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A promise to learn – a commitment to act

Improving the Safety of Patients in England

At its core, the NHS remains a world-leading example of commitment to health and health care as a human right – the endeavour of a whole society to ensure that all people in their time of need are supported, cared for, and healed. It is a fine institution. But the events at Mid Staffordshire have triggered a need to re-examine what the NHS does and determine how it can improve further. The only conceivably worthy honour due to those harmed is to make changes that will save other people and other places from similar harm.

Our job has been to study the various accounts of Mid Staffordshire, as well as the recommendations of Robert Francis and others, to distil for Government and the NHS the lessons learned, and to specify the changes that are needed.The following are some of the problems we have identified:

●●Patient safety problems exist throughout the NHS as with every other health care system in the world.
●●NHS staff are not to blame – in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems
●●Incorrect priorities do damage: other goals are important, but the central focus must always be on patients.
●●In some instances, including Mid Staffordshire, clear warning signals abounded and were not heeded, especially the voices of patients and carers.
●●When responsibility is diffused, it is not clearly owned: with too many in charge, no-one is.
●●Improvement requires a system of support: the NHS needs a considered, resourced and driven agenda of capability-building in order to deliver continuous improvement.
●●Fear is toxic to both safety and improvement.To address these issues the system must
●●Recognise with clarity and courage the need for wide systemic change.
●●Abandon blame as a tool and trust the goodwill and good intentions of the staff.
●●Reassert the primacy of working with patients and carers to achieve health care goals.
●●Use quantitative targets with caution. Such goals do have an important role en route to progress, but should never displace the primary goal of better care.
●●Recognise that transparency is essential and expect and insist on it.
●●Ensure that responsibility for functions related to safety and improvement are vested clearly and simply.
●●Give the people of the NHS career-long help to learn, master and apply modern methods for quality control, quality improvement and quality planning.
●●Make sure pride and joy in work, not fear, infuse the NHS.

The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.