As we await our own inspection results, I was heartened to read this week’s Care Quality Commission report into the critical issue of learning from deaths in the NHS. The CQC have seen that progress is being made towards the new national guidance, supporting investigations and improving family engagement.
For us, learning from deaths is a BHAG – those big hairy audacious goals which form the basis of all we deliver. This shows how seriously we take this; we are not at all complacent in how far we too have to travel. For the CQC, their focus comes from their 2016 review ‘Learning, candour and accountability’ and this is rightly now getting proper national attention.
The second part of the CQC’s findings here were about culture. Their Chief Inspector of Hospitals, Professor Ted Baker said that “there needs to be continued support from the centre, including support for behaviours that encourage more openness and learning across the NHS”. He is right that a trust’s culture and the staff’s ability to speak out and speak freely is crucial. Failure to fully embrace an open, learning culture may be holding organisations back. This chimes really powerfully for me and I am sure it will for many of you. We have a Just and Learning Culture which really does meet its front line in how each of us as colleagues, managers and as a Trust, deals with this most serious of issues.
I'm pleased our regulators have so clearly made the connection between learning from deaths and a more open culture. As we've said all along, we're not creating an uncritically tolerant culture – these are exceptionally serious issues – but neither can we have one which goes straight to blame without asking “what has happened and how can we learn from this?”
You'll have heard the pledge that £20 million a year extra is to be invested in the NHS. The NHS Long Term Plan sets out what is expected of us, which includes making it easier for people to access help closer to home and using technology, doing more to help people stay well and specific areas of better support including mental health, learning disabilities and autism.
Our colleagues in Healthwatch Liverpool are asking “What would you do?” If you’re in the area – do take part in this consultation. I would hope and expect the consultation to widen to the other areas we serve and commute from.