Quality failures in the NHSBMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39486.406308.80 (Published 14 February 2008) Cite this as: BMJ 2008;336:340
- Chris Ham, professor of health policy and management
- 1Policy and Management, Health Services Management Centre, University of Birmingham, Birmingham B15 2RT
The report of the committee of enquiry into Ely Hospital, Cardiff, in 1969, was the first major inquiry into quality failures in the National Health Service.1 Thirty years later the report of the expert group chaired by the chief medical officer, An Organisation with a Memory, emphasised the need for the NHS to learn from its mistakes, and to be more systematic in acting on inquiry reports.2 A new analysis by the Healthcare Commission builds on these reports by summarising lessons from 13 major investigations it has undertaken since 2004.3
Readers of the commission’s report can be forgiven if they experience a strong sense of déjà vu. Although the investigations it undertook covered a wide range of services in different parts of the country, the general themes that emerge are depressingly familiar. The quality failures examined resulted from the interplay of several factors, including weak leadership, conflicting targets, inadequate use of data, and lack of teamwork. One of the problems highlighted in the commission’s report is the poor standard of care found on general hospital wards, including examples of patients not being helped to eat their food and not being given their drugs.
Why is it so difficult to learn from mistakes and reduce avoidable errors? Part of the answer lies in the sheer size of the NHS and the large number of interactions between patients and providers that occur each day. In the absence of well developed systems to promote consistently high standards of care, mistakes are likely to occur, sometimes with tragic consequences.
In fact, the problems investigated by the commission were less the result of individual failings than the consequence of institutional shortcomings. The story that emerges from its report is of hospitals and services lacking effective direction and tolerating ways of working in which quality failures are accepted rather than challenged. In the words of the chief medical officer’s report, the institutions concerned lacked a “safety culture” and were therefore at risk of patients being abused and adverse events occurring.
What needs to be done to restore memory to NHS organisations? A major step forward would be for ministers and civil servants to heed the warnings contained in the report about the negative consequences of continuous organisational restructuring on the quality of patient care. As the report states, “if not carefully managed, the process of organisational change can divert management away from maintaining service quality.”3
Equally important is the need to ensure that NHS boards pay as much attention to quality and safety as financial balance and hitting government targets. In theory, the duty of clinical governance laid on the NHS in 1999 should have persuaded chief executives to take quality seriously. The evidence reported here shows that this has not happened universally, nor have board members always used and questioned the data presented to them to exercise their stewardship role effectively.
Even more challenging will be bringing about the changes in culture that will enable the NHS to achieve the same level of safety as the airline and nuclear power industries. Among other things, this entails putting in place systems designed to reduce errors, providing appropriate training and development for staff, and ensuring that mistakes are measured and monitored. Above all, NHS organisations need to encourage the open reporting of adverse events and avoid staff feeling they will be blamed when things go wrong.
Diagnosing what needs to be done is relatively easy; making it happen is much more difficult. An Organisation with a Memory emphasised how important it was for the NHS to learn from mistakes and to do this actively rather than passively. The analysis produced by the Healthcare Commission shows that this has yet to happen, so that inquiries and investigations in the future may find similar failings, unless leaders at all levels make a commitment to ensuring that quality and safety are taken seriously.
If this is to happen, the NHS needs to match its record of achievement as a “doing organisation” and become a “learning organisation.” Governments have rightly focused on priority areas—for example, cutting waiting times and improving areas of clinical priority such as cancer and heart disease—because of the legacy of poor performance in the NHS. Success in dealing with these priorities needs to be complemented by a focus on continuous quality improvement, in which clinical teams are supported to build on what works well and to learn from things that have gone wrong.
How to make this happen can be gleaned from a new study of high performing healthcare organisations in different countries, which describes the journey taken by these organisations and the factors that have contributed to their success.4 As the study makes clear, achieving high levels of performance cannot be reduced to a cookbook approach in which organisations implement lessons from the study of failure and success. A more nuanced approach is needed, starting from the position that each organisation has to find its own path of improvement appropriate to the context in which it operates and based on making changes on several fronts at the same time.
An area of common ground between this study and the report of the Healthcare Commission is the emphasis placed on leadership in bringing about change. Of particular relevance for the NHS is the commission’s view that continuity of leadership is important (one of the organisations it investigated had seven chief executives in 10 years). Strengthening leadership for quality improvement may be the key that will finally unlock the secret of learning from mistakes, provided that this is done in the clinical teams providing care as well as at board level.
Competing interests: CH was director of the strategy unit in the Department of Health between 2000 and 2004.
Provenance and peer review: Commissioned; not externally peer reviewed.