The demands of Covid-19, Brexit and fiscal austerity distracted health leaders from the goal of improving patient safety, a renowned health expert has suggested, as Britons reel from Lucy Letby’s conviction for murdering babies in her care.
Dr Don Berwick was speaking after Letby, a former neonatal nurse, was sentenced to life imprisonment for killing seven babies and attempting to end the lives of six more. Doctors who worked with Letby said they tried to raise the alarm but were ignored by managers.
Berwick was among a number of leading healthcare figures interviewed by the Financial Times who suggested that NHS culture still needed to change to ensure staff felt safe reporting concerns over poor care.
Following Letby’s conviction this week, the government announced an independent inquiry into the circumstances that allowed her crimes at the Countess of Chester hospital to remain undetected for so long.
A decade ago, Berwick was commissioned to examine what lessons should be learned from a different tragedy — the deaths of 1,200 patients who died needlessly at Mid-Staffordshire NHS Foundation Trust between 2005 and 2009.
An inquiry found the victims had been failed “by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety”.
In his report, Berwick concluded that “the most important single change . . . would be for [the NHS] to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end-to-end”.
Despite the commitment of many healthcare leaders, not enough progress had been made in the decade since, he suggested.
This had partly been because of the pressures of Covid, and austerity cutbacks which meant health trusts became “worried about their financial status and deficits”, he argued. Brexit “was another shock” and “attention to patient safety as a primary concern, [or] first duty, waned”.
Pointing to the challenges of changing NHS culture, Berwick told the FT that at Mid Staffs the leadership had “responded more with fear and justification than they did with openness and inquiry”.
Likewise, in the Letby case, staff who were suspicious about what was happening “were not responded to with the kind of openness and embrace and trust that is necessary for learning”, he added.
The NHS was not alone in falling short, he said. “Every large system is finding it difficult to achieve this culture change.”
Chris Ham, co-chair of the NHS Assembly which advises NHS England, and a former director of strategy at the Department of Health, said that while the Letby case was “an extreme example”, there had been other recent instances of concerns going unheeded.
He highlighted an inquiry into University Hospitals Birmingham NHS Foundation Trust, which found staff had not felt supported to express worries because of a culture described as “bullying” by Mike Bewick, a former NHS England deputy medical director, commissioned to lead the investigation. A junior doctor at the hospital died by suicide.
Ham lamented that Don Berwick’s recommendations had not been implemented, suggesting that if they had been, “it’s much less likely that we’d be in the position we are today”.
Alison Leary, professor of healthcare modelling at London South Bank University, said a key reason why the NHS often proved unable or unwilling to learn the lessons of past disasters lay in a “command and control culture from central government” that valued activity over quality.
This was manifested in ministers’ “promises to the population — ‘we will cut waiting lists, we will give people faster cancer treatment’ — when we don’t have the capacity to actually do that in the system,” she said.
Leary cited the saying that between “good, fast and cheap you can only pick two”.
She added that “50 years worth of inquiries” had vowed that lessons would be learned “and of course they never are because the environment isn’t created where the learning from those situations can be applied”.
Although the vast majority of treatment in the NHS turned out well, healthcare was “a high harm-potential environment”, she said. Yet in England, there was no single overarching regulator for safety and healthcare. Contrasting this with airline, rail and nuclear sectors, she said it was “the only high-risk, high-harm industry that doesn’t have a safety infrastructure”.
Rob Behrens, the health service ombudsman whose role is to investigate complaints about poor care brought by patients and their families, echoed Leary’s concerns about the complexity of structures to scrutinise safety in the NHS.
In the wake of the Letby affair, he has written to the health department urging “an independent review of what an effective set of patient safety oversight bodies would look like”.
A public servant for 40 years, he said he had “never come across a more regulated sector than health but the problem is that it’s uncoordinated, it’s arcane, and people don’t understand how to use it”.
Official watchdogs such as the health and safety inspectorate division, the patient safety commissioner, separate ombudsmen for health and social care, and the Care Quality Commission were “not as effective as they need to be because they’re not integrated or joined up”.
Unlike most of his ombudsman counterparts around the world, he did not have the authority to investigate incidents unless a specific complaint had been made, he added.
In a letter to senior health managers after the Letby verdict, Amanda Pritchard, NHS chief executive, and other senior colleagues said the NHS was “committed to doing everything possible to prevent anything like this happening again, and we are already taking decisive steps towards strengthening patient safety monitoring”.
“We want everyone working in the health service to feel safe to speak up — and confident that it will be followed by a prompt response,” they added.
Berwick said despite the stresses facing the health service he was hopeful that “NHS leadership will find a way to restore quality improvement and patient safety to the centre of its strategic agenda. It really must do that,” he added.
The health department said: “Providing safe and compassionate care is the heart of what we do, and we’re committed to keep listening to the experiences of patients and their families and using what we hear to implement improvements for them.
“We’re improving the safety of care by increasing transparency and requiring Trusts to inform patients if their safety has been compromised, by the legal protections in place for whistleblowers, and by implementing the first NHS Patient Safety Strategy to create a safe learning culture across the NHS.”
