“There is a culture within many parts of the NHS which deters staff from raising serious and sensitive concerns and which not infrequently has negative consequences for those brave enough to raise them”
(Sir Robert Francis QC, Freedom to Speak Up report - http://webarchive.nationalarchives.gov.uk/20150218150343/https:/freedomtospeakup.org.uk/)
The NHS has an excellent track record in recruiting and developing the very best - the brightest, the most dedicated and the most caring. Our staff have a passion for providing the highest quality care that they can, and a commitment to continuously improving their knowledge and their skills. We must not forget that what staff learn through the experience of giving care is at least as valuable as what they are taught in the lecture theatre. Learning through experience is the key to improving the quality of people’s care. This includes learning from mistakes.
We need to create the right conditions to enable staff to learn from their experiences, including their mistakes. All too often, they tell us that there is a culture of blaming, not learning. That is why the Government wants to change the atmosphere in which NHS staff work.
There is a strong connection between ‘psychological safety’ and a culture of learning within an organisation. In a true culture of learning, staff can feel confident they will be treated fairly, and patients and families can be assured that errors and the causes of them will be fully explored. Creating and sustaining this broader culture of psychological safety and learning is down to leaders and managers in the system. For them to be able to do so, the Department of Health, as steward of the health system, needs to set the right conditions for such a culture to flourish.
Recent inquiries have illustrated that staff need to feel more confident that the information they give to safety investigations, which have the sole function of learning from errors, will not be used unfairly. That is why we are proposing to create a 'safe space' - a statutory requirement that information generated as part of a safety investigation will be kept confidential and will not be shared outside the investigation's boundaries, except in a number of limited circumstances.
This is used currently by the Air Accident Investigation Branch (AAIB), where investigators are able to offer this safe space to those they speak to, thanks to the robust statutory framework in which they work, arising from regulation-making powers in primary legislation. A key aspect of this statutory framework is the duty not to share information given in the course of an investigation with any other individual or body, unless (usually) there is a High Court order.
The proposal outlined in this consultation is to create a statutory prohibition on the disclosure of material obtained during certain health service investigations unless the High Court makes an order permitting disclosure, or in a limited number of other circumstances.
This broadly mirrors the regime followed in the area of air accidents investigations. It would allow the investigator to say to staff involved in incidents:
‘This investigation is not to attribute blame. ‘The information you give me as part of this investigation will not be passed on to those not involved in the investigation unless there is a high court order, or if the information you provide demonstrates to me there is an active and ongoing threat to patient safety represented by the practice or actions of one or more individuals that requires action'.
The safe space approach is designed to improve patient safety standards over time, by enabling clinicians to discuss openly and honestly their experiences, including aspects of care that ought to be improved. These are valuable lessons that others can learn from, and will improve standards, potentially across the whole system. By concentrating on finding these more widely applicable lessons, safe space investigations will address themes rather than re-examine specific cases. But should the investigation uncover evidence of immediate risks to patient safety, criminal activity, serious misconduct or seriously deficient performance then the police or relevant professional regulator will be informed and will take the appropriate immediate action.
Creating a safe space is also a difficult balance to achieve – between reassuring staff that the information they give will not be passed on, while also reassuring patients and families that they have the full facts of their, or their loved ones’, care. We all want the standard of that care to get better and better each year. The purpose of this consultation is to seek the views of patients, the public and the professionals who work in the NHS about our proposed approach. In particular, we want to find out from them about what needs to be changed, added, or strengthened in order to achieve the learning not blaming culture that will underpin quality improvement in the NHS. A copy of the consultation is attached.
This statement has also been made in the House of Lords