Why it’s the little things that matter

This is going to get a bit ranty at points, & I’m finding it really hard to write for some reason, so I will try and remain coherent…

It’s a year since the Francis Inquiry published.  If 2013 was the year of the big 3 reports into NHS failings (Francis/Keogh/Berwick), the details in the Public Inquiry into failings at Mid-Staffs (Francis) was probably the most harrowing as far as personal stories were concerned.  Unsurprisingly, this has generated a lot of interest at the one year anniversary: how do we move on, take the lessons from Francis (and the others), and make the NHS better?

Yesterday I went to a conference on Implementing the recommendations to The Francis Inquiry.

It was a brilliant line-up, including people I’d always wanted to hear in public like Julie Bailey & Ann Clwyd MP.

I work in the NHS and I find some things just appalling.

Why on earth does an organisation that’s responsible for the care of millions of people make it so hard to complain?

Why is it only in the past year that there’s been legal protection for healthcare professionals who blow the whistle on persistent failings?

But if you’re getting as far as making a formal complaint, or whistleblowing, then there’s already a big problem.  More importantly, if as an organisation all you’re paying attention to are the formal complaints, then you’re only listening to the people who have the time and energy to put forward a complaint.  Because we know that getting your voice heard in the NHS to raise your concerns isn’t easy, whether it’s as a patient or as a member of staff.

One of the phrases that keeps coming up again, and again, and again is the need for a culture change.  In the words of Julie Bailey (Cure the NHS) “…we are reliant now on those that work in the NHS to change the culture and to make it safer for us all”

The problem with that is the comment from the Chair for the morning session, Sir Richard Thompson (RCP, London) that started off the morning.  As you can probably tell, this did annoy me a little bit…

Why was I so annoyed? There are the obvious reasons: it’s a hard realisation that actually, despite my pontificating on this blog, that “giving up” on reporting your concerns is a real danger. And that probably affects the response to Francis if we’re honest

I don’t want to think of myself like that, but the reality is that that could be me.

But the other reason is that it doesn’t solve anything.

Now, I take the point that we can’t keep blaming “the system”

But where you have a consistent problem with reporting, then maybe we need to accept these failings, and make the system better.  And that means making it easier for everyone to raise their concerns in the NHS.

What Francis showed is that there were warning signs, and they were ignored.  Nobody wants to get to the state where there’s another Mid-Staffs.  Things are going to happen; if we’re honest we have to accept that the NHS can & will fail patients.

For me, that means that when the warning signs start, we have to pay attention, and pay attention early.

So I think we need to focus on the little things.  

Responding to patient complaints, and protecting whistleblowers; these things are important but they’re just the tip of the iceberg. They’re what happens once there are consistent and repeated failings in the NHS.  What are we doing about the systems that are supposed to act as early warnings?

In my naive brain, here’s how the system is supposed to work:

  1. Healthcare professional reports adverse incident (missed drug administration)
  2. Incident is investigated
  3. Possible underlying causes are identified
  4. Monitoring of other, related incidents is initiated
  5. Feedback to the reporting healthcare professional
  6. Education & development to reduce the modifiable risks

Incident reporting is one example: as doctors, I think we’re terrible at reporting clinical incidents & near-misses.  The process is inconsistent, and we don’t really accept why it’s important.

My personal experience of incident reporting is variable: sometimes I get a clear response of what the investigation has found and what the next steps are.  (These actually do make a difference – like the blood culture samples that disappear because the processing system doesn’t work = new computer system!)

Sometimes the form disappears into a black hole with a polite, noncommittal e-mail telling me that “my time is appreciated”.

And nothing else.

As professionals, if we can’t see the benefits of reporting near-misses/medication errors/under-staffing before they become major problems, then that’s a problem.

It’s a problem for professionals because they are excluded from the system that is part of their professional duty of care.

It’s a problem for Trusts & Boards because they don’t know what’s happening on the floor and can’t react to issues at the “smoke alert” stage

And most importantly, it’s a problem for patients because the systems are there for alerting potential problems but we’re not focusing on the warnings.

So how are we supposed to stop another Mid-Staffs if we’re not concentrating on the small things?


3 thoughts on “Why it’s the little things that matter

  1. Reblogged this on UK ED Monkey and commented:
    I think we can all be guilty of letting the little things slip because the Titanic momentum of the NHS in action can make the problem seem insurmountable. But, like they say, how do you eat an elephant? One bite at a time.

  2. Hi Carmen – I also found the opening comment from the RCP a bit annoying (and quite naive)! I was more impressed when later on his slides he said: “In the right circumstances we can all lapse and be cruel”. I’ve reblogged this on UK ED monkey as I think you have some very valid points about how much we can ignore smoke signals.

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