CONTENTS

politics first | Corridors
ADVERTORIAL
Turning healthcare systems
into learning organisations
Jeremy Hunt, Secretary of State for Health and Conservative MP
for South West Surrey
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And the result? There were dramatic – and
immediate – reductions in the number of
airline fatalities. The number of deaths overall
halved over 30 years – at the same time as
air travel increased nine fold. Ten people died
in the United 173 crash, but the learning that
resulted afterwards has saved thousands more.
Now healthcare is, of course, very different
to aviation. When someone dies in an airline
accident you know there has been a mistake,
whereas with over 1,000 deaths every year in
the average hospital it is not always clear. And,
while modern planes are highly complex, they
are nowhere near as complex as the human
body. But the airline industry changed its
culture. And so can we.
The first step is intelligent transparency. We
need to understand the scale of the problem,
not just nationally, but where we actually
work. The NHS in England will now publish
estimates by every hospital trust of their own
annual number of avoidable deaths.
The second stage is to use intelligent
transparency to turn the NHS into what I
have long wanted it to be: the world’s largest
learning organisation. There is a huge amount
of learning that goes on every day in our NHS,
and the government has played its part by
introducing the new CQC inspection regime;
legislating for the statutory duty of candour;
making progress – not always smoothly –
towards a seven day NHS; and we have asked
every trust to appoint an independent person
so clinicians can relay concerns to someone
other than their line manager. But, if we are
really to tackle potentially avoidable deaths,
we need a culture change from the inside as
well as exhortation from the outside. A true
learning culture has to come from the heart.
And that means a fundamental rethink of our
concept of accountability.
Time and time again, when I responded on
behalf of the government to tragedies at Mid
Staffs, Morecambe Bay, Winterbourne View,
Southern Health, and other places, I heard
relatives who had cried out in frustration that
no one had been “held accountable”. The rush
to blame may look decisive but by pinning the
blame on individuals, we sometimes duck the
bigger challenge of identifying the problems
which often lurk in complex systems and are
often the true cause of avoidable harm.
Organisational leadership is vital if we are
to change that – and we can see world-class
organisations, inside and outside healthcare,
have a very different approach. That is why
we need a new mindset to permeate the
ethos of the NHS, where blame is never the
default option. Justice must never be denied
if a professional is malevolent or grossly
negligent. But the driving force must be the
desire to improve care and reduce harm –
fired by an insatiable curiosity to pursue
improvement in every sphere of activity. That
is what I mean by the world’s largest learning
organisation.
NHS England is working with the Royal
College of Physicians to roll out a standardised
method for reviewing the records of patients
who have died in hospital. The objective is
to make it unnecessary for anyone ever to
feel they have to ‘blow the whistle’ on poor
care. But, as we make that transition, it is vital
that we offer whistleblowers protection so
if we discover there are any gaps in the law
protecting them, we will act to close them.
Karl Popper said that true ignorance is not
the absence of knowledge but the refusal to
acquire it. Now is the time to use the power of
intelligent transparency to make sure we really
do turn our healthcare systems into learning
organisations – and offer our patients the safe,
high quality they deserve.