Having worked as a hospital manager myself before switching to my legal career, I always have sympathy for the dedicated health professionals working on the front-line when reports of widespread errors in the NHS surface.
I know that given my role as chief executive of a legal firm which often holds the NHS to account for mistakes and negligence causing patients harm, it may be a statement which sounds somewhat strange.
However, I have never personally questioned the dedication and desire of the vast majority of those directly caring for patients to do their very best for them, each and every day.
I have personally experienced how consultants, doctors, nurses and ancillary staff work with a passion to provide the very best care, and have seen the devastation felt when things don’t go as they should.
The problem though is that things do often go wrong in the NHS, and on a large scale.
That was highlighted recently when it was revealed prescription mistakes and drugs mix-ups have contributed to as many as 22,300 deaths in a year.
Trusts must be well managed and tackle roots of problems leading to errors
The figures are truly shocking and inexcusable, and led to Health and Social Care Secretary Jeremy Hunt pledging greater transparency over mistakes, bringing in measures to protect people such as pharmacists from being prosecuted for genuine errors.
Mr Hunt says the move aims to create a more open culture across the NHS, where people feel more able to own up to making mistakes.
That is all well and good, and honesty and transparency over errors in the NHS is one thing we consistently call for at my firm Hudgell Solicitors, as we believe it is key to ensuring lessons and learned and changes are made.
This is not a new problem however, or a new pledge by a Secretary of State to improve both candour and safety. Actions and outputs speak louder than words.
There is danger at such times that the focus can be placed too easily on those delivering care, and not those managing it. I also fear still too little focus is being placed on prevention.
Throughout my career both as a hospital manager and as a medical negligence lawyer, I have always found it is rarely an individual to blame for a serious error in care, but a system failure or lack of clear procedure which has caused things to go wrong.
Strong leadership can lead to big improvements in performance of Hospital Trusts
It is my firm belief that strong leadership teams at Hospital Trusts are needed to implement changes and oversee improvements in performance.
I have seen some Trusts turn around their standards and performance once strong leadership teams have taken control. It is all about them owning responsibility for policies, procedures and protocols.
American surgeon, writer, and public health researcher Atul Gawande is a big believer that the medical profession should learn from others in terms of reducing errors, and some years ago described how he believed there was a lot for hospitals to learn from the aviation industry, where mistakes are minimal.
He visited Boeing and was struck by how the air industry relied ‘over and over again on checklists’, which are used by pilots for handling takeoff and landing not just in normal circumstances, but even when handling a crisis emergency with only a couple of minutes to make a critical decision.
Every tiny detail, even the most obvious, is included and checked as part of each and every process.
Such an approach was highlighted as being crucial when pilot ‘Sully’ Sullenberger brought down his plane in the Hudson River after a bird strike, saving 155 lives. He cited ‘teamwork and adherence to protocol’ for getting them down safely – not individual skill and experience.
Gawande explained that when two-minute checklists were introduced into operating rooms in eight hospitals in the US, including using simple reminders such as making sure blood was available and antibiotics were in place, they achieved ‘massively better results’
Basic mistakes were spotted and they also found that simple changes, such as ensuring everyone involved knew one another’s names, made for a more productive environment, where people were more likely to speak up later if they saw a problem.
When a survey was then carried out of doctors who used the checklist, ninety-four per cent said they’d want the checklist when going into an operation – doctors who had previously not seen the need for such a list at all.
Healthcare can’t rely on instinct and knowledge – only strict procedures can lessen risk
Gawande’s point was that healthcare is often too reliant on instinct and expertise developed over time, and knowledge, not procedure.
He called on those in healthcare to recognise that even the best experts are fallible, and that they need to be supported by strong management, and clear systems and protocols which help them do what is without doubt a difficult and challenging job. Essentially, helping them not to make mistakes.
Airlines recognised long ago that systems and protocols are the only way to ensure consistency and reduce errors across the board.
It is certainly something I agree with, as in so many cases in which we see life-changing injuries caused, or even fatalities, we identify a procedure failure at some stage. Mistakes have most often not been down to one individual error, and many could have been prevented at a number of stages in the treatment process.
There are many great people working on hospital wards across England and Wales, but we need even more great leaders, accountable to their local communities.
We need leaders who display clear direction, do not seek to make excuses, and are zealous in their search for, and policing of, the right systems and protocols to help all professionals involved in patient care work better together to cope with the ever-increasing demands upon them, and give patients the treatment they need and deserve.