The other week I rode my bike for the first time in a very long time. I took it out to ‘ride the lights’ on Blackpool’s promenade. The prom was closed to traffic and the famous Illuminations turned on just for the evening. I was joined by literally thousands of other cyclists. There were families, people in fancy dress, quirky bikes; the whole evening was one big extravaganza of lights, colour, noise and bustle. It was simply a brilliant experience, and one I had been looking forward to for ages. I had never done it before and whilst I had read up on previous years reviews, I wasn’t sure what to expect.
The organisers provided some basic rules for all participants, including that each bike had to have lights front and back. They advised that a helmet should be worn. I didn’t have a helmet and have always preferred to ride my bike without one. A former PhD student of mine, whose study was on cycling, would often tell me there was no conclusive evidence that helmets protect cyclists from death. There are many international research studies that appear to partially support this – see here for an example. The latest data available (2016) shows that in that year, 102 cyclists died in road traffic accidents, compared to 816 car drivers and 448 pedestrians. In terms of serious injury, the rate for cyclists is much higher than for car drivers. This data has remained fairly static for the past five years.
As I didn’t know what to expect, I went out and bought a helmet. It was a safety first, psychological assurance decision – a kind of ‘just in case’ decision. Mind you I was surprised at how much they cost and the huge range of styles. As is my wont, I did manage to find one in a fetching combination of shades of black. However, there were so many people on the ‘ride the lights’ that the pace of travel was very slow, and I never felt in danger of having an accident or falling off. But safety is never an absolute concept and should never be so. In my case keeping safe and getting to the end of the ride was my measure of safety on that occasion, whereas it obviously will change in a different situation.
This was something acknowledged in the recently published report ‘The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients’. Now I might be getting mellow in my old age, but this is actually a really good report to have come from those folk at NHS England/Improvement, and I don’t say that very often! If you haven’t seen the report, give it a read. I liked both the tone and intent of the report. The tone is about all of us working together to continually improve patient safety, something that cannot simply be done through regulation. The intention is that this strategy becomes a ‘golden thread’ running through healthcare. Ok we can let NHSE/I off for that one as it did come from marmite Matt (love him or loathe him, he is still the Secretary of State).
The report acknowledges that patient safety is about maximising things that go right and minimising the things that go wrong. Achieving this aim could save 1,000 extra lives and £100 million in care costs each year. Additionally, the NHS could save around £750 million in compensation costs per year. Back in 2018, the NHS paid out £1.7 billion on negligence claims and the estimated total liabilities, if all current claims were successful, stands at a staggering £65 billion. Whilst these are incentives enough, it’s important to remember that each of these claims has a person, their family and friends at the heart of the matter, and someone whose experience of care was woefully inadequate.
The report makes an important point about the need to change the culture around safety. My long-time reluctance to wear a helmet was a result of an unashamed and ego-driven desire to look good, which in my mid at least was associated with some kind of Easy Rider image, hair blowing in the wind, and born to be free (I know shallow, shallow). These days the thought of having a life-changing accident (or even dying) was more than enough to challenge these perceptions of what was important and what I needed to do to change my behaviour. Having bought the helmet, I put it on and after a little fiddling with my hair, I decided that actually I still looked quite good, and felt quite proud to be doing the sensible thing in protecting myself and those I love.
I suspect changing the culture in the NHS will be slightly more complicated. More often than not the approach to any mistake made is to hold the individual to account. Do you remember McGregor's (and I’m not talking Peter Rabbit here), Theory X, Theory Y’ approach to managing people? Developed in 1960, in many places in the NHS Douglas McGregor’s theory still holds true. Where the manager’s assumption about how to get results is through control-orientated approaches – namely, we punish people who make mistakes and they then won’t make them again – then the resulting organisational culture is unlikely to improve safety and reduce mistakes! Of course, in those thankfully rare instances where someone is deliberately malicious and/or knowingly ignores best practice or perhaps is even unfit to practice, then the appropriate action needs to be taken in order to protect patients and other members of staff.
Concepts such as developing a ‘just culture’ are actively promoted in many NHS organisations. A ‘just culture’ recognises that many mistakes made by individuals are often the result of how that person interacts with the systems within which they work. Most people don’t come to work to do a bad job! If we continue to look at blaming individuals (even using ‘reflection and training’ approaches to error management) then the systemic issues will never be addressed. Crash helmets have their place, but it’s improvements in our familiar friends: ‘education’, ‘trust’, ‘compassionate leadership’, ‘teamworking’ and ‘system thinking’ that will keep all our patients safe.
Special thanks go to my colleague @Clairea761 who unknowingly provided the inspiration for this week’s blog and who every day, does so much to keep folk safe and well cared for.