would be saved. By contrast, our system is based on establishing legal liability by proving clinical negligence. This, as the HSCC report notes, puts clinicians in an invidious position: on the one hand they are asked to be open and honest about what happened as part of an investigation and, on the other, interrogated by the Trust’s legal team to find out where the blame lies.
As I have pointed out in other blogs, people and families who have suffered as a result of medical errors have to fight for compensation because proving liability is a long and stressful process. Not only that, but once an investigation is underway, they are often not involved as part of the process to find out what went wrong. As the HSCC report neatly sums up: “While legal redress provides families with financial compensation, that is not the only or primary reason for pursing litigation. Important motivations for families are the desire to prevent similar incidents in the future; the need for an explanation and apology; and the importance of accountability.”
Patient safety should be a core principle
The blame culture identified in the HSCC impacts directly on patient safety and affects all corners of the NHS, not just maternity services, despite there being no shortage of recommendations over the last 10 years on how to improve it. As Patient Safety Learning, a charity dedicated to improving patient safety, notes: “striving to reduce harm is not the same as striving to be safe.” Its ‘A Blueprint for Action’ insists that patient safety should be a core principle within any good healthcare system, much as sterilising surgical equipment is core, rather than as ‘a strategic priority’ which can be traded off against other priorities. However, this is dependent on a willingness to be open about mistakes made and lessons being learned and shared widely - not just among the affected team at Trust level, but beyond, to the whole of the NHS - so that the same mistakes do not keep being repeated. The charity identifies six ‘evidence-based foundations to address the causes of unsafe care’: shared learning; leadership; professionalising patient safety; patient engagement; data and insight; and culture. The HSCC report references all these points.
Open and honest engagement with patients
Time and time again, the patients I represent just want to know what went wrong and to receive an apology. Most accept that things can, and do, go wrong but when they are excluded from the investigation and repeatedly sidelined, their only recourse is to litigate. Although most experts agree that listening to patients and their families, and being open and honest when things go wrong, is critical, such agreement often fails to translate into action. In a recent example, a neurosurgeon at Coventry & Warwickshire Hospitals Trust has recently been (rightly) criticised for his ‘lack of openness’ in a case where his poor standard of surgery resulted in one of his patients suffering nerve damage and bladder incontinence.
All the major inquiries into hospital failures have cited the ignoring of patients and their families as a major factor in the inability to learn from mistakes and implement safer ways of working. Indeed, it was the Cumberlege Report into patients seriously damaged by pelvic mesh implants, that recommended the creation of a Patient Safety Commissioner to act as a champion for patients. This now has a statutory basis in the Medicines and Medical Devices Act 2021 and the government is currently consulting on the appointment process and operation of the position.
Embedding patient safety needs a long term approach
Clinicians occasionally need to be reminded that their first priority should be ‘to do no harm’ and that the patient is central, and not incidental, to the procedure or treatment they are undergoing. The same principle applies if something does go wrong and an investigation is launched: the patient is a central player and their story is critical to the outcome. However, what is crystal clear from all the reports that reference patient safety is that some Trusts have embedded patient safety as core, others still view it as a ‘nice to have’. There must be an overarching desire to bring these jigsaw pieces together to create one picture rather than a patchwork. And then there is the elephant in the room: spend money now, to save billions later. As the HSCC report noted: “Staggeringly, the £1bn paid out in maternity compensation in 2018/19 was nearly twice the wage bill for all of England’s obstetricians and gynaecologists combined.” Patient Safety Learning’s Blueprint for Action made the same point – 15% of hospital expenditure is directly attributable to patient safety failures.
This is not rocket science but it needs politicians to listen and take the long view.