Final Report > Chapter 22: The Culture of the NHS > Looking to the future > A culture of quality and safety

A culture of quality and safety

35 The safety of patients must be a paramount consideration in determining the way forward for the NHS. Safety is fundamental to achieving a high-quality service. As is apparent from the lessons of Bristol, it must be the responsibility of all staff in their various roles to create a culture of safety within the NHS. Standards, guidelines or protocols exist to indicate what the requirements of safety demand. It follows that to fail to meet or comply with them necessarily compromises patients' safety. In all organisations, however, not only in the public sector, corners are cut from time to time. One response is to seek to ensure that standards are adhered to. This approach is typified by the airline industry. The aim is to limit the exercise of discretion by individual operators, and eliminate a `patch and mend' mentality. According to this approach, the standards themselves set the limit of safe conduct. If they are not complied with, the conduct is unsafe. Equally, if they cannot be complied with because of, for example, a shortage of resources, it cannot be safe to proceed.

36 There is much to recommend this approach, but it is not without disadvantage. Safety, in part, depends on the capacity of individuals to adapt and, listen to others, when faced with a problem. Too great a dependence on guidelines stultifies this creative capacity and is, thus, counterproductive in terms of safety. We accept this argument. It serves to show how complex the issues are. The argument does not address, however, but merely restates the central question: is there a point beyond which the exercise of creative discretion is inappropriate?

37 In the NHS, the question is made even harder, not least by the cultural assumption, born of long experience, that nothing would ever be done if the nurse or doctor waited until the relevant standards were set, or where they do exist were met. From one view, this is an anti-safety culture. From another, it is the mend-and-make-do culture which we saw earlier, a necessary pragmatism that keeps `the show on the road'. The challenge historically has been the extent to which the NHS will compromise the culture of safety in favour of the culture of pragmatism. We will examine the issues raised in detail later [Chapter X- Safe Care]. Here we merely point out, by way of illustration, that the answer is that the culture of safety is more complex than it first appears. Pragmatism, it might be thought, must give way to observing the appropriate safety standards. In fact, both of the apparent responses to the fact that standards cannot be met have implications for safety. The first response may be to cease activity until remedial action can be taken. If the remedy is, for example, a new operating theatre, this means a long-term cessation of activity. This means, in turn, that fewer patients will be treated, or patients will have to wait longer, or they will have to travel further for treatment. All of these results have adverse consequences for the safety of the patients affected. This was one of the dilemmas of Bristol. Alternatively, the hospital can carry on offering the service, recognising that safety is being put at risk, but also recognising that those who are successfully treated without extra waiting and travel have gained in terms of safety.

38 Thus, where the culture of safety is compromised hospitals are in a `lose/lose' situation. They put their patients at risk whichever course they adopt. The way forward depends, therefore, on an understanding by all of the nature of this problem, that it often cannot be solved quickly, and that the process of solution requires a series of co-ordinated steps. This is a process, not something to be achieved overnight. Questions of safety must be discussed in an open and transparent manner, so that all, particularly current and future patients, can make suitably informed decisions, not least in the light of the fact that in the process of moving to safer systems, compromises may have to be made along the way if the NHS is to continue to function.

39 It may be objected that to talk of a culture of pragmatism and compromise is to countenance and reinforce unacceptable levels of care. We would reply that, if the measures which we propose later concerning safety are put in place, the problem will be far less significant in the future. And, meanwhile, patients should be entitled to make choices, provided they have honest information.