PATIENT SAFETY NOW

One of the most enjoyable times of my career, and there have been many highlights, was leading the Sign up to Safety campaign from 2014 to 2019.

It was launched at a time when the NHS was dominated by targets and bold ambitions. We were asked to talk about reducing avoidable harm by half and saving 6,000 lives. Our desire though was not to focus on unrealistic and immeasurable targets but on culture. Many of the ideas that are now commonplace were relatively new in 2014 in relation to the cultural and relational aspects of safety. We argued that safer care depended as much on how people worked together as on technical interventions.

We hoped to broaden the conversation so that we could talk about aspects such as Safety II and learning from everyday work, civility and respectful behaviours, just culture, speaking up and ability to talk to each other. Kindness was a thread that was woven throughout all of our work.

At one point it felt like we had grown a national community of like minded people as we talked to and with them in blogs, webinars, via social media and local events. Highlights included the annual ‘kitchen table’ days where we encouraged people to have a conversation about safety and what it meant to them. There was something wonderful and simple about creating space and time for conversation.

But…

Looking back it is hard to see the sustained change that we hoped it would make. Perhaps that shouldn’t surprise me, it was unfortunate that there was no long term infrastructure to sustain the movement we had started to create, but even if that had happened I wonder if the erosion of culture we hoped to create would have occurred anyway – who knows. In the years after the campaign we have had; Covid, rising demand, workforce shortages, improvement fatigue, constant scrutiny and inquiries, financial constraints, industrial action and so on. This has led to a resurgence on seeing performance as far more important than culture.

Cultural change is hard and isn’t ever achieved through a campaign it requires all kinds of factors to enable even a tiny change to be made. The crucial thing is people can change, but when the system hasn’t then the people revert to what is expected of them. People are often willing to change long before the systems around them do. However, if the structures, incentives and expectations remain the same, even the most committed people eventually drift back towards the behaviours the system rewards.

The language of patient safety has undoubtedly evolved, concepts are becoming familiar to most (just culture, psychological safety, safety II, compassionate leadership) but actually living them is most definitely falling short.

What are my key lessons?

One interesting thing about Sign up to Safety was that we focused a great deal in encouraging people to speak up, and rightly so. But we should have devoted just as much attention to helping people listen. Every person who struggles to speak is usually speaking to someone who may, or may not be read or able to listen. Safety depends on both. What I now know is that we have to pay equal attention to helping people hear the messages.

The task is not just to persuade people of the importance of a positive safety culture but to focus on the organisational conditions that allow those values to flourish.

Every single day across the NHS, people still choose kindness over blame, curiosity over certainty, listening over judgement and learning over defensiveness, and humility. Those choices rarely make headlines, but they are happening in thousands of conversations, in handovers, ward rounds, team meetings and quiet moments between colleagues.

Culture is created conversation by conversation, decision by decision, relationship by relationship. Never underestimate what can happen when people believe that safer care begins with how we treat one another. What we need to do is pay attention to people. Pay attention to relationships. Pay attention to the small changes that make a difference everyday.