the right time, the right place...3 3 the right time, the right place throughout the developed world...

An expert examination of the application of health and social care governance arrangements for ensuring the

quality of care provision in Northern Ireland

THE RIGHT TIME, THE RIGHT PLACE

DECEMBER 2014

Review Team | Sir Liam Donaldson | Dr Paul Rutter | Dr Michael Henderson

CONTENTS

1 CONTEXT 3

2 TERMSOFREFERENCEANDWORKINGMETHODS 5

3 THECHALLENGESOFDELIVERINGHIGHQUALITY,SAFECARE 7

4 KEYTHEMESESTABLISHEDBYTHEREVIEW 8

4.1 Asystemunderthemicroscope 8

4.2 Thedesignofthesystemhindershighquality,safecare 11

4.3 Insufficientfocusonthekeyingredientsofqualityandsafetyimprovement 18

4.4 Extractingfullvaluefromincidentsandcomplaints 22

4.5 Thebenefitsandchallengesofbeingopen 34

4.6 Thevoicesofpatients,clientsandfamiliesaretoomuted 37

5 CONCLUSIONS 39

5.1 RelativesafetyoftheNorthernIrelandcaresystem 39

5.2 Problemsgeneratedbythedesignofthehealthandsocialcaresystem 39

5.3 Focusonqualityandsafetyimprovement 40

5.4 TheextenttowhichSeriousAdverseIncidentreportingimprovessafety 41

5.5 Opennesswithpatientsandfamilies 43

6 RECOMMENDATIONS 44

1

3 THERIGHTTIME,THERIGHTPLACE

Throughoutthedevelopedworldmuchhealthcareisofaveryhighstandard.Therangeoftechnologiesanddrugsavailabletodiagnoseandtreatillnessgreatlyincreasedduringthesecondhalfofthe20thCentury,andintothe21st,offeringlifeandhopewherepatients’prospectswereoncebleak.Asaconsequence,thenumberofpeoplelivingwithdiseaseandneedingyearsorevendecadesofsupportfromcaresystemshasexpandedenormously.

TheageingpopulationoftodayisacentralconsiderationinawaythatwasnotforeseenwhenmodernhealthcarecameintobeingintheaftermathoftheSecondWorldWar.Today,peoplearelivingmuchlongeranddevelopingnotjustonediseasebutseveralthatco-exist.Inoldage,thetwinstatesofmulti-morbidityandfrailtyarecreatingacuteandlong-termhealthandsocialcareneedsonanunprecedentedscale.

Technologyhascontinueditsrapidandbeneficialadvance,openingupnewopportunitiesfordiagnosisandtreatmentbutbringingevengreaternumbersthroughthedoorsofhospitalsandhealthcentres.Citizensexperiencethebenefitsofanadvancedconsumersocietyandwhentheyencounterthehealthandsocialcaresystem,theyrightlyexpectittobecommensuratewiththis.Risingpublicexpectationsareafurtherdriverofdemandforhealthcare.Thereareother,lesspredictablesourcesofpressureonservices.Forexample,achangeinthepatternofwintervirusescanbringsurgesindemandthatthreatentooverwhelmemergencydepartments.Inresponsetoallofthis,thesizeofbudgetsdevotedtohealthandsocialcarehashadtoexpanddramatically.

Attheepicentreofthiscomplex,pressurised,fast-movingenvironmentisthepatient.Theprimarygoalofthecareprovidedmustalwaysbetomaketheirexperience,theoutcomeoftheircondition,theirtreatment,andtheirsafetyasgoodasitgets.Healthandsocial

caresystemsaroundtheworldstruggletomeetthissimpleideal.Evaluationsrepeatedlyshowthat:variationinstandardsofcarewithincountriesisextensive;someofthebasicssuchascleanlinessandinfectionaretoooftenneglected;evidence-basedbestpracticeisadoptedslowlyandinconsistently;theavoidablerisksofcarearetoohigh;thereareperiodicinstancesofseriousfailuresinstandardsofcare;and,manypatientsexperiencedisrespectforthemandtheirfamilies,badcommunicationandpoorcoordinationofcare.

ThehealthandsocialcaresysteminNorthernIrelandservesapopulationof1.8million.Peopleliveinurban,semi-ruralorruralcommunities.Responsibilityforpopulationhealthandwellbeing,andtheprovisionofhealthandsocialcare,isdevolvedtotheNorthernIrelandAssemblyfromtheUnitedKingdomgovernmentinWestminster.AsinotherpartsoftheUnitedKingdom,theNorthernIrelandhealthserviceoperatesbasedonthefoundingprinciplesoftheNationalHealthService-theprovisionofcareaccordingtoneed,freeatthepointofaccessandbeyond,fundedfromtaxation.However,sincetheadventofdevolvedgovernment,England,Scotland,WalesandNorthernIrelandhaveadoptedtheirownstrategiesfor:promotingandprotectinghealth;preventingdisease;reducinghealthinequalities;and,planningandprovidinghealthandsocialcareservices.Thecountrieshavedevelopeddifferentstructuresandfunctionswithintheirsystemstomeettheseresponsibilities.Thus,theyvaryinfeaturessuchas:arrangementsforplanningandcontractingofcare;levelsofinvestmentinpublichealth,primaryandcommunitycareversushospitalprovision;fundingmodels;incentives;useoftheindependentsector;managerialstructures;and,theroleoftheheadquartersfunction.

Variousagencies,groupsandstrategiespopulatethequalityandsafetylandscapeofNorthernIreland.Quality2020istheflagship

1CONTEXT

1


ten-yearstrategy.CommissionedbytheMinisterofHealth,SocialServicesandPublicSafetyin2011,itsvisionistomakeNorthernIrelandaninternationalleaderinhighquality,safecare.Quality2020issponsoredbytheChiefMedicalOfficerandledbytheDepartmentofHealth,SocialServicesandPublicSafety.Ithasasteeringgroup,amanagementgroup,animplementationteam,projectteams,andastakeholderforum.Thesebringtogetherrepresentativesfromacrossthestatutorycarebodiesandbeyond.Separately,aHealthandSocialCareSafetyForumconvenesasimilargroupofstakeholders.

TheRegulationandQualityImprovementAuthority(RQIA)isthemainregulatorinNorthernIreland’scaresystem.Manyofthesocialcareproviders,andsomehealthcareproviders,areregisteredwiththeRegulationandQualityImprovementAuthority.HoweveritdoesnotregistertheTrusts,whichprovidethebulkofhealthandsocialcareinNorthernIreland,orgeneralpractices.TheTrusts’relationshipwiththeregulatorthereforehasasomewhatsofteredgethanmightbethecaseiftheywereformallyregistered,althoughanexpandedrolehasbeenannouncedrecentlybytheMinister.

NorthernIrelandtakesakeeninterestintheworkofqualityandsafetybodieselsewhereintheUnitedKingdom,andoftenimplementstheirguidanceandrecommendations.TheNationalInstituteforHealthandCareExcellence(NICE)andtheformerNationalPatientSafetyAgencyhavebeenprominentinthisregard.

TechnicalqualityandsafetyexpertisesitsnotintheHealthandSocialCareBoard,butnextdoorinthePublicHealthAgency.ThePublicHealthAgencyhasastatutoryroleinapprovingtheHealthandSocialCareBoard’scommissioningplans.TwoexecutivedirectorsarejointlyappointedbetweenthePublicHealth

AgencyandtheHealthandSocialCareBoard.TherearethereforemechanismsthroughwhichqualityandsafetyexpertiseshouldinformtheBoard’swork.TheQualitySafetyExperienceGroupisjointlymanagedbetweenthesetwoagencies.Itmeetsmonthlyanditsprimaryfocusislearning.Itlooksatpatternsandtrendsinincidentsandinitiatesthematicreviews.

Inshort,thereisagooddegreeofactivityinthesphereofqualityandsafetyimprovement.Therearesomeunusualfeaturesofthelandscape,whichwillemergeinsomedetailinthisReview.

Thewayinwhichcentralbodiesseektoachievecompliancewiththeirpoliciesandmakebroaderimprovementchangesisbasedonaverytraditionalandquitebureaucraticmanagementmodel.Thereismuchdetailedspecificationofwhattodo,howtodoit,andthenextensiveanddetailedcheckingofwhetherithasbeendone.Thishasstrengthsinenablingthecentralbodiesandthegovernmenttodemonstratetheiraccountabilityandgivepublicassurances,butitcangreatlydisempowerthoseatthelocallevel.Itcancausethosemanaginglocallytolookup,ratherthanlookingouttotheneedsoftheirpopulations.

Thealternativeisastyleofleadershipbasedoninspiration,motivationandtrustthatthoseclosertothefrontlinewillmakegoodjudgmentsandinnovateiftheyareencouragedtodoso.Perhapstherelationshipneedsalightertouch,toliberatefreerthinkingonhowtomakeservicesbetterforthefuture.


2TheReview’sformalTermsofReferenceareavailableonline1.TheoverallaimoftheReviewhasbeentoexaminethearrangementsforassuringandimprovingthequalityandsafetyofcareinNorthernIreland,toassesstheirstrengthsandweaknesses,andtomakeproposalstostrengthenthem.

Theanalysisinthisreportisbasedonextensiveinputfrom,scrutinyof,anddiscussionwithpeopleacrossthehealthandsocialcaresysteminNorthernIreland.EachofthemainstatutoryorganisationsmadeformalsubmissionstotheReview(includingrecordsofboardmeetings,policies,andplans).TheReviewputsubstantialemphasisontravellingaroundthesystem–bothliterallyandfiguratively–toseeitfromasmanydifferentanglesaspossible,andtocometoaroundedview.

TheReviewTeamvisitedthefiveHealthandSocialCareTrusts,theNorthernIrelandAmbulanceService,theDepartmentofHealth,SocialServicesandPublicSafety,theHealthandSocialCareBoard(anditsLocalCommissioningGroups),thePublicHealthAgency,thePatientandClientCouncil,andtheRegulationandQualityImprovementAuthority.Ineach,theReviewTeammetwiththeexecutiveteam(ChiefExecutiveandexecutivedirectors)and,inmostcases,theChairoftheBoardandothernon-executivedirectors.ThemanagementteamofeachorganisationgaveaseriesofpresentationscoveringtheareasofinteresttotheReview,andReviewTeammembersaskedquestionsandleddiscussion.

DuringtheirvisittoeachHealthandSocialCareTrustandtotheambulanceservice,ReviewTeammembersalsoledfocusgroupsdiscussionsamongstfrontlinestaff.IneachofthefiveHealthandSocialCareTrusts,forexample,theteammetwithseparategroupsofconsultants,nurses,juniordoctors,andotherhealthandsocialcareprofessionals.Seniormanagerswerenotpresentforthese

discussions.Participantswereencouragedtospeakopenly,andgenerallydidso.Itwasunderstoodthatnocommentswouldbeattributedtoindividuals.Thefocusgroupscenteredonanyconcernsaboutqualityandpatientsafetyintheirorganisationandincidentreporting,andotherhighly-relatedtopics.Theteamalsometwithtwogroupsofgeneralpractitioners.

TheReviewTeampaidparticularattentiontotheexperiencesofpeoplewhohavecometoharmwithintheNorthernIrelandhealthandsocialcaresystem.AteachTrust,includingtheambulanceservice,theteamreviewedtworecentSeriousAdverseIncidentsindetail,particularlyconsideringtheincidentitself,thewayinwhichpatientsandfamilieswerekeptinformedandinvolved,andthelearningderived.TheteamlaterreturnedtotwoTruststoreviewfurtherincidents,thistimeselectedbytheReviewTeamfromalistofallseriousadverseincidentsinthepreviousyear.TheReviewTeammetwithpeoplewhohavecometoharm.Mostofthesemeetingswereinperson;somewerebytelephone.Inadditiontopeopleaffecteddirectly,theReviewTeamspoketotheirfamilymembersandcarers.Weareparticularlygratefultoalloftheseindividualsforgivingoftheirtime,andforgraciouslysharingtheirstorieswithus,whichwereoftenpainful.

Finally,theReviewTeammetwithaseriesofotherindividualsandgroupsthatformpartofthewiderhealthandsocialcaresysteminNorthernIreland,orhaveastronginterestinit.Thesewere:theAttorneyGeneral,theBritishMedicalAssociation,theChestHeartandStrokeAssociation,theCommissionerforOlderPeopleforNorthernIreland,DiabetesUK,theGeneralMedicalCouncil,MacMillanCancerSupport,theMultipleSclerosisSociety,theNorthernIrelandAssociationofSocialWorkers,theNorthernIrelandHumanRightsCommissioner,theNorthernIrelandMedical&DentalTrainingAgency,TheHonourableMrJusticeO’Hara,

2TERMSOFREFERENCEANDWORKINGMETHODS

http://www.dhsspsni.gov.uk/tor-080414.pdf


2theOmbudsmanforNorthernIreland,thePainAllianceofNorthernIreland,PatientsFirstNorthernIreland,theRoyalCollegeofNursing,andtheVoiceofYoungPeopleinCare.OtherpatientandclientrepresentativegroupswereinvitedtomeetwiththeReviewTeam,ortomakewrittensubmissions.

ToinformoneaspectoftheReview,theRegulationandQualityImprovementAuthorityoversawalook-backexercise,reviewingthehandlingofallSeriousAdverseIncidentsinNorthernIrelandbetween2009and2013.TheirreportwasreceivedlateintheReviewprocess,buthasbeenconsideredbytheReviewTeamandreflectedinthisreport.

Betweenstartingandproducingitsfinalreport,theReviewTeamhashadarelativelyshortperiodoftime.Ithasnotbeenpossibletoundertakeresearch,extensivedataanalysis,large-scalesurveysofopinion,orformalevidence-takingsessions.However,thedocumentsreviewed,themeetingsheld,thevisitsmade,andtheviewsheardhavegivenastrikinglyconsistentpictureofqualityandsafetyintheNorthernIrelandhealthandsocialcaresystem.TheReviewTeamisconfidentthatalongerexercisewouldnothaveproducedverydifferentfindings.


3 3THECHALLENGESOFDELIVERINGHIGHQUALITY,SAFECARE

Patientsinhospitalsandotherhealthandsocialcareservicesaroundtheworlddieunnecessarily,andareavoidablyinjuredanddisabled.Thissadfacthasbecomewellknownsincetheturnofthe20thCentury.Awarenessofithasnotbeenmatched,unfortunately,byeffectiveactiontotackleit.

Thereisconsistencyinthetypesofharmthatoccurinhigh-incomecountries.Inlow-incomecountries,harmismainlyrelatedtolackofinfrastructureandfacilities,aswellaspooraccesstocare.However,inNorthAmerica,Europe,Australasia,andmanypartsofAsiaandtheMiddleEast,analysisofincidentreportsandthefindingsofpatientsafetyresearchstudiesshowsadifferent,strikinglyconsistentpattern.Between3%and25%ofallhospitaladmissionsresultinanadverseincident,abouthalfpotentiallyavoidable.Withinanyhealthorsocialcareservice,therearemanypotentialthreatstothequalityandsafetyofthecareprovided:

1. Weakinfrastructure-therangeanddistributionoffacilities,equipmentandstaffisinadequatetoprovidefairandtimelyaccesstorequiredcare.

2. Poorco-ordination-thecomponentsofcarenecessarytomeettheneedsofapatient,orgroupofpatients,donotworkwelltogethertoproduceaneffectiveoutcomeandtobeconvenienttopatientsandtheirfamilies.

3. Lowresilience -thedefencesinplace,andthedesignofprocessesofcare,areinsufficienttoreliablyprotectagainstharmsuchasthatresultingfromerrorsorfromfaultyandmisusedequipment.

4. Poorleadershipandadverseculture-theorganisationorserviceprovidingcaredoesnothavecleargoalsandaphilosophyofcarethatitisembeddedinthevaluesoftheorganisationandvisibleineveryoperationalactivity.

5. Competence,attitudes,andbehaviour-thepractitionersandcare-providersworkingwithintheservicelacktheappropriateskillstodealwiththepatientsthattheyencounter,

ortheyareunprofessionalintheiroutlookandactions,ortheydonotrespectotherteammembers,norworkeffectivelywiththem.

6. Sub-optimalserviceperformance-thewaythattheserviceisdesigned,organisedanddeliveredmeansthatitdoesnotdeliverprocessesofcaretoaconsistentlyhighstandardsothatovertimeitchronicallyunder-performsofteninawaythatisnotnoticeduntilcomparativeperformanceislookedat.

7. Slowadoptionofevidence-basedpractice-theservicedoesnotconformtointernationalbestpracticeinparticularareasofcareoroverall.

Theamountofeachtypeofharmvariesbuttheoverallburdenhaschangedlittleoverthelastdecadedespitetheunprecedentedprioritythathasbeengiventopatientsafetywithinthesehealthsystems.Littleisknownaboutthelevelandnatureofharminprimarycare,thoughmoreattentionisnowbeinggiventoit.

Althoughthesethreatsaredescribedinrelationtohealth,theyapplyalsotosocialcare.Manyarestronglyrelatedtothelevelofresourcesthatisavailabletoahealthandsocialcaresystem.Theextenttowhicheachproblemispresentvarieshugelyacrosstheworld,withincountries,andevenbetweendifferentpartsofthesameserviceorareaofcareprovision.

Insomewaysitisreassuringtobelievethattheproblemsofqualityandsafetyofcarearesomehowuniversal,andthatnocountryhastheanswers.Thisisdangerousthinking.Thebestservicesintheworldshowthatevenwiththeallthepressuresoflargenumbersofpatients,manywithcomplexneeds,excellencecanbeachievedconsistentlyacrossallfieldsofcare.TheNorthernIrelandhealthandsocialcareservicemustnotbesatisfiedwith‘goodenough.’Withaclearrecognitionofthereasonsforitscurrentproblemsinqualityandsafetyofcare,andwitheveryoneworkingtogether,itcouldbeamongstthebestintheworld.


4TheReviewestablishedsixkeythemes.Eachissetoutinsomedetailbelow.ExplorationofthesethemesprovidesthebasisfortheReview’sconclusions(insection5)andrecommendations(section6).

4.1 ASYSTEMUNDERTHEMICROSCOPE

NorthernIreland’shealthandsocialcaresystemissubjecttoahigh,perhapsunrivalled,levelofmediacoverage–muchofitnegative.Overrecentyears,ithasalsobeenthesubjectofaseriesofhighprofileinquiries.Allhavehighlightednumerousfailingsintheleadershipandgovernanceofcare.Manyhavemadeextensiverecommendationsandtheextenttowhichthesehavebeenimplementedhasitselfbeencontroversial.Thepressuresofincreasingdemandforcarehavemeantthataccesshasbeenmoredifficult.Therehasbeenafocusonover-crowdinganddelaysinemergencydepartments,thefrontdoorofthehospitalservice.AllofthishasmeantthatthelastfiveyearshasbeenaperiodofunprecedentedscrutinyofthewaythathealthandsocialcareinNorthernIrelandisplanned,providedandfunded.

4.1.1 A stream of inquiries highlighting service failuresThenumberofrecentmajorinvestigationsandinquiriesintoshortfallsinstandardsofcareinhealthandsocialcareservicesinNorthernIrelandisstrikinginrelationtothesizeofitspopulation.ThisdoesnotnecessarilymeanthatsuchoccurrencesarecommonerthanelsewhereintheUnitedKingdom.Itmaysimplybethatthelevelofpublicandmediascrutinyishigherandthepressurefromthistriggersastatutoryresponsebygovernmentministersandofficials.Theend-resultisthattheprofileoftheserviceismoreoftenoneoffailureratherthansuccess.

InMarch2011,DameDeirdreHine,aformerChiefMedicalOfficerforWales,issuedthereportofherinquiryintodeathsfromClostridiumdifficileinhospitalsintheNorthernTrustarea.Shehadbeenbroughtintoinvestigate60deathsthathadbeenattributedtotheorganism.Shefoundthatthetruefigurewas31deaths.Shefoundmanagement,organisational,clinicalgovernanceandcommunicationfailings.Shemade12recommendations.Ittook23monthstocomplete.

InFebruary2011,theBelfastTrustrecalled117dentalpatientsfollowingareviewoftheclinicalperformanceofaseniorconsultant.AnindependentinquirycommissionedbytheMinisterwaspublishedinJuly2013andmade45recommendations.AnactionplandevelopedbytheDepartmentofHealth,SocialServicesandPublicSafetyidentified42keyactionsincludingonstaffing,training,supervisionandclinicalgovernance.InNovember2013,theRegulationandQualityImprovementAuthorityconductedanassessmentofimplementationofthoseactions.

InDecember2011,anindependentreportbytheRegulationandQualityImprovementAuthorityexamineddelaysinthereportingofplainX-raysinallTrustsafterconcernswereexpressedaboutdelaysintwohospitals.Thereviewfoundthatseriousdelayshadoccurredandwerecausedbythreemainfactors:ashortfallinconsultantradiologystaffing,agrowthinnumbersofx-raystobereportedaftertheintroductionofdigitalimagingandtheintroductionofanewpolicytoreportonallhospitalchestx-raysbecauseofworriesaboutpatientsafety.Thereviewfoundthattherewaslittleawarenessatregionallevelthataseriousbackloginreportingwasdevelopingwithpotentialriskstopatientsduetodelayeddiagnosis.Thereviewmade14recommendations.

4KEYTHEMESESTABLISHEDBYTHEREVIEW


4InMay2012,DoctorPatTroop,formerchiefexecutiveofficeroftheHealthProtectionAgencyinEngland,issuedherfinalreportoftheindependentinvestigationintoanoutbreakofinfectionsinneonatalunitsduetotheorganismPseudomonasaeruginosa.Fivebabieshaddiedintheoutbreakand32recommendationsweremadecoveringtechnicalmatters,management,governance,communication,training,andoutbreakmanagement.

InApril2012,theMinisteraskedforspecialmeasurestobeputinplacetooverseetheBelfastTrustbecauseofmajorconcernsaboutseriousadverseincidentsintheemergencydepartment,recommendationsfromthePseudomonasreview,reviewsofpaediatriccongenitalcardiacsurgeryandrecommendationsofthedentalinquiry.

InDecember2012,theMinisterappointedaTurnroundandSupportTeamtogointotheNorthernHealthandSocialCareTrustbecauseofconcernsabouttheweaknessofgovernanceandqualityassurancesystems,thepaucityofclinicalleadership,anduncertaintiesaboutthereliabilityofmortalitydata.ThisparticularTrusthashadfivechiefexecutiveofficersinthelastsevenyears.

InJune2014,theRegulationandQualityImprovementAuthorityreportedonitsreviewofunscheduledcareservicesintheBelfastTrust.Theconcernsthatledtothereviewincluded:thedeclarationofamajorincident,12-hourwaitingtimebreaches,dysfunctionalpatientflowsandgrossovercrowdingofpatientcareareas.Thistriggeredafullerreviewthatlookedatmattersregion-wide.Thisproduced16recommendations.

ThedominantinquiryinrecenttimesremainstheIndependentInquiryintoHyponatraemia–RelatedDeaths.Itisexaminingthedeathsofchildrenafterbeingtransfusedinhospitalwithafluidthatwassubsequentlyfoundtocarrya

significantrisk.Concernshadbeenraisedbytheparentsandothersthatthisriskshouldhavebeenidentifiedmuchearlier,thatactionshouldhavebeentakentostopitbeingused,thattherewasacover-upandthatsystemsformonitoringsafetywereinadequate.ItisbeingchairedbyJohnO’HaraQCandwascommissionedin2003/4but,becauseofotherlegalprocesses,wasnotabletohearfullevidenceuntilmorerecently.Thereportisexpectedin2015.

Thecriticismsininquirieslikethesehavebeenlargelyjustifiedandmustbefollowedbyactiontoimprovethesituations.Whetherestablishingformal,oftenlengthy,andcostlyinquiriesistherightwaytodriveimprovementisverydebatable.Certainlydoingsoasthenormativeresponsetofailurehasimportantdisadvantages.Inparticular,itoftenparalysestheorganisationunderscrutinyasitsstaffbecomepre-occupiedwithpreparingevidenceandsupplyinginformation.Thelearningisoftenputonhold-sometimesnevertobereturnedto-untiltheinquiryisover.Theburdenofrecommendationstobeimplementedandprogress-checkedcanbeoverwhelming,sothattheimplementationbecomesabureaucraticexerciseratherthanawatershedmomentforleadership,cultureandthecontentofpractice.Itmightbebettertodefineaclearthresholdforwhenafull-blowninquiryisinitiated.

4.1.2 Intense political and media interest in service provisionNorthernIreland’shealthandsocialcaresystemissubjecttoahighdegreeofpolitical,aswellasmedia,interest.Thisisavalidandexpectedfeatureofapublicly-fundedsystem.Ironically,though,thewayinwhichthisinterestbecomesmanifestoftencreatesresultsthatarecountertothetruepublicinterest.Therehavebeenmanyexamplesoflocalcommunities–andthereforetheirpoliticians–wantingtokeepalocalhospitalopen,contrarytotheanalysisofserviceplanners.Thishascreated


4asituationinwhichNorthernIrelandhasmoreinpatientunitsthanisreallyjustifiedforthesizeofpopulation,andtheexpenseofmaintainingthemimpedesprovisionofotherservicesthatwouldrepresentbettervalueformoneyandmoreappropriatelymeettheneedsofthepopulation.Likewise,politicalpressureandmediainteresthaspreventedthesalariesoftopmanagersfrombeingraisedtoosubstantially.However,seniorexecutivesintheNorthernIrelandcaresystemarenowpaidmuchlessthantheircounterpartselsewhereintheUnitedKingdom.Thepublicwouldbebetterservediftheircaresystemcouldcompetetoattracttheverybestmanagerialtalent.Thepressuretokeepsalariesdownmaybepenny-wiseandpound-foolish.


44.2 THEDESIGNOFTHESYSTEMHINDERSHIGHQUALITY,SAFECARE

WhenaqualityorsafetyproblemarisessomewherewithintheNorthernIrelandcaresystem,thetendencyistopointtotheindividualsorservicesinvolved,andtofindfaultthere.Aswithsomanyotherfeaturesidentifiedinthisreport,thistendencyisfarfromuniquetoNorthernIreland.Butitrepresents,intheviewoftheReviewTeam,toonarrowafocus.Inreality,thegreatestthreatstothequalityofcarethatpatientsreceive,andtotheirsafety,comefromthewayinwhichthesystemasawholeisdesignedandoperates.

Inshort,theservicesthatexistarenottheservicesthatthepopulationtrulyrequires.Politicalandmediapressureactstoresistchange,despitethefactthatchangeismuchneeded.Itisnotclearwhoisinchargeofthesystem,andthecommissioningsystemisunderpowered.Allofthiscompoundsthepressures,creatinghighintensityenvironmentsthatarestressfulforstaffandunsafeforpatients–particularlyoutofhours.Theseeffectsareexploredfurtherbelow.

TheNorthernIrelandcaresystemhassomeelementsincommonwiththeotherUnitedKingdomcountries,andsomethatdiffer.Observers,askedtodescribetheNorthernIrelandsystem,oftenpointfirsttotheintegrationofhealthandsocialcareasitsdistinguishingfeature.ItisclearthoughfromthefindingsofthisReviewthatwhilsttheintegrateddesignofthesystemhasgreatadvantages,itfallswellshortofperfectioninpromotingthehigheststandardsofcareandinpreventingthedysfunctionsintheco-ordinationofcarethatareprevalentelsewhere.

4.2.1 Service configuration creates safety concernsAstrikingfeatureoftheprovisionofcareinNorthernIrelandisthewidedistributionofhospital-typefacilitiesoutsidethemajorcity,Belfast,someservingrelativelysmallpopulationsbyUnitedKingdomstandards.Thisgeographicalpatternleadstospecialistexpertisebeingtoothinlyspread,andtothepatchyavailabilityofexperiencedandfullycompetentstaff.Itmeansthatitisnotpossibleeverywheretodeliverthesamequalityofserviceforanacutelyillpersonat4a.m.onaSundayasat4o’clockonaWednesdayafternoon.Thereisthereforeatwo-tierserviceoperatinginNorthernIreland-in-hoursandout-of-hours-thatismorepronouncedinsomeplacesthaninothers.Thisisoneofthebiggestinfluencesonthequalityandsafetyofcare.Deliveryofservicesistoooftenhigherriskthanitshouldbeina21stCenturyhealthcaresystembecauseofthepatternofservices.

Pastanalystsandobservershavepointedtothecurrentlevelandsitingofprovisionnotbeinginkeepingwithmaintaininghighstandardsofcare.Somepopulationsarejusttoosmalltowarrantfull-blowngeneralhospitalfacilitiesyettheyarekeptinplacebecauseofpublicandpoliticalpressure.Amongstthosewhoworkwithinthesystem,thereisdeepfrustrationthatthepublicarenotproperlyinformedaboutthehigherrisksofsmallerhospitalsandthatthemisapprehensionthatalternativeformsofprovisionareinsomewayinferiortoahospital.TheseissuesareilluminatedbytwowrycommentsmadetotheReview:“theword‘hospital’shouldberemovedfromtheOxfordEnglishDictionary”and“NorthernIrelandneedsmoreroadsnotmorehospitals.”

Despiteitssmallsize,thereislessco-operativeworkingacrossNorthernIrelandthanmightbeexpected.Silosreignsupreme.TheHealthandSocialCareBoardrunsregionalcommissioningteams,coveringareassuchaslearning


4disability,mentalhealth,prisonhealthandaverybroadcategoryof‘hospitalandrelatedservices’.However,particularscopeexiststodomoreinimprovingstandardsinareasofclinicalcarewherethereisastrongevidencebaseforwhatiseffective.Inthecaseswhereclinicianshaveworkedtogetheracrossorganisationalboundaries,remarkabletransformationshaveoccurred.Thishappenedincardiologywherearegionallyplannedandcoordinatedservicemeansthatmorepatientswithheartattacksgettreatedearly,getlessdamagetotheirhearts,andmorepeopleliveratherthandie.TheAmbulanceTrustistheonlyoneofthesixTrustsorganisedonaregionalbasis.TheReviewTeamwasverystruckbyhowmuchpressurethisimportantservicewasunder.ThisisconsistentwiththeheadlinestoriesinotherpartsoftheUnitedKingdomaboutambulanceservicesbeingunabletomeettheirservicestandardsbecauseofhugesurgesindemand.Allpartsoftheservicearetakingthestrain–fromthoseinthecontrolcentretothoseontheroad.Yetwhenthedetailoftheirsituationsisexploredindepth,itisclearagainthattheproblemsstemfromdysfunctionalpatientflowsandpathwayswheredifferentpartsofthesystemarenotworkingtogether.

4.2.2 Adverse consequences for primary and social careThepressuresonhospitalshaveconsequencesforprimaryandcommunityservices.Thereisaconstantneedforhospitalstodischargepatientsassoonastheypossiblycantofree-upbedsfornewadmissions.Generally,thishappenswhenanolderpersonisjudgedmedicallyfitfordischarge.However,thisdoesnotnecessarilymeanthattheirphysicalandsocialfunctioninghasreachedalevelwheretheycancopewithareturntothecommunity.TheReviewwastoldbygeneralpractitionersandsocialcarestaffthattheyoftenhavetostepintoprovideunscheduledsupportinsuchcircumstancesand,becauseofinadequatecommunicationatthetimeofdischarge,theycanbeleftinthe

darkaboutongoingtreatmentplansandevenbeunclearaboutsomethingasbasicasapatient’smedicationregime.Somegeneralpractitionersspokeofspendinglong,frustratinghourstryingtogettospeaktoahospitaldoctorabouttheirpatient,withoutsuccess.

Overthelastdecade,therehasbeenamajorincreaseinthedependencylevelsofpeoplebeingcaredforinthecommunity.Forexample,theuseofPEGfeeding(directlyintothestomachthroughatubeintheskin)isnowcommonplaceincommunitysettings,whereasitusedtobeahospitaltreatment.Asaresult,communitynursingstaffhavemuchmorecomplexcaseloads.Thereisalsogreatercomplexityintheotherformsofdisability,aswellasinthetreatmentsthatpeoplearereceivingandothertechnologiesthataresupportingthem.

TheReviewTeamwasverystruckbytheexperienceofoneon-callpharmacistwhomtheytalkedto.HewasresponsibleforpreparingthedischargemedicationforpatientsleavinghospitalonaparticularBankHolidayweekend.Hereportedfillingadoctor’sprescriptionfor20differentmedicationsforeachoffourpatients.Thisstronglyillustratesseveralpoints.Firstly,itisnotrightthatsuchanexcessiveamountofmedicationshouldberoutinelyprescribed.Itshouldberigorouslyreviewedandadjusted.Secondly,itagainshowsthecomplexityandmultipleconditionsaffectingmanypatients,whomoveregularlybetweenhospitalandcommunity.Thirdly,ithighlightstheopportunityforamuchstrongerroleforunder-appreciateddisciplineslikepharmacyontheboundarybetweenhospitalandpopulation.

TheintegrationofhealthandsocialcaremeansthattheReviewTeam’sdiscussionswithinTrustsnecessarilytookaccountoftheimportantroleofsocialcarestaff,andparticularlysocialworkers.Theyareavitalpartoftheworkforceandalthoughunderequalpressuretotheir


4healthcarecounterparts,theReviewwasencouragedtohearaboutthestrongemphasisonprofessionaldevelopmentinNorthernIrelandandtheparticularexpertiseinspecialistareassuchasadultsafeguarding.

Theknock-oneffectsofpressuresinthehospitalsystemforcommunityservicesarenotrestrictedtopost-dischargematters.Manyhospitaldepartmentsaresopre-occupiedwithurgentworkandthehighvolumeofpatientsthattheydonothavetimetoprovideproperresponseswhenpatientsortheirdoctorsmakecontacttoaskaboutprogresswithanoutpatientappointmentortestresults.

4.2.3 High-pressure environments fuel risk to patients and sap moraleThedemandfrompatientswhoneedemergencycare,aswellasthosewhorequireplannedinvestigationsandtreatments,isextremelyhigh.Thepressuresonemergencydepartmentsandhospitalwardsareverygreat.Over-crowdedemergencydepartmentsandoverflowinghospitalwardsarehigh-riskenvironmentsinwhichpatientsaremorelikelytosufferharm.Thisisbecausedelaysinassessmentandtreatmentoccurbutalsobecausestaffhavetomaketoomanyimportantanddifficultdecisionsinashortspaceoftime-whatpsychologistscallcognitiveoverload.Thattheywillmakemistakesandmisjudgmentsisinevitable,andsomeofthemwillbeinlife-and-deathareas.Experienceinothersafety-criticalindustries,andresearch,showsthathigh-pressure,complex,andfast-movingenvironmentsaredangerous.Ifinadequatestafflevelsareaddedtothemix,risksescalatefurther.

TheReviewmetwithmanygroupsofhealthandsocialcarestaff,speakingonconditionofanonymity.Theyareoverwhelminglyconscientiouspeoplewhofeeldeeplyfortheirpatientsandwanttoexcelinthecarethattheydeliver.Yet,theworkloadsinsomesituationsareunacceptablyhigh;sotooarestresslevels.

Thestresscomesnotonlyfromthelargenumbersofcasesperse,butmuchmorefromthefeelingofstaffthattheyarenotgivingpatientsthequalityofcaretheyweretrainedtodeliver.Thereisguilttooinknowingthattheyareforcedtocompromisetheirstandardstolevelsthattheywouldnotacceptfortheirownfamilies.Thephrase“doingjustenough”wasrepeatedlyusedintheReview’smeetingswithfront-linestaff.Thereareextrapressuresforsomegroupsofstaff.Doctorsintrainingcanfindthemselvesinsituationsthatarebeyondtheircompetenceandexperience.Sometimestheycancallonback-upfromseniorstaff,sometimestheyhavetodotheirbestuntilthemorningorMondaycomes.Somenursescanfindthemselvesdealingwithanunacceptablylargenumberofpatientsonahospitalwardatnight.Theytoofeelthattheyarehavingtolowertheirprofessionalstandards.Thisassessmentisnotbasedonisolatedanecdotesbutmuchmorewidespreadandconsistentaccounts.

4.2.4 Transformation efforts are moving slowlyTransformingYourCarebeganasasubstantialreviewofhealthandsocialcareprovisioninNorthernIreland,commissionedin2011.Thereviewwasledbythethen-ChiefExecutiveoftheHealthandSocialCareBoard,supportedbyanindependentpanel.Itwasastrong,forward-thinkingpieceofwork.

ThewholeoftheUnitedKingdom,likemostdevelopedcountries,hasafundamentalproblem:thehealthandsocialcaresystemthatithasisnotthehealthandsocialcaresystemthatitneeds.Thepatternofill-healthinthepopulationhaschangedsubstantiallysincethesystemswerefounded,andthesystemshavenotchangedtokeepup.TheTransformingYourCarereviewsetoutaconvincingcaseforchange.Itdescribedinequalitiesinhealth,risingdemands,andaworkforceunderpressure.ItparticularlyestablishedthatNorthernIrelandhastoomanyacutehospitals


4-thatelsewhereintheUnitedKingdom,apopulationof1.8millionpeoplewouldlikelybeservedbyfouracutehospitals–notthe10thatNorthernIrelandhad.

TransformingYourCaresetoutabroadnewmodelofcare,whichaimedtobetailoredtotoday’sneedsandperson-centered.Inpracticalterms,itsmostsubstantialproposalwastomove£83millionawayfromhospitalsandgiveittoprimary,communityandsocialcareservices.

ThoseinterviewedbythisReviewTeamunanimouslysupportedtheneedforthisinitiative.Thewidespreadfeeling,though,isthatTransformingYourCareissimplynotbeingimplemented.

Asaresultofweakcommunicationandlittleaction,thereissubstantialskepticismaboutTransformingYourCare.TheReviewTeamhearditvariouslyreferredtoas“TransferringYourCare”,“PostponingYourCare”,andeven“TakingYourChances”.Oneofitscentralconcepts,‘shiftleft’,isviewedparticularlywarily.Carersseeitasaeuphemismfordumpingworkontothem;generalpractitionerslikewise.Thoseworkinginthecommunityseetheirworkloadincreasing,andworrythatthereisnoclarityatallaboutwhattheoverallcaremodelissupposedtobe.

ThefrustrationsofthegeneralpractitionercommunityinNorthernIrelandthatTransformingYourCarehasnotworked,isnotproperlyplannednorfunded,hasledthemtotakemattersintotheirownhandsandformfederations.Generalpracticesthemselvesarefinanciallycontributingtothese,inamovetoestablishcommunity-centeredcarepathways.

TheneedsthatTransformingYourCaresetsouttoaddressarebecomingevermorepressing.Itsimplementationneedsamajorboostinscaleandspeed,andcommunicationneedsparticularattention.

4.2.5 An under-powered system of commissioningAt1.8million,thepopulationofNorthernIrelandisrelativelysmalltojustifywhatisaquiteintricatelydesignedhealthandsocialcaremanagementstructure.InadditiontotheDepartmentofHealth,SocialServicesandPublicSafety,therearesixTrusts,aHealthandSocialCareBoardwithfiveLocalCommissioningGroups,aPublicHealthAgency,andseveralotherstatutorybodies.

Acentralfeatureisthesplitbetweencareprovidersandcommissioners,whichincreasesthecomplexityofthesystemanditsoverheadcosts.Thisbeganlifeastheso-calledpurchaser-providersplit,introducedbyMargaretThatcher’sgovernmentinthelate-1980s.Invariousiterations,ithasremainedafeatureoftheNHSeversince.Theintroductionofapurchaser-providersplitwasoriginallyintendedtocreateacompetitive‘internalmarket’todriveupqualityandsoincreasevalueformoney.However,thescopeforgenuinecompetitionhasalwaysbeenverylimited.Theterm‘commissioning’subsequentlysuperseded‘purchasing’.Commissioninginvolvesawidersetoffunctions–assessingneedandplanningservicesaccordingly,andtheuseoffinancialincentivestointentionallydrivethesystem’sdevelopmentrelatingtothetypeofservicesprovided,theirqualityandtheirefficiency.

WithintheUnitedKingdom,theEnglishNHShasthemostdevelopedcommissioningsystem.NHSEngland,thenationalcommissioningboard,isnowseparatefromthecentralgovernmentDepartmentofHealth.Itisapurecommissioningorganisation,completelyfreefromoverseeingtheperformanceofTrusts.Itsonlyrelationshipwiththeprovidersideofthemarketisthroughthecommissioningprocess.ItdevolvesthevastmajorityoffundstolocalClinicalCommissioningGroups(ofgeneralpractitioners)thatmakedecisionsabouttheallocationofmoneyagainstanational


4frameworkofpoliciesandgoals.Servicesarepricedunderatariffsystem.Thistariffhasbecomeincreasinglycomplex,tofacilitatelocallyagreedvariationandtoincorporatepay-for-performanceelements.

ThereareseveralcontextualdifferencesbetweenEnglandandNorthernIreland,ofwhichthemostobviousispopulationsize.InEngland,theoverheadcostsassociatedwithestablishingandadministeringacomplextariffsystemareessentiallydividedbetween53millionpeople.Withapopulationone-thirtieththesize,thecostperheadofrunningasimilarsysteminNorthernIrelandwouldbedifficulttojustify.

TheproblemforNorthernIrelandisthatithasgonejustpartiallydownthecommissioningpath.Itdoesnothavethebenefitsofasophisticatedcommissioningsystem,yethasthedownsideofincreasedcomplexityandoverheadcosts.Theworstofbothworlds.

NorthernIrelandhasnoservicetariffs.TheHealthandSocialCareBoardallocatesmoneybyaprocessakintoblockcontracting.ThisapproachwasabolishedyearsagoinEnglandbecauseitwasconsideredold-fashioned,crudeandnotconducivetoachievingvalueformoney.Fullydevelopedtariffsystemsreimburseprovidersonacase-by-casebasis,withtheamountpaiddependentonthediagnosisortheprocedureundertaken,thecomplexityofthepatientand,insomecases,measuresofthequalityofcare.InNorthernIreland,thefundingsystemisfarmorebasic.StafftheReviewTeamspoketobelievedthatitmakesnodistinction,forexample,betweenacystoscopy(asimplediagnosticprocedure,usuallyadaycase)andacystectomy(acomplexoperation),aclearabsurdityiftrue.

NorthernIreland’sfiveLocalCommissioningGroupsarenotlikeEngland’sClinicalCommissioningGroups.TheLocalCommissioningGroupshaveaprimaryfocusonidentifyingopportunitiesforlocal

serviceimprovement.Theyhaveveryfewresourcesand,ineffect,areadvisersandprojectmanagersratherthancommissioners.England’sClinicalCommissioningGroups,bystarkcontrast,haveahighdegreeofcontroloverresourceallocation.

Itisimperative,somewhereinthesystem,forneedstobeassessed,servicesplannedandfundsallocated.Whicheverpartofthesystemisresponsibleforthismustbesufficientlyresourcedtodoitwell–arguably,theHealthandSocialCareBoardiscurrentlynot.

TheNorthernIrelandsystemwouldbenefitfromstrongerthought-leadershipfromwithin.Thereisnoestablishedhealthandsocialcarethink-tank,andsomekeydisciplinessuchashealtheconomicsarenotstronglyrepresented.

NorthernIrelandcouldchoosetogodownanynumberofdifferentroutes.ItcouldstrengthenthecurrentHealthandSocialCareBoard,particularlytocreateatariffthatincludesastrongqualitycomponent.Alternatively,itcoulddevolvebudgetaryresponsibilitytothefiveTrusts,makingthemsomethingakintoAccountableCareOrganisationsinothercountries,responsibleformeetingthehealthandsocialcareneedsoftheirlocalpopulation.TheTrustswouldthenbuyinprimarycareservices,andcontractbetweenthemselvesfortertiarycareservices.

RecommendingacommissioningmodelisbeyondthescopeofthisReview.Itisclear,though,thattheNorthernIrelandapproachtocommissioningisnotcurrentlyworkingwell,andthatthisissurelyaffectingthequalityofservicesthatarebeingprovided.Forthatreason,theReviewTeammustrecommendthatthisissuebeaddressed.


44.2.6 Who runs the health and social care system in Northern Ireland?ItwasinstructivefortheReviewTeamtohaveaskedthisquestionofmanypeople.Thequestionelicitedavarietyofanswers,thecommonfeatureofwhichwasthatnoonenamedasingleindividualororganisation.Indeed,mostreflectedtheiruncertaintywithaninitialgeneralcomment.Typicalwasaremarklike:“TheMinisterhasahighprofile.”Whenpressedtodirectlyanswerthequestion:whorunstheservice?Theiranswersincluded:“TheMinister”,“ThePermanentSecretaryintheDepartmentofHealth”,“TheChiefExecutiveoftheHealthandSocialCareBoard”,and“TheDirectorofCommissioningoftheHealthandSocialCareBoard.”

TheseresponsesreflectthecomplexityofthegovernancearrangementsatthetopofthehealthandsocialcaresysteminNorthernIreland.Theyshowthatambiguityhasbeencreatedinthemindsofpeople–bothcliniciansandmanagers–throughoutthesystem.

Thequestionofwhoisinchargeisbothsimpleandsubtle.Whilstoverallaccountabilityversuscallingtheshotsversusmakingthingshappenareaspectsofgovernancethatwouldhaveasingleleadershiplocusinmanyplaces,thisisnotthecaseinNorthernIreland.Thereisnosinglepersonorplaceintheorganisationalstructurewherethesethingscometogetherinawaythateveryoneworkingintheservice,thepublicandthemediaclearlyunderstand.

ThepresentarrangementshaveevolvedovertimebuttheReviewofPublicAdministrationin2007ledtomanyofthem.PriortothistheDepartmentofHealth,SocialServicesandPublicSafetywaslargerandoversawfourCommissioningBoardsand18Trusts.Therewerehighly-centralisedcontrolmechanismsandtheservicewassubjectedtomanyandfrequentcircularsanddirectives.SincethentherehasbeenasmallerDepartmentofHealth,

SocialServicesandPublicSafetythatismorefocusedonprovidingpolicysupporttotheMinister.AsingleHealthandSocialCareBoardhasbeencreatedfromthepreviousfour.ThenumberofTrustshasbeenreducedfrom18tosix,fiveorganisedtoprovidehealthandsocialcareservicesbygeographicalareaandthesixthanambulanceTrustforthewholeregion.Anotherimportantchangehasbeentheadventofafully-devolvedadministrationandtheendofdirectrulewherepowerwasinthehandsofcivilservantsratherthanelectedlocalpoliticians.ThelackofclarityaboutwhoisinchargeisamajorproblemforNorthern’sIrelandcaresystem.Thedifficultyisnotthatthereisnofigurehead,butthatstrategicleadershipdoesnothavethevisibilityofothersystems.Withoutaclearleader,progressispiecemealandchangeishesitantandnotdriventhroughatscale–theReviewTeamwastold“therearemorepilotsthanintheRAF”.

4.2.7 Clarifying the role of healthcare regulationAsidefrombeingcommissionedbytheDepartmentofHealth,SocialServicesandPublicSafetytoconductoccasionalservice-specificinspections,theRegulationandQualityImprovementAuthorityhasuntilnowconductedaprogramofthematicreviewsdrivingmoreatqualityimprovementthanatregulation.

From2015,theMinisterhasdecidedthattheregulatorshouldundertakearollingprogrammeofunannouncedinspectionsofthequalityofservicesinallacutehospitalsinNorthernIreland.TheRegulationandQualityImprovementAuthorityisbeingdirectedinthistasktoexamineselectedqualityindicatorsinrelationtotriage,assessment,care,monitoringanddischarge.Asaresultofthischange,theregulatorwillreduceitsnormalannualprogrammeofthematicreviews.


4ThesechangesgivetheRegulationandQualityImprovementAuthorityamuchstrongerlocusinthehealthcaresideofprovision.However,thisbodyhasnorealtraditionofdoingthiskindofwork,unlikeitscounterpartselsewhereintheUnitedKingdom.Forexample,inEngland,thevarioushealthregulatorshaveevolvedovera15-yearperiodwithframeworks,methodologies,metricsandinspectionregimes.Forthisreason,theReviewisrecommendingthathealthcareregulationinNorthernIrelandisre-examinedintheround,ratherthanapproachingitpiecemealonaninitiativebasis.


44.3 INSUFFICIENTFOCUSONTHEKEYINGREDIENTSOFQUALITYANDSAFETYIMPROVEMENT

Therecognitionthatqualityandsafetyshouldbeapriorityintheplanninganddeliveryofhealthandsocialcarearrivedlatetothissectorindevelopednations.Untiltheearly1970s,servicesoperatedonthetacitunderstandingthatdoctors’andnurses’education,training,professionalvaluesandstandardsofpracticeensuredthatmostcarewasgoodcare.Itwasnotuntilmeasurementofqualitybecamemorecommonplacethatitwasrealisedthatfaithinthisethoshadbeenbadlymisplaced.AseriesofscandalsblewapartpublicconfidenceintheNHS.Thereweremanyvictims,anditbecameclearthattrustalonewasnotsufficient.Often,sucheventsdepictedculturesinsomehealthandsocialcareorganisationsintheUnitedKingdomandothercountriesthathadtoleratedpoorpracticeandevensoughttoactivelyconcealit.

Organisedprogrammestoassurequalityandimproveitinitiallycameintohealthcarethroughapproachesdevelopedintheindustrialsector,notablytotalqualitymanagementandcontinuousqualityimprovement.Until1998,therehadneverbeenaframeworktoprogressqualityandpatientsafetyintheUnitedKingdom’sNHS.Fromthattime,acomprehensiveapproachwasintroducedwith:standardssetbytheNationalInstituteforClinicalExcellenceandinNationalServiceFrameworks;aprogrammeofclinicalgovernancetodeliverassuranceandimprovementsatlocallevelbackedupbyastatutorydutyofquality;and,inspectionofstandardsandclinicalgovernancearrangementscarriedoutbytheCommissionforHealthImprovement.Theseroleshavechangedovertime.Somestillcoverall,ormost,oftheUnitedKingdom,whilstothershavebeentakenupdifferentlyinthefourcountries.

MuchrecentcommentaryontheNHSintheUnitedKingdomhasfocusedonwhetheritsleadershipisreallyseriousaboutqualityandsafety.Thereisawidespreadviewwithintheservicethatfinancialperformanceandproductivityarewhatreallymattertomanagers,despitewhatmightbeinthemissionstatementsoftheirorganisations.ThiscamehometoroostinthescandalouseventsattheMid-StaffordshireNHSTrustinEnglandwheretheFrancisInquiryheardthatconcernsaboutqualityweredown-playedagainstfinancialviabilityinthepressuretogainFoundationTruststatus.

Akeyconsiderationinqualityandsafetyofhealthcareiswhetheritisembeddedinthemainstreamatalllevels.Upuntilthelate-1990s,itwaslargelythedomainofacademicsandenthusiasts.Sincethen,thosewhoarefullycommittedtoitsunderlyingprinciplesandgoalshaveincreasedinnumber.However,itisstilldebatablewhatproportionofboardmembers,managementteams,andclinicalleadersare‘card-carrying’qualityandsafetyenthusiasts.

Prominentininternationalexperiencearefouressentialingredientstoimprovingthequalityandsafetyofcare.Theseare:clinicalleadership,culturalchange,datalinkedtogoals,andstandardisation.InNorthernIrelandseedsofeachcanbefound,butnoneisblossoming.ThisissubstantiallyholdingNorthernIreland’scaresystembackfromachievingitsfullpotential.

4.3.1 Clinical leadershipAcrucialtestofthestrengthofthequalityandsafetysystemistheextentofclinicalengagement.Thisispartlyaquestionofheartsandmindsbutalsoacaseofknowledge,skillsandthephilosophyofclinicalpractice.

Thequalityandsafetyofcarewillonlygetbetterifthosewhodeliverthecarearenotonlyinvolvedinimprovingit,butareleadingtheimprovementeffort.Intheverybesthealthcare


4systemsintheworld,cliniciansareinthedrivingseat,supportedbyskilledmanagers.Traditionally,doctors,nursesandotherhealthprofessionalshaveseentheirdutytothepatientinfrontofthem.Rightly,thisremainstheimportantprimaryrequirementforestablishingacultureofgoodclinicalpractice.However,thisisnotenoughtoenableconsistentlyhighstandardsofcare,nortomakecarebetteryear-on-year.Thisrequiresaparadigmshiftinclinicalpractice,adifferentmissionofpractice,sothatallhealthcareprofessionalsseetheessenceoftheirworknotjustinthecareofindividualpatientsbutinensuringthattheserviceforalltheirpatientsreachesaconsistentlyhighstandardandthatopportunitiesforimprovementareidentifiedandtaken.Accomplishingthisisnoteasy.Clinicianswillpointoutthattheirworkloadsaretooheavytomaketimetoreflectonthesewiderconsiderationsorthattheydonothaveaccesstoreliabledatatoallowthemtocomparetheirservicetobestpracticeorthattheyhavenothadtraininginqualityandsafetyimprovement.

Cliniciansneedtostepforwardtolead.Thisinvolvesexpandingtheirsenseofresponsibilitybeyondtheindividualpatientinfrontofthemtothesystemasawhole.Whencliniciansdostepforward,theyneedtobesupported.Theyneedtobegivenresponsibilityandresources.Theyneedtobegiventraining,becauseleadingimprovementistechnicallyandemotionallydifficult.

InNorthernIreland,theReviewTeammetasmallnumberoftalentedclinicianswhohavedecidedtostepforward,andwhoaresucceedinginleadingpositivechange.TheReviewTeammetmanymoreclinicianswhohavetriedtoengagewith‘management’inthepast,havebeenknockedback,andhavegivenuptrying.Therearemanygreatideaslyinglatentintheheadsandheartsofclinicians,untappedbythesystem.TheReviewTeamsawsomeeffort,particularlyintheSouthEasternTrust,toprovideclinicianswiththeskillsthat

theyneedtoleadimprovementprojects.Acrossthesystemasawholethough,thescaleandscopeoftheseisnowherenearwhatisneeded.

4.3.2 Cultural changeCulturedetermineshowindividualsandteamsbehavedaytoday.Itdetermineshowcliniciansviewandinteractwithpatients;whethertheyconsiderharmtobe“oneofthosethings”,“thecostofdoingbusiness”,orafeatureofhealthcarethat,witheffort,canbebanished;whethertheyreacttoseeingproblemsinthesystembycomplaining,orbytakingonresponsibilityforfixingthem.

Allhealthcaresystemsintheworldrealisetheimportanceofculture.Thedifferencebetweenthebestandtherestiswhattheydoaboutthis.Theverybestdonothopethatculturewillchange;theyputmajoreffortintoactivelychangingit.Theirapproachisnotlight-touchorscattergun;theyseechangingcultureasacentralmanagementaim.

TheClevelandClinicintheUnitedStatesofAmerica,forexample,setouttoimprovepatientexperience,mostofwhichisdeterminedbyhowstaffbehavetowardspatients.TheClinic’smanagementwantedallstafftobetterworkasateam,andtoseetheirroleasbeingimportantforpatientcare–fromdoctorsandnurses,tocleaners,receptionistsandelectricians.Theydesignatedthemall‘caregivers’.All40,000caregiversattendedaseriesofhalf-daytrainingsessions,designedtobuildtheirpracticalcommunicationskillsandtheirawarenessofself,othersandteam.Theymadepatientexperiencescoreswidelyavailable–rankedbydoctor,byhospital,andbydepartment.Theseeffortshavecontinuedforseveralyears.In2013,theChiefExecutive’sannualaddresstoallcaregiversincludedapowerfulvideoaboutempathy.Ithassincebeenviewed1.8milliontimesonYouTube.Inshort,theClevelandClinicmadeamajorconcertedefforttomakepatientexperienceimportanttoallwhoworkthere.


4Ithaspaidoff.Withstaffnowmoreengagedthanever,theClevelandClinichasbeenabletomoveontomakingsafetyandotherelementsofqualityacrucialpartoftheculturetoo.

InNorthernIreland,asinmanyplaces,noefforthasbeenmadetoinfluencecultureonanythinglikethisscale.Manypeopleinthesystemareabletodescribetheculture,andmanyciteitasimportant.Scatterguneffortsaremade–aspeechhere,anawardsceremonythere–butshiftingcultureishard,andscattergunwillnotdoit.Cultureisviewedwithadegreeofhelplessness–buttheevidencefromelsewhereisthatitcanbechanged,andthatdoingsoispowerful.

4.3.3 Data linked to goalsTheimportanceofdataandgoalsarenewstonobody.YetinNorthernIreland,asintoomanyotherhealthcaresystems,datasystemsareweakandpropergoalsaresorelylacking.

Improvinghealthcarerequiresclearandambitiousgoals.Itrequiresastatementthatpreventableharmwillbereducedtozero,orthattheoccurrenceofhealthcareassociatedinfectionswillbecutinhalfwithinayear.ManagementguruJimCollinswouldcalltheseBHAGs–BigHairyAudaciousGoals.Theyaregoalsthatareatonceexcitingandscary.Theygetpeopleinterestedandmotivated.TheyarethekindofgoalsthatNorthernIrelandshouldbesettingforitscaresystem.

Ifthegoalisthedestination,strongdataarethesatnav.Theyshowthecurrentpositioninaformthatprovidesusefulinformationforaction.Toooften,datashowwherethesystemwasoverthelastthreemonths,orwhatperformancehasbeenacrosslargeunits.Theyneedinsteadtoshowthesituationinreal-time,orasneartoitaspossible.Andtheyneedtoshowperformanceattheverylocallevel.

Aswithcultureandleadership,datacapabilityisanareathatthebestcaresystemsintheworldhaveinvestedinheavily.Theyhaveonlinedashboardsthatenableallaspectsofthesystemtobemeasured,understood,andthereforemanaged.Incomparison,NorthernIreland(andmanyotherplaces)hasacaresystemthatisbeingmanagedasifthroughablindfold.Investmentininformationtechnologyiscrucialand,ifdoneintelligently,willpaydividends.

4.3.4 StandardisationDoctorsgenerallydislikestandardisation(nurseswarmtoitmore),butitisacrucialpartofimprovingthequalityandsafetyofhealthcare.

OnehealthcarestandardisationtoolistheWorldHealthOrganization’sSafeSurgeryChecklist.Modelledafterthecheckliststhatpilotsusethroughouteveryflight,itlistsaseriesofsimpleactionsthatshouldbetakenbeforethepatientreceivesanaesthetic,beforetheoperationstarts,andbeforethepatientismovedfromtheoperatingtheatre.Eachitemonthelistissomethingblatantlyobvious–checkingthepatient’sidentity,confirmingthetypeofoperationthatisplanned,andsoforth.Withoutthechecklist,eachofthesethingsisdonemostofthetime–butnotallofthetime.Thechecklistensuresthattheyaredoneallofthetime–toavoidtheoccasionalinstance,ashappens,inwhichnobodyproperlycheckstheoperationtype,andthepatienthasthewrongoperation.

Carebundlesareaconceptthatinrecentyearshavebroughthigherqualitytotheareasofcarewheretheyhavebeenusedwell.Theyhelpclinicianstoreliablygiveeveryelementofbestpracticetreatmentforcommonconditionssuchaspneumonia.Theevidenceisclear:theysavelives.Withoutthem,patientsgetbest,safestpracticeonlysomeofthetimeandthosewhodonotaretheunluckyoneswhocansuffergreatlyasaconsequence.


4Checklistsandcarebundlesarenotwidespreadinhealthcareprimarily,becausetheyarecounter-cultural.Doctors’training,inparticular,emphasisestheimportanceofretainingknowledge,ofautonomy,andofvariationbetweenpatients.Allofthesegoagainsttheideaofstandardisation.Theconceptofstandardisationdoesnotjustrelatetonovelmethodslikechecklistsorcarebundles.Itisalsoconcernedwithallpatientswithaparticulardiseasereceivingaconsistentprocessofcarebasedonbestpracticeinternationally.Theideathatpeoplewithconditionslikeboweloroesophagealcancershouldbereceivingdifferenttreatmentbasedonclinicalpreferenceorwheretheyliveisadisgrace.Healthcareshouldnotbealottery.

Thebesthealthcaresystemsintheworldhaveahighdegreeofstandardisation.Notforeverything–butfortheareasofcarewheretheevidenceshowsthatitmakesadifference.Theyhaveasubstantialnumberofcarepathways,checklists,andcarebundles.Thisdoesnotleavetheclinicianswithoutajob–farfromit.Theirjudgementisvitalindecidingwhichpathway,checklistorcarebundletouse,andinspottingthecasesinwhichastandardapproachisnotappropriate.Theystillspendthemajorityoftheirtimeworkingwithoutreferencetoanyofthesethings,butusethemwhenevertheyareneeded.

NorthernIrelandhassomegoodexamplesofworkinthisarea,includingtherolloutofaNationalEarlyWarningSystemforacutelyillpatients,acarebundleforsepsis,aninsulinpassport,andregionalchestdraininsertiontraining.However,theopportunityforstandardisationismuchgreaterandneedstobeappliedatamorefundamentallevel,whichinfluencesthemodelofpracticebeyondthisseriesofindividualinitiatives.Thereisnotyetacriticalmassofcliniciansclamouringformorestandardisation.TherearemultipleexamplesofdifferentTrustsapproachingthesameclinicalscenarioindifferentways,andwantingtoretain

theirautonomytodoso.IfNorthernIrelandwantstobeanythinglikeasgoodonsafety,clinicaleffectivenessandpatientexperienceastheClevelandClinicandothercentresofexcellence,itneedstobemoreopentobigchange.

4.3.5 The recipe for successThereislittledoubtthatqualityandsafetyarenotfullyembeddedintheplanning,designanddeliveryofservicesinNorthernIreland.Moresleepislostoverbudgetsthanaboutwhetherpatientsaretreatedwithdignityandrespect,whetheroutcomesofcarearegenuinelyworldclassandwhetherpatientsareproperlyprotectedfromharmwhentheyarebeingcaredfor.

Fourvital,andoftensuperficiallytreated,ingredientsforqualityandsafetyimprovementare:clinicalleadership,culturalchange,datalinkedtogoals,andstandardisation.Theyarehighlyinter-linked.

TheNorthernIrelandcaresystemisnotseeingthewoodforthetreesontheseingredients.TheQuality2020strategycitesthem(anddoessetsomebiggoals),buttheyarenotheldascentralandarethereforesomewhatlost.Theyneedtobegivenfarmoreprominence,becausetheyformthebedrockonwhichallqualityandsafetyimprovementisbuilt.

Withfocusedeffort,NorthernIrelandcould:buildacadreofskilledclinicalleaders;developacultureinwhichqualityimprovementissecondnature;setbiggoals;establishtheinformationtechnologysystemsrequiredtomeasurequalitylocallyandinreal-time;andstandardiseprocessessubstantially.Ifthecaresystemmakestheseactivitiescentraltoitsqualityandsafetyefforts,improvementwillfollowandwillflourish.Withoutbuildingthisbedrock,noothereffortstoimprovequalityandsafetywillgainanysignificantpurchase.


44.4 EXTRACTINGFULLVALUEFROMINCIDENTSANDCOMPLAINTS

Mostpatientsafetyprogrammeshaveattheircoreaprocesstocaptureandanalyseerrorsandaccidentsthatariseduringtheprovisionofcare.Thisisbasedonthelong-establishedpremisethatonlybylearningfromthingsthatgowrongcansimilareventsbepreventedinthefuture.Tosomeextent,thisdrawsontheexperienceofotherindustriesthathavesuccessfullyreducedaccidentsandriskyear-on-year.Thisthinkinghasledtotheestablishmentofincidentreportingsystemsinhealthservicesacrosstheworld,someoperatingonlyatthelevelofhealthcareorganisations,someencompassingwholecountriesandsomerestrictingreportstothosewithinonefieldofmedicine(e.g.surgery).

Itisnotalwaysappreciatedthatreportingofincidents(whichcanbevoluntaryormandatory)isonlyonewayofassessingharminthecareofpatients.Numerousotherapproacheshavebeenused,including:prospectiveobservationofcareprocesses;triggertoolsinvolvingretrospectivecasenotereview;expertcasenotereview;HospitalStandardisedMortalityRatios(andsimilarmetrics);andminingelectronichospitaldatabases.

AlongsideNorthernIreland’sincidentreportingsystemsrunsacomplaintssystem.Globally,surveyshaveconsistentlyshownthatwhatpatientswantfromacomplaintssystemare:anexplanation,anapology,andareassurancethatimprovementstotheservicewillbemadebasedontheirexperience.Otherjurisdictionshavefoundthatthefeaturesofagoodcomplaintssystemare:satisfactorylocalresolutionofthemajorityofcomplaints;speedyresponsetimes;excellentcommunicationwithpatients;goodrecordkeeping;apologiesmadein-personbytheseniorstaffinvolvednotontheirbehalf;accuratemonitoringofthenumbersandcategoriesofcomplaint;effectivelearningatthelocalandsystemiclevel.

Allthesesystemshaveacommonprimarypurpose:toimprovethequalityofcare,andtoreduceavoidableharm.

4.4.1 Incident reporting elsewhereGlobally,incidentreportingsystemsvarygreatlyin:thenatureofthedatacaptured,theextentofpublicreleaseofinformation,whetherreportingisvoluntaryormandatory,andthedepthofinvestigationundertaken.

Mostreportingsystemsstartbydefiningingeneraltermswhatshouldbereported.Terminologyvaries;adverseevent,incident,error,untowardincidentareallincommonuseinternationally.Theepithetseriouscanbeappliedtoanyoftheterms.ThelargestnationalsystemintheworldwasestablishedintheNHSinEnglandandWalesasaresultofthereportAnOrganisationwithaMemory.From2004untilrecently,itwasrunbyanindependentbody,theNationalPatientSafetyAgency,andiscalledtheNationalReportingandLearningSystem.NHSstaffareencouragedtomakeanincidentreportofanysituationinwhichtheybelievethatapatient’ssafetywascompromised.

Inthissystem,a‘‘patientsafetyincident’’isdefinedas‘‘anyunintendedorunexpectedincidentwhichcouldhave,ordid,leadtoharmforoneormorepatientsreceivingNHScare.”ReportsarefirstmadetoalocalNHSorganisationandthensentinbatchreturnsbythelocalriskmanagertothenationallevel.StaffmakeasmallnumberofreportselectronicallydirectlytotheNationalReportingandLearningSystem.Theinformationrequiredcovers:demographicandadministrativedata;thecircumstancesofoccurrence;acategorisationofcausation;anassessmentofthedegreeofharmas‘‘no’’,‘‘low’’,‘‘moderate’’,‘‘severe’’,or‘‘death’’;andactiontakenorplannedtoinvestigateorpreventarecurrence.Thesedataarecapturedinastructuredreportingform,butthereisalsoasectionoffreetextwherethereporterisaskedtodescribe


4whathappenedandwhytheythinkithappened.Dataareanonymisedtoremovethenamesofpatientsandstaffmembers.

Injustoveradecade,coveringtheNHSinEnglandandWales,nearly10millionpatientsafetyincidentshaveaccumulatedinthisdatabase.Since2012,ithasbeenmandatorytoreportallcasesofsevereharmordeath.Itremainsvoluntarytoreportallotherlevelsofharm.

Duringtheperiodofitsexistence,theNationalPatientSafetyAgencyinEnglandandWalesissued77alertsandmanyothernoticesaboutspecificrisks,mostofwhichhadbeenidentifiedbyanalysisofpatientsafetyincidentreports.NewarrangementsforissuingalertsareinplacefollowingtheabolitionoftheNationalPatientSafetyAgency.

ThissystemofincidentreportinginEnglandandWalesholdsahugeamountofdatabutonlyasmallproportionofitiseffectivelyused.Itiscurrentlybeingreviewedandisunlikelytocontinueinexactlythesameway.

Worldwide,theproblemsassociatedwithincidentreportingareremarkablyconsistent,whateversystemdesignisadopted.Firstly,under-reportingisthenorm,althoughitsdegreevaries.Thisseemstodependontheprevailingcultureandwhetherincidentsareseenasanopportunitytolearnorasabasisforenforcingindividualaccountabilityandapportioningblame.Italsodependsonstaffperceptionsaboutthedifferencetheirreportwillmakeandhoweasyitisforthemtoconveytheinformationthattheyarerequiredto.Reportingratesaremuchlowerinprimarycareservicesthaninhospitals.Secondly,giventhevolumeofreportsmade,thereisofteninsufficienttime,resourceandexpertisetocarryoutthedepthofanalysisrequiredtofullyunderstandwhytheincidenthappened.Thirdly,thebalanceofactivitywithinreportingsystems

goesoncollecting,storing,andanalysingdataattheexpenseofusingitforsuccessfullearning.Indeed,therearerelativelyfewexamplesworldwideofmajorandsustainedreductionsinerrorandharmresultingbecauseoflessonslearntfromreporting.

4.4.2 Incident reporting in Northern IrelandIncidentreportingbeganintheNorthernIrelandhealthandsocialcaresystemin2004.Twocategoriesofincidentwereestablished:anadverseincidentandaseriousadverseincident.TheformerwerereportedandinvestigatedlocallywithineachTrust.ThelatterweredocumentedandinvestigatedlocallybutalsohadtobereportedtotheDepartmentofHealth,SocialServicesandPublicSafety.Staffmake80,000to90,000adverseincidentreportseachyear.Over400SeriousAdverseIncidentreportsweremadein2013.Inthefive-yearperiodfrom2009,thenumberofSeriousAdverseIncidentsrelatedtoEmergencyDepartmentsrosefrom8to36.

Anadverseincidentisdefinedas:

“Anyeventorcircumstancesthatcouldhaveordidleadtoharm,lossordamagetopeople,property,environmentorreputation.”

In2010,majornewguidancewasissuedpassingresponsibilityformanagingandfurtherdevelopingtheseriousadverseincidentsystemtotheHealthandSocialCareBoard,whereitremainstothisday.Furtherguidancewasissuedin2013withnewreportingrules.

ToberegardedasaSeriousAdverseIncidentforreportingpurposes,theincidentmustfallintooneofthefollowingcategories:theseriousinjuryorunexpected/unexplaineddeathofaserviceuser,staffmemberorvisitor;thedeathofachildinhealthorsocialcare;anunexpectedseriousrisktoaserviceuserand/orstaffmemberand/ormemberofthepublic;anunexpectedorsignificantthreattoservicedeliveryorbusinesscontinuity;serious


4self-harmorassaultbyaserviceuser,staffmember,ormemberofthepublicwithinahealthcarefacility;seriousself-harmorseriousassaultbyanypersoninthecommunitywhohasamentalillnessordisorderandisinreceiptofmentalhealthand/orlearningdisabilityservices,orhasbeenwithinthelasttwelvemonths;and,anyseriousincidentofpublicinterest.

Anystaffmembermayreportanadverseincident.Thereporterisnotaskedtomakeajudgmentaboutwhethertheincidentmeetstheseriousadverseincidentcriteria.Aresponsiblemanagermakesitbasedontheirreadingoftheincidentandapplicationoftheguidelines.AnySeriousAdverseIncidentmustbereportedtotheHealthandSocialCareBoardwithin72hours.AsubsetofSeriousAdverseIncidentsmustbesimultaneouslyreportedtotheHealthandSocialCareBoardandtheRegulationandQualityImprovementAuthority.

TrustsinNorthernIrelanddifferslightlyintheprocedureadoptedforencouraging,receivingandinvestigatingincidentreports.Generally,allstaffareencouragedtomakereportsasawayofmakingcaresafer.TheycompleteanincidentreportandsubmitittotheTrust’sriskmanagementdepartmentsothatitcanbeenteredintotheriskmanagementdatabase.Increasingly,morereportsarebeingmadeon-linewhichcutsoutthelaboriousform-fillingwhichisanundoubtedbarriertostaffmakingareportandoftenleadstopapermountainsintheriskmanagementdepartment.Trustsvaryintheproportionofincidentsthattheyinvestigate,thedepthofthatinvestigationandtheextenttowhichactionisagreedandimplemented.Clinicalgovernancecommittees(ortheirequivalents),sub-committeesoftheTrustboardortheBoarditselfusuallylookataselectionofindividualincidentreports,ataggregatedincidentdataoratboth.

ThenumberofSeriousAdverseIncidentsvariesbetweenTrusts(Figure1).Tosomeextentthisreflectstheirdifferingnumberofpatients.However,thereisnowayofknowingatpresentwhetherahigherlevelofincidentsmeansthattheorganisationislesssafethanothersorthatitismoresafeandthatitsstaffaremoreconscientiousinmakingreportssothatlearningcanimprovepatientsafety.WhilstdataareavailableonSeriousAdverseIncidenttypes,thecategoriesandclassificationsuseddonotmakeiteasytoaggregatedatainawaythatenablessystemicweaknessestobeidentified.OpportunitiesarethereforebeinglostforsurveillanceofpatientsafetyacrossNorthernIreland.

ThevastmajorityofSeriousAdverseIncidentsarereportedbythefiveacuteTrusts.Muchsmallernumbersarereportedbytheambulanceserviceandbyprimarycare(Figure2).Thenumberofincidentsreportedhasincreasedquitesubstantiallyfrom2013to2014(Figure3).Inpartthisisbecauseofimprovedawarenessofthereportingsystem.Inpartitisbecausethereportingcriteriawerechanged–mostnotably,requiringthatallchilddeathsbereported.


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Figure 1. Serious Adverse Incident reports: by Trust

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Figure 2. The great majority of Serious Adverse Incident reports are made by the Health & Social Care Trusts

Serious Adverse Incident Reports, Apr-Sept 2014

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Child deaths (New reporting requirements)

Figure 3. Serious Adverse Incident reporting increased between 2013 and 2014. Some of the increase was because reporting criteria changed, particularly introducing a requirement to report all child deaths.

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4AllSeriousAdverseIncidentsareinvestigated.Thetype(andthereforeintensity)oftheinvestigationshoulddependontheseverityoftheincident,itscomplexity,andthepotentialtolearnfromit.Threelevelsofinvestigationarestipulated:

• Level1involvesaSignificantEventAudit–amethodofassessingwhathashappenedandwhy,agreeingfollow-upactions,andidentifyinglearning.

• Level2involvesaRootCauseAnalysis–amoredetailedexercisetodeterminecausationandlearning,undertakenbyaformalinvestigationteamchairedbysomebodynotinvolvedintheincident.

• Level3involvesafull-blownindependentinvestigation.

MostSeriousAdverseIncidentsstartatLevel1investigation,andmayproceedtoLevel2or3iftheLevel1investigationsuggeststhatthisisnecessaryorwouldbeuseful.AminoritystartatLevel2or3immediately,bypassingLevel1.

ADesignatedReviewOfficer,assignedbytheHealthandSocialCareBoardandPublicHealthAgency,providesindependentassurancethatanappropriatelevelofinvestigationhasbeenchosen,andthatitisconductedappropriately.

TheprocessofdealingwithSeriousAdverseIncidentsattheoperationalleveloftheserviceisveryinvolvedandhighlyregulatedwithlittleroomforflexibility.Thereareanumberofdecision-makingpointsatwhichimportantjudgmentsmustbemadebystaffonmatterssuchaswhatleveltheincidentfallsintoandwhethertoreferanincidenttothecoroner.

4.4.3 Frustrations with the incident reporting systemThestaffwhousetheincidentreportingsystemhaveconcernsandfrustrations.Firstly,atthepolicylevel,therequirementstoreportSerious

AdverseIncidentsplacesaconsiderableburdenonthemtocompleteformsandmeetdeadlines,withverylittleflexibilitytodeviatefromtheproscribedprocedure.ThereisanacceptancebystaffthatitisimportanttodocumentandinvestigateSeriousAdverseIncidentsbutthepressuretocompleteallthestepsoftheprocessoftenmeansthatthereisnotimetoreflectonwhatcanbelearnedsoastoreduceriskforfuturepatients.OneoftheSeriousAdverseIncidentsthattheReviewTeamdiscussedwithTruststaffhadinvolvedinterviewswith34differentpeople.ItwasbynomeansthemostcomplexincidentthattheReviewTeamheardabout.

ThereisanalmostuniversalviewthattherequirementtoreportandinvestigateallchilddeathsinhospitalasSeriousAdverseIncidentshasbeenaretrogradeanddamagingpolicydecision.Theconsequenceofithasbeenthat,ifachilddiesfromacausesuchasterminalcanceroracongenitalabnormality,agrievingfamilymustbeadvisedthatthereistobeaninvestigation.Inevitably,thisstronglyimpliesthattheservicehasbeenatfault.Suchanapproachisnotkindtosuchfamilies,putsstaffinaverydifficultposition,anddivertsattentionfromtheinvestigationofgenuinelyavoidableincidentsinvolvingthecareofchildren.Inaseparateaspectofincidentpolicy,manystaffworkingwithinthementalhealthfieldhaveconcernsabouttheinflexibilityoftheSeriousAdverseIncidentschemeasitappliestosuicideoftheirpatients.Whilstthetime-scalesforinvestigationimposeanecessarydisciplineontheprocessgenerally,therangeoffactors,individualsandagenciesthatneedtobepartofthedeterminationoftherootcausesofthesuicideofamentalhealthpatientareverygreatindeed.Thepressuretoadheretostatutorydeadlinescanmeanthattheworkinsuchcasescansometimesbeincompleteandsohaslimitedvalueinpreventingrecurrences.


4Secondly,attheculturallevel,somemedical,nursingandsocialcarestaffareconcernedthat,inreportinganadverseincident,theywillexposethemselvestoblameandpossibledisciplinaryaction.JuniordoctorstoldtheReviewTeamthatmakingtoomanyreportsdrawssuspicionthattheyaretrouble-makersandthatanactiveinterestinpatientsafetycoulddamagetheircareerprospects.Theyprefertomaketheirviewsonpatientsafetyknownthroughthemedicaltraineeannualsurvey(Figure4),wheretheycanremainanonymous.

Figure 4. Percentage of medical trainees reporting concerns about patient safety and the clinical environment

Trust: Belfast Northern South Eastern Southern Western

Patient safety 6.5% 6.8% 3.0% 4.7% 3.2%

Clinical environment 2.8% 3.6% 0.8% 1.4% 0.4%

Total 9.3% 10.4% 3.8% 6.0% 3.7%

Source:GeneralMedicalCouncilNationalTrainingSurvey2013.Numbersarerounded.

TheseculturalbarrierstoreportingandlearningarenotuniquetoNorthernIreland.Creatingaculturewherethenormativebehaviorislearning,notjudgment,isverymuchtheresponsibilityofpoliticalleaders,policy-makers,managersandseniorclinicians.Thisdoesnotmeanthatno-oneiseveraccountablewhensomethinggoeswrongbutitdoesmeanthataproperregardshouldbegiventotheoverwhelmingevidencethataclimateoffearandretributionwillcausedeathsnotpreventthem.

Thirdly,attheoperationallevel,stafffrustrationswiththeincidentreportingprocessesrangefromtheverypractical,suchasnotbeingabletofindtheformnecessarytomakethereport,tothedeeperde-motivatingfeaturesofthesystemsuchasneverreceivinganyfeedbackorinformationontheoutcomeofthereportthattheyhadmade.Otherweaknessesoftheprocessperceivedbystaffinclude:havinglittletraininginhowto

investigateproperly,reportinganincidentthenbeingaskedtoinvestigateityourself,andatendencyforinvestigationstodescendintosiloseventhoughtheremighthavebeenamulti-specialtyelementtothepatient’scare.

4.4.4 The complaints system in Northern IrelandPatients,theircarers,andtheirfamiliescanmakeacomplaintabouttheservicesreceivedinperson,bytelephoneorinwriting.IfthecomplaintconcernsthehealthorsocialcareservicesdeliveredbyoneofthesixTrustsinNorthernIreland,aseniorofficerwithintheorganisationwillworkwiththestaffinvolvedintheperson’scaretoinvestigateandproducearesponse.AletterfromthechiefexecutiveofficeroftheTrustmustgotothecomplainantwithin20workingdays.However,performanceissuboptimalandveryvariableinthisrespect(figure5).


4Figure 5. All Trusts are failing to meet the standard 20-day substantive response time for complaints (% meeting standard shown; 2013-14)

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Ambulance Service

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Thebestoutcomeisforthecomplainttoberesolvedlocallytothecomplainant’scompletesatisfaction.Thisisnotalwayspossibleandifthecomplainantisnotsatisfiedwiththeresponse,thecomplaintcanbere-openedandfurtherinvestigationcanbeundertakenorexternaladvicesought.Ifthisstilldoesnotresolvethecomplaint,thecomplainantcanmakeasubmissiontotheOmbudsman.Hewilllookatwhethertheprocessofrespondingtothecomplaintwasundertakenappropriately.Hecanalsoinvestigatethesubstanceofthecomplaintbutunderpresentlegislation,hecannotmakethesereportspublic.ThisbizarresituationmeansthatthepublicisunawareofwherestandardshavefallenshortandwhattheOmbudsmanthinksshouldbedone.

AnincreasingnumberofpeoplewhohavecomplaintscontactThePatientandClientCouncilaskingforhelp.TheCouncildoesnothavepowerstoinvestigatecomplaints,onlytoprovidesupport.Nearly2000complainantscontactedtheCouncillastyear.Manysuchcontactswerefrompeoplewhohadtriedtonavigatethecomplaintssystemaloneandhadhaddifficulties.ThePatientandClientCouncil’s

involvementoftenhelpsinfacilitatingresolutionofthecomplaint,sometimesbyarrangingmeetingsofthetwosides.

Complaintsaboutprimarycarearehandledsomewhatdifferently.TheyareraisedwiththeHealthandSocialCareBoarddirectly.Thenumberofcomplaintsfromprimarycareislowerthanmightbeexpected.Thismayreflectthereluctanceofpatientstocomplainaboutaservicethattheyaretotallyrelianton.

4.4.5 Involvement of the coronerNorthernIreland,likeelsewhere,isstillgrapplingwithadifficultquestion:whatistheappropriaterolefortheCoronerintheinvestigationofdeathsthatmayhavebeencaused,atleastinpart,bypatientsafetyproblems?Thisisnotaneasyquestion.Itisdifficulttocreateguidancethatpreciselydefineswhichdeathsshouldbeinvestigatedbythecoronerandwhichshouldnot.AndCoroner’sinquestshavemajorprosandcons.

Whensomebodydiesandtheircaremayhavebeenperceivedaspoor,somefamiliescallforaCoroner’sinquest.ThepositiveelementsofthisarethattheCoronerisindependentofthehealthandsocialcaresystem,hasclearlegalpowers,andisskilledintheinvestigationofdeaths.

Ontheotherhand,conductinganinquestintoeverySeriousAdverseIncidentthatresultsinadeathwouldbearesource-intensiveundertaking.Italsomaynotresultinthemosteffectivelearning.Fewcouldhonestlysaythatthecourtroomenvironmentdoesnotintimidatethem.Itisnottheeasiestplacetobuildaconstructiverelationshipbetweenthecliniciansinvolvedinthecareofthedeceasedandthedeceased’sfamily.Itisnotthemostconduciveenvironmenttoopen,reflectivelearning.

Incasesofnegligenceorgrossbreachesofstandardsofcare,itisveryclearthatreferraltotheCoroneristhemostappropriatecourse.


4Attheotherendofthespectrum,inafewcasesthereisaSeriousAdverseIncidentatsomepointduringapatient’scareandthispatientsubsequentlydies,butthedeathisentirelyunrelatedtotheincidentandsoaninquestisreallynotwarranted.Inbetweenthesetwoextremesliesasubstantialgreyarea,inwhichtherelativemeritsofaCoroner’sinquestandaninternalSeriousAdverseIncidentinvestigationaredebatable.ThisisnotonlythecaseinNorthernIreland,butacrosstheUnitedKingdomasawhole(exceptthatScotlanddoesnothaveaCoroner).

Thisisacomplexissue.CurrentlyonlyasubsetofthedeathsthatcouldbethesubjectofaCoroner’sinquestactuallybecomeso.Somearenotreportedtothecoroner’soffice(largelyappropriately,itseems)andsomearediscussedwiththecoroner’sofficebutnotlistedforinquest.Inotherwords,thejudgmentsofcliniciansandcoroners’officersalikehaveasubstantialbearingonwhichcasesproceedtoinquest.Thesubsetofcasesthatendupinfrontofacoroner’sinquestarealsodeterminedasmuchbyfamily’swishesasbythecontentofthecases.

Tosomethismaysoundshockingbut,giventhecomplexityoftheissuesinvolved,thestatusquoisnotentirelyunreasonableandisinlinewithpracticeinternationally.Butthestatusquoiscertainlynotideal.Thereissubstantialroomforimprovement,sothatthecoronercanmoreoptimallycontributetothesystem’slearning.

4.4.6 RedressThecreationoffinancial,andothernew,formsofredresswouldhavetobelinkedtothehandlingofcomplaints,incidentsandmedicalnegligenceclaimsinawholesystemsmanner.ThisisahighlycomplexareathatwasextensivelyexaminedinEnglandinthereportMakingAmends.Intheend,thecentralideaofintroducingsomepaymentsforvictimsofharmandrecipientsofpoorqualitycare,aswellaspotentiallitigants,wasnottakenforward.Thereweresoundprinciplesbehind

theproposals,buttherewasaleap-in-the-darkelementtoo.Prioritywasgiveninsteadtoactiontoimprovethequalityandsafetyofcareandtoimproveresponsestocomplaints.However,oneoftheotherproposalsofMakingAmends,theintroductionofaDutyofCandour,isfinallybeingimplementedinEngland.TheReviewTeamconsidersthatpriorityinNorthernIrelandshouldbegiventotheareascoveredbyitsrecommendations,tomakingimportantchangestogeneratesaferhigherqualitycare,ratherthanembarkingonnewpoliciesforredress,includingfinancialcompensation.

4.4.7 The nature of learningThewholequestionofhowlearningtakesplaceinhealthcarethroughthescrutinyandanalysisofincidentreportsorthroughtheirinvestigationhasbeenlittledebated.Indeed,thetermlearningitselfisverylooselyappliedinthiscontext.Strictlyapplied,itwouldmeanacquiringnewknowledgefromincidentsabouthowharmhappens.Yet,thewayinwhichthewordlearningisrepeatedlyusedinthecontextofpatientsafetyismorethanincreasingunderstanding.Itimpliesthatbehaviourwillchangeoractionswillbetakentopreventfutureharm.Unfortunately,althoughtherearesomeexceptions,thereislittleevidencethatmajorgainsinthereductionofharmhavebeenachievedinNorthernIrelandorinmanyotherjurisdictionsthroughtheso-calledlearningcomponentofpatientsafetyprogrammes.

InNorthernIreland,themainformally-identifiedprocessesforreducingriskorimprovingpatientsafety,asidefromactionplansderivedatTrustlevel,are:

• theproductionoflearningletters• thebi-annualSeriousAdverseIncident

LearningReport• thecirculationofnewsletterssuchas

LearningMatters• thematicreviews• trainingandlearningevents


4• implementingtherecommendationsof

reviewsandinquiries• disseminatingalertsandguidanceimported

fromotherpartsoftheUnitedKingdomorfurtherafield.

Onmany,perhapsmost,occasionswhensomethinggoeswrong,thepotentialforlearningfromthisisveryrichindeed.Thispotentialtoooftengoesunrealised.ThisisaproblemnotjustinNorthernIreland,butincaresystemsworldwide.

Threefeaturesdeterminetheextenttowhichinvestigationofanadverseeventresultsinriskbeingreduced:

• Howdeeptheinvestigationgets,inunderstandingthetruesystemicissuesthathelpedsomethinggowrong

• Howsystemictheinvestigation’sfocusis,inconsideringwhereelseasimilarproblemcouldhaveoccurredbeyondthelocalcontextinwhichitdidoccur

• Howstrongthecorrectiveactionsareinactually,andsustainably,reducingtheriskofarepeat

Thefirstofthese,depthofinvestigation,isdonereasonablywell.Adecadeago,harmwasoftenputdownto‘humanerror’.Thereisnowfargreaterrecognitionthatthisisasuperficialinterpretation–thattherearealmostalwaysproblemswithinthesystemwhichnotonlyallowedthatharmtooccurbutmadeitmorelikely.ThetechniqueofrootcauseanalysisiswidelyusedinNorthernIreland,andhelpstouncoversomeofthecausalelements.Often,though,itdoesnotfindthedeeperreasons.Thisispartlybecauseofthetimepressurestofinishtheinvestigation,partlybecausenotallstaffhavehadthenecessarytrainingtodothisdeeperanalysis,andpartlybecauseofalackofhumanfactorsexpertiseintheprocess.Also,manyhospitalincidentsinvolveprimarycareinthechainofpossiblecausation,yetprimarycarestaffplayaminor,orno,roleinmanyinvestigations.

Inrelationtothesystemicview,whenaproblemoccurs,thereistoogreatatendencytoinvestigatethatspecificproblem,withoutlookingforthebroadersystemicissuesthatithighlights.Problemsareoftenaddressedinthedepartmentwheretheyoccur,withoutaskingwhethertheycouldhaveoccurredinotherdepartments,forexample.Similarly,ifamedicationincidentoccurs,thereisatendencytofixtheproblemforthatmedication,withoutlookingatwhetherthereisaproblemforsimilarmedicationorroutesofadministration.

Thisnarrow,reactiveapproachfailstomakefulluseofincidentreports.Inshort,itreflectsanerroneousassumptionthatthesystemasawholeisworkingfine,andthattheproblemsthatallowedtheeventtooccurarespecific,localones.Thisisnotthecase.Therearesystemicproblemsthroughthehealthandsocialcaresystem.Incidentsofharmaredistributedlargelybychance–bylocationandbytype.Fixingeachspecificproblemislikeplaying“Whack-A-Mole”–itdoesnotgettothenuboftheissues.

Theultimateaimofinvestigationistoreducetheriskofharm,notsimplytounderstandwhatwentwrong.Correctiveactionistooofteninadequate.Thereisnoautomaticlinkbetweenunderstandingwhatwentwrongandbeingabletoreducetheriskofithappeningagain.Indeed,makingtheleapbetweeninvestigationandriskreductionisreallyverychallenging.

InNorthernIreland,theactionliststhataregeneratedbySeriousAdverseIncidentinvestigationcommonlyfeatureplansofthefollowingkinds:

• Makingstaffawarethattheincidenttookplace

• Explainingtostaffwhatwentwrong• Circulatingawrittendescriptionofthe

incidentandactionstakentootherpartsofthehealthandsocialcaresystemtosharethelearning


4Suchinformationsharingactionsshouldformpartoftheplanbuttheydonotamounttosystemicmeasuresthatwillreliablyandsignificantlyreducetherisktopatients.

Researchandexperienceoutsidehealthcarehasshownthatsafetycomesdowntoappreciatingthatbigimprovementsarenotmadebytellingpeopletotakecarebutbyunderstandingtheconditionsthatprovokeerror.

Actionplansoftenalsofeaturesomechangetocurrentpaperworkorintroductionofnewdocumentation.This,too,isveryreasonablebutoftenhasaweakimpactonoutcomes.Italsohastheimportantdownsidethatmountingpaperworkreducesthetimeforpatientcareandintroducescomplicationsofitsown.

Sowhatdostrongcorrectiveactionslooklike?Technologicalsolutionshaveanimportantroletoplay.Electronicprescribingsystems,patientmonitoringsystems,andsharedcarerecordscanaddressmultiplepatientsafetyissuessimultaneously(althoughtheirimplementationanduseisnotwithoutrisk).Policies,rules,andchecklistscanalsobeuseful,butareeasytoimplementbadlyandmoredifficulttoimplementwell.

AsdiscussedearlierinthisReport,oneareaofhighpotentialistheuseofstandardisationofprocedure.Itisunderutilisedinhealthcareworldwidebutwhereitisappliedithasbroughtresults.Standardisationofprocedureisamainstayofsafetyassuranceandimprovementinothersectors.

Inlargepart,though,healthcaresystemsworldwidearenotyetgoodatimplementingsolutionsthatwilltrulyreducerisk.ItisnotthecasethatNorthernIrelandislaggingbehind–butthatNorthernIrelandisstrugglingwiththisproblemalongsideothercountries.

Identifyingthesystemicissuesandidentifyingstrongcorrectiveactions:eachoftheseistough;anartandascienceinitself;anareainneedofintenseandrigorousstudy.Untiltheseissuesaretackledheadon,inNorthernIrelandandelsewhere,thesystem’slearningwhenthingsgowrongwillfallshort.

Whensomethinggoeswrong,patientsandfamiliesaskforreassurancethatitwillnothappenagain.Asitstands,nobodycanhonestlyprovidethisreassurance.Infact,itisdifficulteventosaythattheriskhasbeensignificantlyreduced–letalonetozero.Thisneedstochange.4.4.8 Strengths and weaknesses of Northern Ireland’s systems for incident reporting and learningNosystemofreportingandanalysingpatientsafetyincidentsisperfect.Inanidealworld,alleventsandoccurrencesinahealthservicethatcausedharmorhadthepotentialtocauseharmwouldbequicklyrecognisedbyalert,knowledgeablefront-linestaffwhowouldcarefullydocumentandcommunicatetheirconcern.Theywouldbeenthusiasticabouttheirinvolvementinthisactivitybecausetheywouldhaveseenmanyexamplesofhowsuchreportsimprovedthesafetyofcare.Theresultinginvestigationwouldbeimpartialandmulti-disciplinary,involvingexpertisefromrelevantclinicalspecialtiesbut,crucially,alsofromothernon-healthdisciplinesthatsuccessfullycontributetoaccidentreductioninotherfieldsofsafety.Investigationwouldbecarriedoutinanatmosphereoftrustwhereblameandretributionwereabsent,anddisciplinaryactionorcriminalsanctionswouldonlybetakeninappropriateandrarecircumstances.Actionresultingfrominvestigationwouldleadtore-designofprocessesofcare,products,proceduresandchangestotheworkingpracticesandstylesofindividualsandteams.Suchactionswouldusuallyleadtomeasurableandsustainedreductionofriskforfuturepatients.Sometypesofharmwouldbeeliminatedentirely.


4Veryfew,ifany,healthservicesintheworldcouldcomeanywhereneartothisideallevelofperformanceincapturingandlearningfromincidentsofavoidableharm.Thisissoforallsortsofreasonsrangingfromaninsufficiencyofleadersskilledandpassionateenoughtoengagetheirwholeworkforcesonaquesttomakecaresafer,throughaninabilitytoinvestigateproperlythevolumeofreportsgenerated,totheweakevidence-baseonhowtoreduceharm.

ThesystemofadverseincidentreportinginNorthernIrelandoperatestohighly-specifiedprocessestowhichprovidersofhealthandsocialcaremustadhere.Themainemphasisisonthe

SeriousAdverseIncidents.Therequirementslaiddownforreporting,documentingandinvestigatingsuchincidentstogetherwiththerulesforcommunicatingaboutthemandformulatingactionplanstopreventrecurrencehavecreatedanapproachthathasstrengthsandweaknesses(Figure6).Ingeneral,themandatorynatureofreportingmeansthatthereislikelytobelessunder-reportingthaninmanyotherjurisdictions.However,staffinTrustsmustexercisejudgmentonwhethertoclassifyoccurrencesofharmasSeriousAdverseIncidents.Whethertheyalwaysmaketherightdecisionhasnotbeenformallyevaluated.TheReviewdidnotfindanyevidenceofsuppressionorcover-upofcasesofseriousharm.

Figure 6. Serious Adverse Incident reporting system in Northern Ireland: Strengths and weaknesses

Dimension Strengths Weaknesses

Accountability Absoluterequirementtoreportandinvestigate

Createssomefearanddefensiveness

Coverage Relativelyhighforseriousoutcomes

Lessattentiongiventoincidentswithlowerharmlevels

Timescales Cleardeadlinesforinvestigationandcommunication

Pressuretomeetdeadlinesleaveslittletimeforreflection

Investigation Reasonabledepthwithfrequentrootcauseanalysis

Qualityvariableandlittleuseofhumanfactorsexpertise

Staff engagement Allappeartounderstandtheimportanceofreporting

Donotoftenseethereportstranslatingintosafercare

Patient and family involvement Requirementtocommunicatereinforcedbychecklist

Oftencreatestensionandlittleongoingengagement

Learning Specifiedactionplanrequiredineverycase

Notclearwhetheractioniseffectiveinreducingfuturerisk


4Tighttime-scalesarelaiddownforthevariousstagesofhandlingaSeriousAdverseIncident.Thesegenerallyaddanecessarydisciplinetoaprocessthatinotherplacescanbecomeprotractedordriftoff-track.Thereisaneed,though,forsomeflexibilitywhereaninvestigationrequiresmoretime.Thisisparticularlysointhementalhealthfieldwheretheavoidablefactorsinadeathcanbeverycomplexandareonlydiscernibleafterinterviewingverymanypeople.

Itisimportanttorecognisethat,whilstalmostalloftheexperienceandresearchliteratureisaboutpatientsafety,NorthernIrelandhasanintegratedhealthandsocialcaresystem.SocialcareintheUnitedKingdomhasitsowntraditionsinrecognising,investigatingandlearningfromepisodesofseriousharminvolvingthosewhouseitsservices;thefieldsofchildprotectionandmentalhealthexemplifythis.Itisnotentirelystraightforwardtointegrateincidentsinsocialcareintotheoverallpatientsafetyapproachbuttheessentialprinciplesandconceptsarelittledifferent.

TheNorthernIrelandhealthservicefallsshortoftheidealjustasdomostotherpartsoftheUnitedKingdomandmanyotherplacesintheworld.Inalloftheseplaces,includingNorthernIreland,patientsaredyingandsufferinginjuriesanddisabilitiesfrompoorlydesignedandexecutedcareonascalethatwouldbetotallyunacceptableinanyotherhigh-riskindustry.

TheNorthernIrelandapproachtoincidentreportingandlearningdoesnotmakeitsservicesanylesssafethanmostoftherestoftheUnitedKingdomormanyotherpartsoftheworld.However,thisshouldnotbeareasonforcomfort,noracauseforsatisfaction.

Thecurrentrequirementforallchilddeathstobereportedandmanagedasseriousadverseincidentsseemstobedoingfarmoreharmthangood.Itisdistressingforfamilies,burdensomeforstaff,andisnotproducingusefullearning.

Theethosofimprovingsafetybylearningfromincidentinvestigationsneedstoshift:

• Awayfromactionsthatonlymakeadifferenceintheparticularunitwheretheincidentoccurred,towardsactionsthatalsomakeadifferenceacrossthewholeofNorthernIreland

• Awayfromactionsthatonlytargetthatparticularincident,towardsactionsthatalsoreducetheriskofmanyrelatedincidentsoccurring

• Awayfromweakactionssuchasinformingstaff,trainingstaffandupdatingpolicies,towardsstrongeractionsofimprovingsystemsandprocesses

• Awayfromlonglistsofactions,towardssmallernumbersofhigh-impactactions

LessattentionhasbeengiveninNorthernIrelandtoadverseincidentsthatdonotmeetthedefinitionofaSeriousAdverseIncident.Theyarereported,analysedandacteduponatTrustlevel.Onlyexceptionallyaretheyconsideredcentrally.Thenumbersaremuchgreatersothelogisticsofanalysingmorewouldbeconsiderable.However,thereismuchtobelearnedfromsituationswhensomethingwentwronginapatient’scarebuttheydidnotdieorsufferseriousharm.


44.5 THEBENEFITSANDCHALLENGESOFBEINGOPEN

Thehealthandsocialcaresystemaspirestoa‘noblame’culture,ora‘just’culture,inwhichstaffcanbeopenwithoutfearofinappropriatereprisal.Inreality,thisisnottheculturethatcurrentlyexists.Thisisnotprimarilythefaultofthosedeliveringhealthandsocialcare.

Opennessisnotsomethingthatcansimplybedemanded.Itneedstherightconditionsinordertoflourish.Theenemyofopennessisfear.

Whensomethinggoeswrong,manypatients’andfamilies’firstreactionistowanttoknowwhoistoblame.Thesituationoftenescalates,withthemediacoverageandpoliticalpressurethatthedetailofthestorygenerates.Inanidealworld,leadersofthesystemshouldbeabletostepintopaintaproperpictureofthebackgroundtothesecomplexevents,andtobuildpublicunderstandingthatfewarea

simplecaseofincompetenceandcarelessness.Instead,toremovetheheatfromthesituation,approachesareannouncedthatmaynotbethemosteffectivewaytoachievelearning.Ontopofthis,day-by-daythemediaportrayshealthandsocialcareinamainlynegativelight.Therehasbeenoneinquiryafteranother.Theseareconditionsconducivetoblameandfear,nottotransparencyandopenness.

Despitetheseadverseconditions,theReviewTeamfoundfront-linestaffwillingtotalkaboutproblems,andtobeopenwithfamiliesandpatientswhenthingsgowrong.Thereisawillingnesstobeopen–butthereisblame,andthereisfear.

NorthernIrelandneedstoincreasethedegreeofopennessandtransparencyintalkingaboutharm,anddecreasethedegreeofblameandfear.Theresponsibilitycannotliesolelywithinthehealthandsocialcaresystem.Theyarecomplexcycles.

Figure 7. The vicious cycle of suspicion and fear

Negative coverage of healthand social care system

Simplistic coverage of situations in whichpatients have been harmed

Prior beliefs about the nature of harm,and how the system reacts

Suspicion

Prior beliefs about the nature of harm,and how the system reacts

Suspicion

Individual staff fearful about engaging withaffected patients and staff, or apologising

Defensive organisational behavioure.g. carefully worded, unfriendly letters

CARE PROVIDERSPATIENTS AND FAMILIES

MEDIA POLITICAL LEADERS


4Opennessandtransparency,blameandfear:thesearemulti-dimensionalissuesthatcannotbeimproveddirectlybylegislation,rulesorproceduresalone.AsthisReporthasmadeclear,NorthernIrelandisfarfromunique.

4.5.1 Governance arrangements to promote opennessPromotingopennessandavoidingfearisaboutculture.Responsibilityforthissitswithmanypeople,withinandbeyondthehealthandsocialcaresystem.Governancemaysoundlikeablunttooland,usedalone,itwouldbe.Butalongsideotherapproaches,appropriategovernancearrangementscanpromoteopennessanddispelfear.

TheSeriousAdverseIncidentprocesscurrentlyrequiresTruststoinformaffectedpatients(orfamilies)thattheircareisthesubjectofinvestigation.Ingeneral,theyareinvitedtoprovideinputandareprovidedwithacopyoftheinvestigationreport.Achecklisthasbeenintroducedtopromptinvestigatorstotakethesesteps.Thisiscommendable,andrepresentsabasic,butimportant,degreeofopennesswithpatientsandfamilies.

ThenatureoftheinvolvementwithpatientsandfamiliesintheaftermathofaSeriousAdverseIncidentcannotbeshapedbyachecklistalone.TheReviewTeamheardfromeachoftheTrustshowtheyhandledthisaspectofthepolicy.Itisclearthatthisisadifficultareatogetright.Earlycontactwiththefamilyintheeventofadeathisimportantbutcouldcomeatatimewhenfuneralarrangementsarebeingmadeandperceivedasintrusiveorinsensitive.Thebureaucracyoftheprocedurecancreateanofficialfeelingthatopensupdistanceintherelationshipwiththefamily.ItisimportantthatstaffintheTrusthavetheskill,experienceandcredibilitytocommunicatewithafamily.Itishelpfultohavestaffwhodealwiththissituationregularlyandhavegoodinter-personalandcounsellingskills.Theyshouldbetherewiththe

clinicalstaffwhomayencounterthesituationlessfrequently.Experiencefromelsewheresuggeststhatregularcontactwiththepatientandfamilyisimportant,notjustacoupleofone-offmeetingswithlongsilencesinbetween.Inthebestservices,thepatientandfamilyarefullyinvolvedintheprocessoflearningandaction-planning.Wherethishappens,itisempoweringforeveryone.ThisisonlyhappeningtoalimitedextentinNorthernIrelandcurrently.

TheSeriousAdverseIncidentprocessisalsooverseenbyaDesignatedReviewOfficerwithinthePublicHealthAgency.Thisisalsoawelcomefeatureofthesystemalthoughthereispotentialfortheseofficers,ortheirfunction,toplayamoresubstantialrole.

EveryTrusthasappropriatearrangementsforSeriousAdverseIncidentstobediscussedwithinthedepartmentsaffected.Thefactthattheseconversationsaretakingplaceusefullypromotesacultureinwhichtalkingaboutharmbecomeseasier,andopennessbecomesthenorm.

EveryTrustalsohasarrangementsfororganisation-leveloversightofthisprocess.Inmost,thisresponsibilitysitswithasub-committeeoftheTrustboard.Thistooisgoodpractice.

Whensomethinggoeswrong,thereisatendencyfortheDepartmentofHealth,SocialServicesandPublicSafetytodealdirectlywiththeTrust’sExecutiveTeam,bypassingtheboard.Thishappenspartlyfromexpediency–becausetheexecutivedirectorsarepresentfull-time,andarethereforeavailabletotakeanurgentphonecallfromanofficialconcernedaboutbriefingtheminister.Butitservestodiminishtheroleoftheboard,andmissesopportunitiestobuildtheboard’sfamiliaritywiththeseissuesandcapabilityindealingwiththem.

Thereisgreatconcernanddepthoffeelingamongststaffinthesystemwhohaveattemptedtouncoverpoorstandardsof


4careandbeendenigrated.Theirroleaswhistleblowershasplacedtheminanevenmoreisolatedposition.Thisunsatisfactorysituationneedstoberesolved.

4.5.2 Perceptions of opennessTheSeriousAdverseIncidentguidelinesincludesomerequirementsintendedtohelpopennessandtransparency.Arecentlook-backexercise,qualitycontrolledbytheRegulationandQualityImprovementAuthority,suggeststhatpatientsandfamiliesarebeingappropriatelyinformedwhenaSeriousAdverseIncidentoccurs.Thiscreatesasubstantiallyhigherdegreeofopennessthanisthecaseinmanycountriesworldwide.Inthemain,theTruststaffwhoareleadingtheinvestigationarewillingtospendtimemeetingwithpatientsandfamilies.

However,severalfeaturesoftheinvestigationprocesstoooftengivepatientsandfamiliesanadverseimpression:

• Theinvestigationprocessisfrequentlydelayedbeyondthestipulatedtimeline,andpatientsandfamiliesexperiencedelaysingettingresponsestocallsandemails.Suchdelaysmakepeoplestarttowonder,“whatisgoingon?”

• Whentheinvestigationprocessstarts,thedegreeofopennessandtransparencythatthepatientand/orfamilyfeeltheyareseeingishighlydependentonthecommunicationskillsoftheTruststaffthattheymeetwith.Somestaffarehighlyskilledinthesepotentiallydifficultmeetings;othersarenot.

• Standardpracticeisforpatientsandfamiliestomeetwiththemanagerand/orclinicianleadingtheinvestigation,andnottobeaskedwhomelsetheywouldliketomeetwith.Many,forexample,wouldfindithelpfultomeetwiththestaffdirectlyinvolvedintheincident,toputtheirquestionsdirectly,butthisisnotroutinelyoffered.Suchmeetingshavethepotentialtobeintenselydifficult;tobeveryusefuliftheygowell,butharmfuliftheygobadly.

4.5.3 Duty of candourIn2003,theheadoftheReviewTeam(asChiefMedicalOfficerforEngland)issuedaconsultationpaper,MakingAmends,whichsetoutproposalsforreformingtheapproachtoclinicalnegligenceintheNHS.Onekeyrecommendationwasthatadutyofcandourshouldbeintroduced.

Aslongagoas1987SirJohnDonaldson(norelation),whowasthenMasteroftheRolls,said“Ipersonallythinkthatinprofessionalnegligencecases,andinparticularinmedicalnegligencecases,thereisadutyofcandourrestingontheprofessionalman”.Therewas,atthetimeoftheMakingAmendsreport,nobindingdecisionofthecourtsonwhethersuchadutyexists.

InNovember2014,theGeneralMedicalCouncilandtheNursing&MidwiferyCouncilissuedajointconsultationdocumentproposingtheintroductionofaprofessionaldutyofcandour.SuchadutywillgivestatutoryforcetotheGeneralMedicalCouncil’sCodeofGoodMedicalPracticefordoctors.

IntheconcomitanthealthcareorganisationalmeasuresintroducedinEngland,anew“DutyofCandour”schemewillmeanthathospitalsarerequiredtodiscloseinformationaboutincidentsthatcausedharmtopatients,andtoprovideanapology.

InNorthernIreland,itisalreadyarequirementtodisclosetopatientsiftheircarehasbeenthesubjectofaSeriousAdverseIncidentreport.Thereisnosimilarrequirementforadverseincidentsthatdonotcausethemoreseveredegreesofharm.Inpromotingacultureofopenness,therewouldbeconsiderableadvantagesinNorthernIrelandtakingaleadandintroducinganorganisationaldutyofcandourtomatchthedutythatdoctorsandnursesarelikelytocomeunderfromtheirprofessionalregulators.


44.6 THEVOICESOFPATIENTS,CLIENTSANDFAMILIESARETOOMUTED

Thebestservicesintheworldtodaygivemajorprioritytoinvolvingpatientsandfamiliesacrossthewholerangeoftheiractivities,fromboard-levelpolicymaking,todesignofcareprocesses,toqualityimprovementefforts,toevaluationofservices,toworkingonreducingrisktopatientsaspartofpatientsafetyprogrammes.

Attheheartofthetraditionalapproachtoassessingwhetheraserviceisresponsivetoitspatientsandthepublicaresurveysofpatientexperienceandattitudes.Thisisstillaveryimportantpartofmodernhealthandsocialcare.Inmanymajorcentreswhoseservicesarehighlyrated,suchsurveysareregularlycarriedoutandusedtojudgeperformanceattheorganisational,serviceandindividualpractitionerlevel,aswellas,insomecases,beinglinkedtofinancialincentives.Indeed,intheUnitedStatessystem,observerssaythatitwasnotuntilsurveysofpatientexperiencewerelinkedtodollarsthatitwastakenseriously.ThisisnotaprominentfeatureoftheNorthernIrelandsystem,althoughthereissomeverygoodpractice,forexamplethe10,000Voicesinitiative,whichhassofardrawnontheexperienceofover6,000patientsandledtonewpathwaysofcareinpainmanagement,caringforchildreninEmergencyDepartments,andgenerallyfocusingontheareasofdignityandrespect.Lookedatfromfirstprinciples,thekindofquestionsauser,orpotentialuser,ofaservicecouldlegitimatelyrequireananswertowouldinclude:

HowquicklywillIfirstbeseen,howquicklywillIgetadiagnosisandhowquicklywillIreceivedefinitivetreatment?

Ifmyconditionispotentiallylife-threatening,willthelocalservicegivemethebestoddsofsurvivalorcouldIdobetterelsewhere?

WilleachmemberofstaffIencounterbecompetentandup-to-dateintreatingmyconditionandhowwillIknowthattheyare?

Doestheservicehavealowlevelofcomplicationsfortreatmentlikeminecomparedtootherservices?

HowlikelyamItobeharmedbythecarethatIreceiveandwhatmeasuresdoestheservicetaketopreventit?

IfIamunhappywithacare-provider’sresponsetoacomplaintaboutmycare,willthesubstanceofitbelookedatbypeoplewhoaregenuinelyindependent?

WhichparticularserviceelsewhereintheUnitedKingdom,andotherpartsoftheworld,achievesthebestoutcomeforsomeonelikemewithmycondition?Howclosewillmyoutcomebetothatgoldstandard?

VeryfewofthesequestionscouldbeansweredreliablyinNorthernIrelandandotherpartsoftheUnitedKingdom.

Therearemanypotentialthemesforpatientandfamilyengagementinhealthandsocialcare,forexample:

• inshapinganddesigningservices• inmeasuringthequalityofcare• insettingstandardsforconsultation• inshareddecision-making• inself-careofchronicdiseases• inpreventingharm• ingivingfeedbackonpractitioner

performance

Fewservicesdoallofthese,someonlyscratchthesurfaceofgenuineinvolvement,othersdoafewwell.Overall,theNorthernIrelandcaresystemisengagedinsomeoftheseareasbutcertainlynotinanorganisedandcoherentway.


4ThetermsofreferenceoftheReviewputparticlaremphasisonharm.Globally,thereisaspectruminhowwellhealthandsocialcaresystemsinteractwithpatients,clientsandfamilieswhenthingsgowrong(figure8).Theidealapproachistoengagepatientsand

familiescompletelyintheprocessoflearning.Theyoftenfindthishugelybeneficial,becauseitallowsthemtoplayanactivepartinreducingtheriskforfuturepatients.Itisalsoimmenselypowerfulforstaff,tohearpatients’storiesfirst-handandtoworkwiththemtoimprovethings.

Figure 8. Levels of engagement with patients and families when something goes wrong

NO COMMUNICATION

OPEN, BUT POOR COMMUNICATION

OPEN AND STRONG COMMUNICATION

COMPLETE ENGAGEMENT

NorthernIrelandshouldaimforlevelthreeasanabsoluteminimum,butstriveforlevelfour.

Thesystemistoooftenfallingdowntoleveltwobecause:

• StaffwhocommunicatewithpatientsandfamiliesduringtheSeriousAdverseIncidentinvestigationprocesshavevariablecommunicationskills–someareexcellent,butsomearelessgood.Littleformalefforthasbeenmadetotrainstafftomanagethesedifficultinteractionswell.

• Patientsandfamiliesareoftennotofferedtheopportunitytomeetwiththosewhotheywouldliketo–thestaffdirectlyinvolvedintheincident.Instead,theytendtomeetwithmanagers,andwithclinicianswhowerenotinvolved.

• TherearefrequentlydelaysintheprocessofinvestigatingaSeriousAdverseIncident.

• Patientsandfamiliesaretoooftensentlettersfilledwithtechnicaljargonandlegalese.

Whensomethinggoeswrong,theharmitselfisintenselydifficultforpatientsandfamilies.Poorcommunicationcompoundsthisenormously.


55.1 RELATIVESAFETYOFTHENORTHERNIRELANDCARESYSTEM

5.1.1Thereissomeperceptionamongstpoliticians,thepressandthepublicthatNorthernIreland’shealthandsocialcaresystem:

• Hasfundamentalsafetyproblemsthatarenotseenelsewhere

• IslesssafethanotherpartsoftheUnitedKingdom,orcomparablecountries

• Suffersfromlackoftransparency,atendencytocover-up,andanadverseculturemorebroadly.

5.1.2TheReviewfoundnoevidenceofdeep-seatedproblemsofthiskind.NorthernIrelandislikelytobenomoreorlesssafethananyotherpartoftheUnitedKingdom,orindeedanycomparablecountryglobally.

5.1.3Thisdoesnotmeanthatsafetycanbedisregarded,becauseitisclearfromreadingtheincidentreportsandaccountsofpatients’experiencethatpeoplearebeingharmedbyunsafecareinNorthernIreland,astheyareelsewhere.NorthernIreland,likeeverymodernhealthandsocialcaresystem,mustdoallitcantomakeitspatientsandclientssafer.

5.2 PROBLEMSGENERATEDBYTHEDESIGNOFTHEHEALTHANDSOCIALCARESYSTEM

5.2.1Therearelongstanding,structuralelementsoftheNorthernIrelandcaresystemthatfundamentallydamageitsqualityandsafety.Thepresentconfigurationofhealthfacilitiesservingruralandsemi-ruralpopulationsinNorthernIrelandisnotfitforpurposeandthosewhoresistchangeorcampaignforthestatusquoareperpetuatinganossifiedmodelofcarethatactsagainsttheinterestsofpatientsanddeniesmany21stCenturystandardsofcare.Manyacutely-illpatientsinNorthernIrelanddonotgetthesamestandardofcareonaSundayat4amastheywouldreceiveonaWednesdayat4pmand,therefore,atwo-tierserviceisoperating.Itmaybethatlocalpoliticsmeansthatthereisnohopeofmoremoderncareforfuturepatientsandifsothisisaverysadposition.

5.2.2Thedesignofasystemtoprovidecomprehensive,highquality,safe,caretoarelativelysmallpopulationlikeNorthernIreland’sneedsmuchmorecarefulthought.Thisappliestoalmostallaspectsofdesignincluding:theroleofcommissioning,thestructuringofprovision,therelationshipbetweenprimary,secondaryandsocialcare,thedistributionoffacilitiesgeographically,thefundingflows,theplaceofregulation,themonitoringofperformance,andtheuseofincentives.Nowhereistheoldadage:“Iwouldnotstartfromhere”truerthanintheNorthernIrelandcaresystemtoday.

5CONCLUSIONS


55.2.3ThereiswidespreaduncertaintyaboutwhoisinoverallchargeofthesysteminNorthernIreland.Instatutoryterms,thePermanentSecretaryintheDepartmentofHealth,SocialServicesandPublicSafetyischiefexecutiveofthehealthandsocialcaresystembuthowthisroleisdeliveredfromapolicy-makingpositionisnotwidelyunderstoodorvisibleenough.

5.2.4Inthespecificdomainofqualityandsafetyitself,whilstitisreflectedinthegoalsandactivitiesofboardsandseniormanagementteamsinNorthernIreland,itisnotyetfullyembeddedwiththecommitmentandpurposetomakearealdifference.TheReviewwasmostimpressedwiththeworkoftheSouthEasternTrustinthisregard.TheReviewTeamcouldnotassesseachTrustindepth,butitsjudgmentontheSouthEasternTrustisbackedup,forexample,bythenationalsurveyoftraineedoctors.

5.3 FOCUSONQUALITYANDSAFETYIMPROVEMENT

5.3.1Quality2020isaten-yearstrategywithaboldvision–thatthehealthandsocialcaresystemshould“berecognisedinternationally,butespeciallybythepeopleofNorthernIreland,asaleaderforexcellenceinhealthandsocialcare”.Threeyearson,thereisgoodevidenceofthestrategybeingimplemented.Aninfluentialsteeringgroupoverseesthework.

5.3.2TheReviewTeamjudgedthatQuality2020representsastrongsetofobjectives,andthatthereisclearevidenceofextensiveworkandofsomesuccessesinimplementation.However,thisdoesnotamounttoqualityandsafetyimprovementbeinggiventheprimacyoffocusthatitneeds,andNorthernIrelandisnotseeingthewoodforthetreesabouttheneedtoestablishcrucialaspectsofqualityandsafetyimprovementwhicharenotwellrepresentedatpresent:clinicalleadership,culturalchange,datalinkedtogoals,andstandardisation.


55.4 THEEXTENTTOWHICHSERIOUSADVERSEINCIDENTREPORTINGIMPROVESSAFETY

5.4.1ThesystemofSeriousAdverseIncidentreportinginNorthernIrelandhasbeenanimportantwaytoensurethatthemostsevereformsofharmthatareinadvertentlycausedbycareprocessesarerecognisedandinvestigated.

5.4.2TheSeriousAdverseIncidentprocessfulfilsfivemainpurposes:

• apublicaccountabilityfunction• aresponsetothepatientsandfamilies

involved• acommunicationsalertroute• abarometerofriskwithinhealthand

socialcare• afoundationforlearningandimprovement

5.4.3ThekindsofincidentsreportedintothissystemappearlittledifferenttootherpartsoftheUnitedKingdomandaresimilartomanyotherpartsofEurope,NorthAmericaandAustralasia.ManyharmfuleventsarepotentiallyavoidableandthehumancosttopatientsandfamiliesinNorthernIrelandisofgraveconcern,asitisinotherjurisdictions.

5.4.4Goodpracticeelsewhereintheworldsuggeststhatpatientswhosufferharmandtheirfamiliesshouldbefullyinformedaboutwhathashappened,howithappenedandwhatwillbedonetopreventanothersimilaroccurrence.Morethanthis,theyshouldbefullyengagedinworkingwiththeorganisationtomakechange.PatientandfamilyengagementisagoodandestablishedfeatureofSeriousAdverseIncidentreportinginNorthernIrelandbutitoftenfallsshortofthisfullyengagedscenario.Theextenttowhichitisvaluedandtrustedbypatientsandfamiliesappearstovary,dependingonthestaffcommunicatingwiththem.

5.4.5Thedesignforthespecification,andrecording,ofinformationoneachSeriousAdverseIncidentissub-optimalparticularlyingatheringappropriateinformationoncausation;thishindersaggregationofdatatomonitortrendsandassesstheimpactofinterventions.

5.4.6TheprocessforinvestigatingSeriousAdverseIncidentsisclearlysetoutandinvolvesrootcauseanalysis-typemethods.Inmanycases,itlackssufficientdepthinkeyareassuchashumanfactorsanalysis.Thedegreeofoversightbysupervisoryofficials(theDesignatedReviewOfficers)isvariableinextentandtimeliness.Localhealthandsocialcarestaffgenerallyapproachthetaskofinvestigationconscientiouslybutmanylackthetrainingandexperiencetoreachastandardofinternationalbestpracticeinunequivocallyidentifyingthecauseandspecifyingtheactionablelearning.Theygetlittleexperthelpandguidanceinundertakingthisactivity.

5.4.7Themostimportanttestofthecapabilityofapatientsafetyincidentreportingsystemisitseffectivenessinreducingfutureharmofthekindthatisbeingreportedtoit.Unfortunately,therearefewplacesaroundtheworldwherethereisapowerfulflowoflearningthatmovesfromidentifyinginstancesofavoidableharm,throughunderstandingwhytheydidorcouldhappen,tosuccessfuleliminationoftheriskforfuturepatients.NorthernIrelandisnoexceptiontothisregrettablestateofaffairs.

5.4.8TherearetwomainlevelsoflearningfromSeriousAdverseIncidentsinNorthernIreland.Thefirstislocal.Thelackofaconsistentlyhighstandardofinvestigationandaction-planningarebarrierstoeffectiverisk-reductionwithinhealthandsocialcareorganisations.Anotherbarrieristhelimiteddegreetowhichfront-linestaffareinvolvedindiscussingandseekingsolutionstothingsthathavegonewrong.Experienceelsewheresuggeststhatthispracticalandintellectualengagement,


5ifwell-led,oftensparksgreatinterestandcommitmenttopatientsafetyamongstfront-linestaff.ThisisnotreallyhappeninginNorthernIrelandatpresent,foranumberofreasons.Firstly,staffdonothavethetimeandspacetodoitandtheleadershipofTrustsisnotconsistentlycreatingandfacilitatingsuchopportunities.TheRegulationandQualityImprovementAuthorityhasestablishedtraininginRootCauseAnalysisforfront-linestaff,andthiswillhelp.Secondly,thespecifiedrulesoftheSeriousAdverseIncidentsystemmeanthatTrustsareunderagreatdealofpressuretomeetthetime-scaleslaiddownandareoftendealingwithmanysuchcasessimultaneously.Asaresult,theactivityistoooftenslippingintoanincidentmanagementroleorworseanecessarychorethat‘feedsthebeast’.

5.4.9ThesecondleveloflearningisacrosstheNorthernIrelandhealthandsocialcaresystemasawhole.ThemainroleisplayedbytheHealthandSocialCareBoardworkingwiththePublicHealthAgency(andtheRegulationandQualityImprovementAuthoritywhereappropriate).Thesebodieshaveestablishedamulti-disciplinaryQualitySafetyandExperienceGroupthatundertakesmuchoftheworkinassessingpatterns,trendsandconcernsarisingfromtheanalysisoflocally-generatedSeriousAdverseIncidentsanddecidingwhatactionneedstobetakenonaNorthernIreland-widebasis.Itdoessobyissuinglearningletters,reports,guidance,newslettersandotherspecifiedactionthattheserviceneedstotake.Thisisavaluablefunctionfromwhichconsiderableactionaimedatimprovementhasflowed.Experienceofimprovingpatientsafetyelsewherehasshownthatspecifyingactiononaparticularsafetyproblemisnotthesamethingasimplementingthechangerequired.Thelatterisoftenmuchmoredifficultanddependsonfactorssuchasthesystems,culture,attitudes,localprioritiesandleadershipintheorganisationreceivingtheactionnote.IntheNorthernIrelandcaresystemmoreskillneeds

tobeaddedtotheimplementationprocess.Thisiscloselylinkedtothedifficultiesthatarisewhenlocalservicesfeeloverloadedwithcentralguidanceandrequirementsforaction.Theyonlyhaveenoughmanagementandclinicalleadershipcapacitytoimplementasmallnumberofchangesatatime.

5.4.10Generalpractitioners,andothersinprimarycare,reporttheirSeriousAdverseIncidentsdirectlytotheHealthandSocialCareBoard,notthroughanyoftheTrusts.Levelsofreportingofpatientsafetyincidentsinprimarycareservicesaroundtheworldareverylowandmuchlessisknownaboutthekindsofharmthatariseinthissettingcomparedtohospitals.ItisnotsurprisingthatthesameissoinNorthernIreland.AnotheraspectoftheprimarycaredimensionisthatmanyoftheincidentsthattheReviewdiscussedwiththeTrustsinNorthernIrelandhadaprimarycareelementinthekeyareasofthecareprocessesthathadfailed,yetgeneralpractitionersseemedtobelessfrequentlyinvolvedintheinvestigationandplanningofremedialaction.

5.4.11TherearetwoparticularaspectsofthecriteriaforSeriousAdverseIncidentreportinginNorthernIrelandthatarenotworkinginthebestinterestsofasuccessfulsystem.Firstly,therequirementthateverydeathofachildinreceiptofhealthandsocialcareshouldautomaticallybecomeaSeriousAdverseIncidentiscausingmajorproblems.Aproportionofsuchdeathseverymonthareduetonaturalcauses.Someoftheconditionsconcerned-forexample,terminalcancerandseriouscongenitalabnormalities-areparticularlyharrowingfortheparents.Afterthedeathofachild,insuchcircumstances,forafamilytobetoldthattheirchild’sdeathhasbeencategorisedasaSeriousAdverseIncidentcarriestheclearimplicationthatthequalityorsafetyofcarewaspoorandatfaultoreventhatthedeathcouldhavebeenavoided.Thiscanbeenormouslydistressingforfamiliesand


5isgruelingforstaff.Itiscruel,unnecessaryandliabletounderminepublicconfidenceinchildren’sservices.

5.4.12Secondly,usingthesametime-scalesforinvestigatingSeriousAdverseIncidentsinmentalhealthasininotherfieldsofcareisalsocausingmajorproblems.Thecomplexityofmanymentalhealthcases,thelongpasthistoryofmanysuchpatientsandclients,andthenumberofpeopleandorganisationswhomaybeabletocontributerelevantinformationtotheinvestigationmeanthatalongerperiodisnecessarilyrequiredtogettothetruththaniscurrentlypermitted.

5.4.13Overall,thesystemofSeriousAdverseIncidentreportinginNorthernIreland,incomparisontobestpractice,scoreshighlyonsecuringaccountability,reasonablyhighlyonthelevelofreporting,doesmoderatelywellonmeaningfulengagementwithpatientsandfamilies,andisweakinproducingeffective,sustainedreductioninrisk.Also,theclimateofaccountabilityandintensepoliticalandmediascrutinydoesnotsiteasilywithwhatbestpracticehasrepeatedlyshownisthekeytomakingcaresafer:aclimateoflearningnotjudgment.

5.4.14TheReviewconcludedthatfront-lineclinicalstaffareinsufficientlysupportedtofulfilltheroleofassessingandimprovingthequalityandsafetyofthecarethattheyandtheirteamsprovide.Thelackoftime,thepaucityofreliable,well-presenteddata,theabsenceofin-servicetraininginqualityimprovementmethods,andthepatchinessofclinicalleadershipareallmajorbarrierstoachievingthisvitalshifttomassclinicalengagement.

5.5 OPENNESSWITHPATIENTSANDFAMILIES

5.5.1TheSeriousAdverseIncidentinvestigationsystemcontains,intheviewoftheReviewTeam,sufficientchecksandbalancestoensurethataffectedpatientsandfamiliesareinformedthatsomethingwentwrong,exceptinexceptionalcircumstances.

5.5.2Suchmechanismsarepartofgoodgovernance,butaloneareinsufficient.Itwillbeculture–notaccountability–thatincreasesthereportingofharm,andstaff’scomfortintalkingopenlyaboutharm.

5.5.3Thoseconductinginvestigationsarecommittedtorigorousinvestigation,andtobeingopenwithpatientsandfamiliesaboutwhatisfound.Butwhilstsomecommunicatewellinpersonandinwriting,othersarelessstrong.Thiscancomeacrosstofamiliesasalackofopenness.

5.5.4High-profileinquiriesandnegativemediacoveragehaveledsometobelievethatthereiswidespreadcover-upofharminthehealthandsocialcaresystem.ThisissimplyinconsistentwithwhattheReviewTeamobserved,whichwasasystemtrying,asmanyothersintheworldare,togettogripswiththedifficultproblemofpatientsafety.

5.5.5Fearandsuspicionpowerfullyinhibitopenness.Thehealthandsocialcaresystemneedstorisetothechallengeoftacklingthesethreatsheadon.Perceptionisimportant–evensimpledelaysandcommunicationweaknessescanfuelsuspicion.Andifstaffhearmorefromthemediathandirectfromtheirleaders,thisdoesnotdispelfear.


6Recommendation 1: Coming together for world-class care

Aproportionofpoorquality,unsafecareoccursbecauselocalhospitalfacilitiesinsomepartsofNorthernIrelandcannotprovidethelevelandstandardofcarerequiredtomeetpatients’needs24hoursaday,7daysaweek.Proposalstocloselocalhospitalstendtobemetwithpublicoutrage,butthiswouldbeturnedonitsheadifitwereproperlyexplainedthatpeopleweretradingadegreeofgeographicalinconvenienceagainstlifeanddeath.Findingasolutionshouldbeabovepoliticalself-interest.

We recommend that all political parties and the public accept in advance the recommendations of an impartial international panel of experts who should be commissioned to deliver to the Northern Ireland population the configuration of health and social care services commensurate with ensuring world-class standards of care.

Recommendation 2: Strengthened commissioning

TheprovisionofhealthandsocialcareinNorthernIrelandisplannedandfundedthroughaprocessofcommissioningthatiscurrentlytightlycentrally-controlledandbasedonacrudemethodofresourceallocation.ThisseemstohaveevolvedwithoutproperthoughtastowhatwouldbemosteffectiveandefficientforapopulationassmallasNorthernIreland’s.Althoughcommissioningmayseemlikeabehind-the-scenesmanagementblackboxthatthepublicdonotneedtoknowabout,qualityofthecommissioningprocessisamajordeterminantofthequalityofcarethatpeopleultimatelyreceive.

We recommend that the commissioning system in Northern Ireland should be re-designed to make it simpler and more capable of reshaping services for the future. A choice must be made to adopt a more sophisticated tariff system, or to change the funding flow model altogether.

Recommendation 3: Transforming Your Care – action not words

ThedemandsonhospitalservicesinNorthernIrelandareexcessiveandnotsustainable.ThisisaphenomenonthatisoccurringinotherpartsoftheUnitedKingdom.Althoughtriggeredbymultiplefactors,muchofithastodowiththeincreasinglevelsoffrailtyandmultiplechronicdiseasesamongstolderpeopletogetherwithtoomanypeopleusingthehospitalemergencydepartmentastheirfirstportofcallforminorillness.High-pressurehospitalenvironmentsaredangeroustopatientsandhighlystressfulforstaff.ThepolicydocumentTransformingYourCarecontainsmanyoftherightideasfordevelopinghighqualityalternativestohospitalcarebutfewbelieveitwilleverbeimplementedorthatthenecessaryfundingwillflowtoit.Damagingcynicismisbecomingwidespread.

We recommend that a new costed, timetabled implementation plan for Transforming YourCare should be produced quickly. We further recommend that two projects with the potential to reduce the demand on hospital beds should be launched immediately: the first, to create a greatly expanded role for pharmacists; the second, to expand the role of paramedics in pre-hospital care. Good work has already taken place in these areas and more is planned, but both offer substantial untapped potential, particularly if front-line creativity can be harnessed. We hope that the initiatives would have high-level leadership to ensure that all elements of the system play their part.

6RECOMMENDATIONS


6Recommendation 4: Self-management of chronic disease

ManypeopleinNorthernIrelandarespendingyearsoftheirliveswithoneormorechronicdiseases.Howthesearemanageddetermineshowlongtheywilllive,whethertheywillcontinuetowork,whatdisablingcomplicationstheywilldevelop,andthequalityoftheirlife.Toomanysuchpeoplearepassiverecipientsofcare.Theyaredefinedbytheirillnessandnotaspeople.Prioritytendstogotosomediseases,likecanceranddiabetes,andnottootherswhereprovisionremainsinadequateandfragmented.Qualityofcare,outcomeandpatientexperiencevarygreatly.Initiativeselsewhereshowthatifpeoplearegiventheskillstomanagetheirownconditiontheyareempowered,feelincontrolandmakemuchmoreeffectiveuseofservices.

We recommend that a programme should be established to give people with long-term illnesses the skills to manage their own conditions. The programme should be properly organised with a small full-time coordinating staff. It should develop metrics to ensure that quality, outcomes and experience are properly monitored. It should be piloted in one disease area to begin with. It should be overseen by the Long Term Conditions Alliance.

Recommendation 5: Better regulation

Theregulationofcareisaveryimportantpartofassuringstandards,qualityandsafetyinmanyotherjurisdictions.Forexample,theCareQualityCommissionhasaveryprominentroleintheinspectionandregistrationofhealthcareprovidersinEngland.IntheUSA,theJointCommission’sroleinaccreditationmeansthatnohospitalwantstofallbelowthestandardssetoritwilllosereputationandpatients.TheReviewTeamwaspuzzledthattheregulatorinNorthernIreland,theRegulationandQualityImprovementAuthority,wasnotmentionedspontaneouslyinmostofthediscussionswithothergroupsandorganisations.TheAuthorityhasagreaterroleinsocialcarethaninhealthcare.Itdoesnotregister,orreallyregulate,theTruststhatprovidethemajorityofhealthcareandalotofsocialcare.Thislight-touchroleseemsveryoutofkeepingwiththepositioningofhealthregulatorselsewherethatplayamuchwiderroleandhelpsupportpublicaccountability.TheMinisterforHealth,SocialServicesandPatientSafetyhasalreadyaskedthattheregulatorstartunannouncedinspectionsofacutehospitalsfrom2015,buttheseplansarerelativelylimitedinextent.

We recommend that the regulatory function is more fully developed on the healthcare side of services in Northern Ireland. Routine inspections, some unannounced, should take place focusing on the areas of patient safety, clinical effectiveness, patient experience, clinical governance arrangements, and leadership. We suggest that extending the role of the Regulation and Quality Improvement Authority is tested against the option of outsourcing this function (for example, to Healthcare Improvement Scotland, the Scottish regulator). The latter option would take account of the relatively small size of Northern Ireland and bring in good opportunities for benchmarking. We further recommend that the Regulation and Quality Improvement Authority should review the current policy on whistleblowing and provide advice to the Minister.


6Recommendation 6: Making incident reports really count

ThesystemofincidentreportingwithinhealthandsocialcareinNorthernIrelandisanimportantelementoftheframeworkforassuringandimprovingthesafetyofcareofpatientsandclients.Thewayinwhichitworksisfallingwellbelowitspotentialforthemanyreasonsexplainedinthisreport.Mostimportantly,thescaleofsuccessfulreductionofriskflowingfromanalysisandinvestigationofincidentsistoosmall.

We recommend that the system of Serious Adverse Incident and Adverse Incident reporting should be retained with the following modifications:• deaths of children from natural causes

should not be classified as Serious Adverse Incidents;

• there should be consultation with those working in the mental health field to make sensible changes to the rules and time-scales for investigating incidents involving the care of mental health patients;

• a clear policy and some re-shaping of the system of Adverse Incident reporting should be introduced so that the lessons emanating from cases of less serious harm can be used for systemic strengthening (the Review Team strongly warns against uncritical adoption of the National Reporting and Learning System for England and Wales that has serious weaknesses);

• a duty of candour should be introduced in Northern Ireland consistent with similar action in other parts of the United Kingdom;

• a limited list of Never Events should be created

• a portal for patients to make incident reports should be created and publicised

• other proposed modifications and developments should be considered in the context of Recommendation 7.

Recommendation 7: A beacon of excellence in patient safety

ThereiscurrentlyacomplexinterweavingofresponsibilitiesforpatientsafetyamongstthecentralbodiesresponsibleforthehealthandsocialcaresysteminNorthernIreland.TheDepartmentofHealth,SocialServicesandPublicSafety,theHealthandSocialCareBoard,andtheRegulationandQualityImprovementAuthorityallplayapartin:receivingSeriousAdverseIncidentReports,analysingthem,over-ridinglocaljudgmentsondesignationofincidents,requiringandoverseeinginvestigation,auditingaction,summarisinglearning,monitoringprogress,issuingalerts,summoning-inoutsideexperts,establishinginquiries,checking-uponimplementationofinquiryreports,declaringprioritiesforaction,andvariousotherfunctions.TherespectiverolesoftheHealthandSocialCareBoardandthePublicHealthAgencyareclearlyspecifiedinlegalregulationsbutseemveryoddtotheoutsider.TheHealthandSocialCareBoardhasnofull-timeofficersofitsownwholeadonqualityandsafetyandnoin-housemedicalornursingdirector.ThesefunctionsaregraftedonfromthePublicHealthAgency.Theindividualsconcernedhavedonesomeexcellentworkonqualityandpatientsafetyandcarryouttheirrolesveryconscientiously.However,symbolically,andongroundsoforganisationalcoherence,itappearsstrangethatthemainbodyresponsibleforplanningandsecuringcaredoesnotholdthesefunctionsintheheartofitsbusiness.TheDepartmentofHealth,SocialServicesandPublicSafety’sroleonpaperislimitedtopolicy-makingbut,inpractice,stepsinregularlyonvariousaspectsofqualityandsafety.TheReviewTeamthoughtlongandhardbeforemakingarecommendationinthisarea.Intheend,webelieveactionisimperativefortworeasons:firstly,thepresentcentralarrangementsarebyzantineandconfusing;secondly,theoverwhelmingneedisfordevelopmentofthepresentsystemtomakeitmuchmoresuccessfulinbringingaboutimprovement.Currently,almostalltheactivities


6(includingthoselistedabove)areorientatedtoperformancemanagementnotdevelopment.Thereisabigspaceforacreative,positiveandenhancingrole.

We recommend the establishment of a Northern Ireland Institute for Patient Safety, whose functions would include:• carrying out analyses of reported

incidents, in aggregate, to identify systemic weaknesses and scope for improvement;

• improving the reporting process to address under-reporting and introducing modern technology to make it easier for staff to report, and to facilitate analysis;

• instigating periodic audits of Serious Adverse Incidents to ensure that all appropriate cases are being referred to the Coroner;

• facilitating the investigation of Serious Adverse Incidents to enhance understanding of their causation;

• bringing wider scientific disciplines such as human factors, design and technology into the formulation of solutions to problems identified through analysis of incidents;

• developing valid metrics to monitor progress and compare performance in patient safety;

• analysing adverse incidents on a sampling basis to enhance learning from less severe events;

• giving front-line staff skills in recognising sources of unsafe care and the improvement tools to reduce risks;

• fully engaging with patients and families to involve them as champions in the Northern Ireland patient safety program, including curating a library of patient stories for use in educational and staff induction programmes;

• creating a cadre of leaders in patient safety across the whole health and social care system;

• initiating a major programme to build safety resilience into the health and social care system.

Recommendation 8: System-wide data and goals

TheNorthernIrelandHealthandSocialCaresystemhasnoconsistentmethodfortheregularassessmentofitsperformanceonqualityandsafetyatregional-level,Trust-level,clinicalservice-level,andindividualdoctor-level.Thisisincontrasttothebestsystemsintheworld.TheReviewTeamisfamiliarwiththeClevelandClinic.Thatserviceoperatesbymanagingandrewardingperformancebasedonclinically-relevantmetricscoveringareasofsafety,qualityandpatientexperience.Thisisstronglylinkedtostandardpathwaysofcarewhereoutcomeisvariableorwheretherearehighrisksinaprocess.

We recommend the establishment of a small number of systems metrics that can be aggregated and disaggregated from the regional level down to individual service level for the Northern Ireland health and social care system. The measures should be those used in validated programmes in North America (where there is a much longer tradition of doing this) so that regular benchmarking can take place. We further recommend that a clinical leadership academy is established in Northern Ireland and that all clinical staff pass through it.


6Recommendation 9: Moving to the forefront of new technology

Thepotentialforinformationanddigitaltechnologytorevolutionisehealthcareisenormous.Itsimpactonsomeofthelong-standingqualityandsafetyproblemsofhealthsystemsaroundtheworldisalreadybecomingevidentinleadingedgeorganisations.Thesedevelopmentsinclude:theelectronicmedicalrecord,electronicprescribingsystemsformedication,automatedmonitoringofacutely-illpatients,roboticsurgery,smartphoneapplicationstomanageworkloadinhospitalsatnight,near-patientdiagnosticsinprimarycare,simulationtraining,incidentreportingandanalysisonmobiledevices,extractionofreal-timeinformationtoassessandmonitorserviceperformance,advancedtelemedicine,andevensmartkitchensandtalkingwallsindwellingsadaptedforpeoplewithdementia.ThereisnoorganisedapproachtoseekingoutandmakingmaximumuseoftechnologyintheNorthernIrelandcaresystem.Itcouldmakeabigdifferenceinresolvingsomeoftheproblemsdescribedinthisreport.ThereisevidenceofindividualTrustsmakingtheirownwayforwardonsometechnologicalfronts,butthisuncoordinateddevelopmentisinappropriate-thesizeofNorthernIrelandissuchthatthereshouldbeoneclear,unifiedapproach.

We recommend that a small Technology Hub is established to identify the best technological innovations that are enhancing the quality and safety of care around the world and to make proposals for adoption in Northern Ireland. It is important that this idea is developed carefully. The Technology Hub should not deal primarily with hardware and software companies that are selling products. The emphasis should be on identifying technologies that are in established use, delivering proven benefits, and are highly valued by management and clinical staff in the organisations concerned. They should be replicable at Northern Ireland-scale. The overall aim of this recommendation is to put the Northern Ireland health and social care system in a position where it has the best technology and innovation from all corners of the world and is recognised as the most advanced in Europe.


6Recommendation 10: A much stronger patient voice

Inthelastdecade,policy-makersinhealthandsocialcaresystemsaroundtheworldhavegivenincreasingemphasistotheroleofpatientsandfamilymembersinthewideraspectsofplanninganddeliveringservices.Externalreviews–suchastheBerwickReportinEngland-haveexpressedconcernthatpatientsandfamiliesarenotempoweredinthesystem.Variousapproacheshavebeentakenworldwidetoaddressconcernslikethese.Sometimesthishasbeenthroughsystemfeaturessuchaschoiceandpersonally-heldbudgets,sometimesthroughgreaterengagementinfieldslikeincidentinvestigation,sometimesthroughuserexperiencesurveysandfocusgroups,andsometimesthroughdirectinvolvementinthegovernancestructuresofinstitutions.IntheUSA,patientexperiencedatanowformspartofthewaythathospitalsarepaidandinsomeitdeterminespartoftheremunerationofindividuals.ThischangecatalysedthecentralityofpatientstothehealthcaresysteminswathesofNorthAmerica.Observerssaythatthebigdifferencewaswhendollarswerelinkedtothevoiceofpatients.NorthernIrelandhasdonesomegoodworkinthefieldofpatientengagement,inparticulartherequirementtoinvolvepatientsandfamiliesinSeriousAdverseIncidentinvestigation,the10,000voicesinitiative,inthefieldofmentalhealthandinmanyaspectsofsocialcare.Lookedatintheround,thoughpatientsandfamilieshaveamuchweakervoiceinshapingthedeliveryandimprovementofcarethanisthecaseinthebesthealthcaresystemsoftheworld.

We recommend a number of measures to strengthen the patient voice:

• more independence should be introduced into the complaints process; whilst all efforts should be made to resolve a complaint locally, patients or their families should be able to refer their complaint to an

independent service. This would look again at the substance of the complaint, and use its good offices to bring the parties together to seek resolution. The Ombudsman would be the third stage and it is hoped that changes to legislation would allow his reports to be made public;

• the board of the Patients and Client Council should be reconstituted to include a higher proportion of current or former patients or clients of the Northern Ireland health and social care system;

• the Patients and Client Council should have a revised constitution making it more independent;

• the organisations representing patients and clients with chronic diseases in Northern Ireland should be given a more powerful and formal role within the commissioning process, the precise mechanism to be determined by the Department of Health, Social Services and Public Safety;

• one of the validated patient experience surveys used by the Centers for Medicare and Medicaid Services in the USA (with minor modification to the Northern Ireland context) to rate hospitals and allocate resources should be carried out annually in Northern Ireland; the resulting data should be used to improve services, and assess progress. Finally and importantly, the survey results should be used in the funding formula for resource allocation to organisations and as part of the remuneration of staff (the mechanisms to be devised and piloted by the Department of Health, Social Services, and Public Safety).

In implementing the above recommendations, the leaders of the Northern Ireland health and social care system should be clear in their ambition, which is in our view realistic, of making Northern Ireland a world leader in the quality and safety of its care. Northern Ireland is the right place for such a transformation, and now is the right time.

the right time, the right place...3 3 the right time, the right place throughout the developed world...

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