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The National Health Executive Podcast is the perfect place to garner insights from across all aspects of healthcare, as we get into the crucial ‘whys’ behind the stories and how they can impact all of us to improve our work, our lives and the care and services we provide as an industry.
Tune in, discover more about our diverse and talented health sector and it may well spark the solution to help you see a problem or challenge in a new light.
I'm looking at it through the lens of what's preventable and what's avoidable. Will those things make a difference? I don't think so. The lack of data within the NHS is just, you know, it's criminal.
This is the national health executive podcast bringing you views, insight and conversation from leaders across the health sector, presented by Louis Morris. Hello and welcome back to the National Health Executive podcast. Welcome Tom Bell, who is our patient safety expert for today. And for those of you who don't know, I'm sure many of you will know who Tom is, but for those who aren't as familiar, Tom, can you explain a little bit about your background, how you came to be in this instance, our patient safety expert and champion?
Yeah. Thank you. how did I get here? Boy, this wasn't on my journey plan, you know, in terms of my career or my life. I happen to get here because I've had some personal experiences. My sister Alison M, took her own life in 1991 and it emerged a few years later that she had been subjected to a period of sexual abuse within the NHS mental health hospital that she had been in the care of, and I say in the care of loosely there. And we've been fighting for Justice Rollinson for many decades after that. I, in a separate incident, in 2017, I was forced to leave the NHS after whistleblowing, expressing my concerns to the regulator about the behaviour of directors in the NHS Trust that I was working for. Now, those two events are completely unrelated and I have to say, I was incredibly disappointed that I had to leave the NHS. I was massively proud to work for it, you know, my grand was a nurse, my aunt was a nurse, my mum was a nurse, my cousin was a nurse. But I've taken all the, skills, if you like, that I've acquired over the years in terms of. I was a former business advisor, I've been a manager at many levels in both the public, the private and the third sector. And I've gone through the stages of anger, as you would expect when you find out these things and you reach a point where you say, well, it's not that we have a healthcare system that's full of bad people or people with bad intent that leads to bad things happening, it's actually a system problem. and so I've, you know, I've explored the behavioural sciences and I've lined those up alongside my own MBA, master of bugger all, as I call it. I, was a chartered marketer for 20 years. I was a former steering member of the Northern Leadership Academy, and I've contributed to numerous national reports, both on patient safety and whistleblowing and on justice. So I've gained this experience, if you like. It's the lived experience that I've gained, which I then sit alongside my learned and my professional experience, and that's brought me to this point. But as I say, it was never on my career plan.
We did mention your family members history of nursing there. You were a nurse, if that's correct. you were more it based, digital?
I was a manager, yeah. So I was a middle manager in the NHS for just over five years. So as far as the. The rest of my family is concerned, I'm the black sheep of the family. I think between us all, we've got something like almost 130 years combined employment experience in the NHS, of which my management experience is the only non clinical experience.
Absolutely. And coming onto patient safety. And we'll get more onto that in a bit of data later. But just to set the scene, what do we mean by patient safety? Because I had it before with digital. What do we mean by digital? Because it could mean one thing to you, completely different thing to me. When we say patient safety, what does it mean to you? And do you think it means something different to other people within the NHS?
That's a great question that you ask, because a lot of people within the NHS right now are, ah, focusing on the implementation of something called PSRF. The NHS loves a good acronym, doesn't it? And PSRF stands for the patient safety incidents incident reporting framework. So NHS trusts are now supposed to be compliant, whatever that might mean. And it means different things to different NHS trusts, as these things always do. The NHS is nothing if not inconsistent, is it? And what you have is a focus on patient safety, which looks really at it from two angles. It says, well, how can we educate and involve the patient in their own safety? So we make sure they do the things which adds to them having a safe experience.
Yeah.
And then there's the bit which says, well, what are we doing as a trust, as an NHS body, to keep patients safe? There's lots going on, isn't there, in terms of safety? Because you've got what be very broad brush and say, right, we've got the preventable. We often call it avoidable harms, haven't we? And there's a continuum of those, isn't there's, the small, minor harm that occurs, which might be important to the person that has experienced it, but, you know, in the overall scheme of things is a small harm, right up to that unnecessary, avoidable death that often occurs in the care of the NHS. And that happens in all kinds of settings, you know, mental health, acute, secondary, tertiary, you name it. And in some respects, it's because health is a risk business, isn't it? It's not a risk free business, you know, it's not. We're not in the realms of selling widgets here or providing simple services which have no risk and are incredibly predictable. We are all unique, you and I, just as our DNA and our fingerprints are unique, often our health is made up of a unique combination of the things that have gone into who we are. So when we talk about patient safety, I think you're right. I think it means different things to different people. I'm looking at it through the lens of what's preventable and what's avoidable, because safety, for me is a product, if you like, it's an outcome you don't. It's a bit like quality. The best companies in the world, they focus on the process which leads to the quality. So if you are looking at any of them, I mean, the classic example is Toyota, isn't it? Toyota is obsessed with reducing variation, what it calls reducing variation in all its processes and in all its supplies, in all its goods, in all its components. And what that does is it leads to a quality product. So Toyota doesn't say, let's focus on quality, Toyota focuses on reducing variation. Now, interestingly, within the NHS, of course, and I said it slightly flippantly, but I think it's true, it is incredibly disparate as a system. It's fragmented. So if you just. Let's take a quick look across the NHS landscape in terms of primary care, which is where most people have their experience of the NHS, you know, I think it's 90% plus, isn't it, of the demand of the use, if you like, if the NHS goes through primary care, you've got just under 9000 practises there, Lewis. Most of them have different websites to each other, different ways of working, different, setups. A lot of them have different it systems. Some of the systems talk to each other, others don't. And so it goes on. If, if you're going to call this a franchise, the NHS would have to be labelled as the most inconsistent franchise on the planet. Yeah, it's a service manager and a service marketer's nightmare. There is no other franchise on the planet that is managed so inconsistently. Then if you go to the level of trust so let's go up a gear to where, you know, where those primary care, those GP practises, are referring their patients into those trusts. Again, there isn't one of them that has the same website as its neighbour, there isn't one of them that offers exactly the same things in the same ways. So that consistency piece, which is often dressed up under one size, won't fit all. That's the famous retort, isn't it? Oh, Tom, you can't have consistency because one size won't fit all. But the reality is that one size will fit the vast majority. And if you design your services against the majority of demand, what you'll do is you'll free up capacity to deal with the things that don't fit the standard templates.
Yeah.
So when we talk about safety, you're right, it means different things to different trusts. It means different things to different people in different parts of different trusts. But, I think, really, really importantly, on the plus side of PSRF, the patient safety incident response framework, there's an attempt there to get some consistency. And the clever thing about PSRF, and I don't often say that about NHS initiatives, but the clever thing about PSRF is that what it's trying to do is achieve an element of culture change. It's trying to get trusts to look at things differently, rather than just apply a set of box ticking exercises to every incident that they uncover. It's encouraging trusts to look at them, to use data, to use anecdotal data, to use empirical data. I, think the danger with it is that, again, it will be applied so inconsistently, I should say it will end up providing different outcomes to different trusts and we'll have a bit of. A. Bit of a postcode lottery. Once again, that was a very long winded answer to your question.
But, yeah, you did mention culture change, though, and there's been a quite a few recent measures when it comes to patient safety, on the surface, at least, by the NHS and the government, we're talking Martha's rule, the death certification process change in the duty of Canda Corps for evidence, which was, I guess, specifically earmarked to, review the culture of NHS. What do you make of the makeup of the present day NHS when it comes to patient safety? You've gone through it, though. Are measures like that enough? Do we need to go deeper?
I don't think we need to go deeper. I think we need to go wider, if that's okay. So let's look at it from a system point of view. I attend many conferences where people are talking about, how do we make the NHS safer? How do we, reduce the levels of preventable, and avoidable harm? And the conversation is almost held in a silo whereby what people do is they look at the NHS and go, right, how can we fix this bit of it? The reality is that the NHS, is interwoven within society. And what I mean by that is, as a publicly funded healthcare service, the NHS is subject to the pressures that the society around it generates.
Yeah.
It seems to me that this conversation that people are trying to have is to say, how can we create this wonderful jewel of a thing? How can we get this beautiful thing to stand in the middle of what many people widely regard as an increasingly fragmented and unequitable society? The answer is, you've got to look at that thing in the round and you've got to say, well, hang on, if we do have a fragmented society here and it is creating more demand, so let's bring this to life with some real examples. We've got hundreds of people taking their own life every year directly linked to gambling related debts. We've got people now with rising levels of obesity, and we've seen that coming for years, haven't we? Part of the problem being that you and I can order any of the foods that we want at any time of day or night. It's just all become too easy. So what you can't do is you can't say, let's look at society separately, and then look at the health service and say, let's make that, brilliant. What you've got to do, I think, is have a conversation about the type of society that you want, because that dictates the type of healthcare service that you'll have. And you can't make the health service safe if you're placing too much pressure and too many demands on it. It doesn't matter how many initiatives, duties of Canada and all this other thing. We've had similar things, haven't we, since 1066, but they don't work. The system pressures are far too great. And what you end up is with people box ticking and saying that they're meeting the requirements of the duty of Condor, or they're meeting the requirements of the fit and proper persons test, or they're doing this or they're doing that. And the reality is, we know that what they're doing is they're saying they're doing it because there's so much pressure on them to say that. The fact of the matter is we've got rising demand and an increasingly stretched NHS. and we see the proof of that all around us, don't we? You know, there's a huge rise in private healthcare, by the way, I'm not a privateer, but I do believe in a vibrant private sector. Yeah, I think there's got to be room for a private sector for people who want to use it. And I absolutely welcome that. Where I think we've got this huge problem is, we saw, I think it was on the news last night about people being violently attacked in hospitals, which I just find absolutely horrendous. That's abhorrent. And somebody's saying, well, it's due to the waiting lists. Okay, there may be an element of truth in that. Maybe frustrations are boiling over, but I think it's actually due to social pressures on people. I don't think it's directly due to waiting lists. I don't think many people who are on a waiting list will run into hospital with a knife to get to the top of the waiting list. It's not going to work that way. Somebody's going to prove me wrong and give me the exception, aren't they? But I think what we've got is we've got a, struggling society. Now, people may argue with that, and of course, I think if you were a Tory MP, you'd say, oh, you've never had it so good. But the reality is that a lot of people, we are in a post austerity era. We are, emerging, if not still in a cost of living crisis. We have rising costs all around us. We have people struggling to pay debts, people struggling just to stay afloat. So there's a lot of pressure on people and we've got huge demand for mental health services. I mean, the kind of levels of demand for mental health services, especially from younger people, that has gone through the roof, hasn't it? That level of demand, it's exceeded anything that I think was ever planned. But that's a social pressure that's occurring, isn't it? You know, so when we talk, I take your point, you know, we've got Martha's law, we've got duties of candour reviews, we've got lots of other things going on. Will those things make a difference? I don't think so. I think unless you actually look at society and you look at the structure of the healthcare service that you want and you then ask questions about what is it that we want the NHS to do and not to do. I mean, let me put this to you and to the listeners, is it right that we have some of the highest paid chief executives in the world taking money out of their gambling corporations who remain nameless, and yet you and I are being asked in our, tax to pay for the setting up and establishing and running of gambling clinics. That's crackers, isn't it? Or is that just me? I don't see on which planet that could be ever seen as logical. We let someone over there say, let's make a massive profit out of creating debt, because that's what being a bookie is. My grandma always said to me that you'll never see a bookie riding a push bike. And, that hasn't changed yet. I think that certainly wouldn't be riding a push bike now. It's probably a bugatti with a personal plate, isn't it? How, do you do that? Because you're pushing people further and further into debt and then you're saying to the NHS, oh, look, can you deal with that? Can you pick up the problems over there? Can you deal with the rise in obesity? Can you deal with the rise in mental health? I hope this is making sense.
It absolutely is. I mean, a lot of what you're saying, it almost refers back to me from my perspective, refers back to what you were getting out, of Toyota. It sounds like prevention and the social pressures. And before dealing with what happened in NHS, we need to work out how people don't end up in the NHS, or within the system, at least. Is that what you're getting at? Is that where you think patient safety needs to go? Is striking further upstream by keeping patients safe, not necessarily in hospital, just keeping them safe enough they don't end up in hospital.
Well, I guess what I'm saying is that they're bound to be unsafe in the numbers that they're coming into the NHS at the moment, because there simply isn't the capacity to deal with them yet. It's rather like saying, can you fly a plane safely with more people on board than it should have? And the answer would be no. You wouldn't let that happen, would you? People would come to harm. If you lay people down on the aisles of an aircraft and then all of a sudden it hits turbulence, you're going to have quite a few people with headaches. That's going to happen. And I think what we're saying to the NHS is, if the NHS was that plane, we'd be saying, well, you know, just carry on as you are. We'll fill you as full as we can and let's see how you fly. And it shouldn't be that way. But if I take you back to, Simon Stephens famous five year forward view, where he talked about the need to increase prevention efforts.
Yeah.
through, you know, through public health and other things. And he recognised, although he did nothing about. I think that's the key thing. Like most politicians, they recognise what needs doing but don't do anything about it. Simon Stevens recognised that the NHS would only succeed if things happened upstream to stop people coming through the front doors. Yeah, he was absolutely right in that respect. But he then hung the NHS future on this upstream intervention, which was never funded and never happened. And that was unfortunate because he essentially left the NHS in a very exposed position. His five year forward view hinged completely on more preventative money, more public health, and public health didn't get that money. so, yeah, you know, it's fascinating, isn't it, when you look at the advertising budgets of the companies. I mean, how many times do you see gambling and fast food advertised on telly? Those budgets dwarf the budgets of Public Health England. If Public Health England think it can go against the grain by launching a few advertising campaigns and doing a little bit of this and that, you know, it is. I won't use the phrase, but it's doing it in the wind.
Yeah.
Because the might of these big corporations with huge advertising budgets is huge. They know how to persuade people to do what they want them to do and then, of course, as I say, when it all goes wrong, the NHS is there to pick up the pieces.
Yeah. And we mentioned earlier, I slightly touched on data talking about prevention and striking upstream. Is that a way to do it? The best way? Is that a way to harness, I guess, working out who's the most at risk and preventing them from being in danger, I guess, is the best way to say it, if I can say that.
No, I mean, use of data is a good thing, isn't it? Now, there's a fascinating experiment being done in China, which I think is ongoing, whereby people's health is monitored in real time and, they are shown. So they're vulnerable, let's say. Vulnerable, yeah. Let's call them people, as we would say over here, with multimorbidities. It could be diabetes COPD and their health is literally shown on a screen, you know, and if there are some indicators goes up, there is contact then made. Yeah, contact is initiated. That's a little bit draconian, I think that's a big bit big brother, isn't it? You know, I wouldn't want somebody, if my fitbit tells me that I'm cycling a bit too hard, and pushing my heart rate a bit too fast, then that's my own silly fault. I wouldn't want somebody calling me on the phone saying, tom, you need to slow down a wee bit. Not that that happens often, by the way, I've got to say. But in terms of data, I mean, it's a brilliant point you're making, because the lack of data within the NHS is just, you know, it's criminal. If I wind you back through the mists of time. When I worked for Carlsberg at the turn of the century, we had access to lots of data about lots of things.
Yes.
So at the end of the day, I could come to this desk that I'm sat here. Now, this room looks slightly different then, but I could plug in with my cat five cable, and I would download, almost in real time, who bought, what was selling, which accounts were up, which accounts were down, which was in profit, et cetera, et cetera. So that data was there. That was a company, albeit a large company, and a very well run company, that was a company that was making a living through selling sugary alcoholic liquid and other things. When I came into the NHS a number of years later, I remember saying to my director of strategy, I said, where's the dashboard that I can access, please? And he looked at me as if I was speaking Swahili. Now, bear in mind, this is the year 2012, so this is almost twelve years after I've left Carlsberg. I said, where's the dashboard that I can look at? I said, well, what do you mean? I said, well, you know, you must have something on screen, do you not, that tells you what the type and frequency of demand is. You must have something that says, we've got this many referrals from that into that service. We've had this many referrals from that GP practise into this service. The trend is up there. The trend is down there. And he looked at me and he said, no, absolutely not. He said, we've got nothing like that at all. Now, at the time, I thought, ah, he's being cute. He doesn't want me to see it because it's commercially confident.
Yeah.
I didn't realise, actually, that most of the stuff they were still doing was on paper. And I was speaking to a guy the other day who's. He's been admitted. I mean, I'm chuckling and I shouldn't chuckle but he's been admitted into a hospital in south Wales where they are dealing with his cancer and they still don't have an electronic patient record. I mean, can you believe that? You know, this is 2024 when, I look at the absence of data. I mean, let's talk about a real. A real example here. Let's imagine that you are on the board of the countess of Chester hospital. Yeah. While Lucy Letbee is doing her terrible acts. Yeah. At the countess of Chester, the fact that, a baby died. One baby died. Right. And there's no flashing light. There's nothing on a dashboard to say that's happened.
Yeah.
In real time. There's nothing there to say that's happened and nobody's looking and saying, why? What's going on? Then a second, then a third.
Yeah.
Imagine that you're running a manufacturing plant where you're selling widgets, or as I say, you know, fizzy pop or beer, whatever it might be, and there's a break in the production line. There's a flashing light goes off immediately. It probably shows up on somebody's screen. It'll probably show up on the. On the, you know, the production manager's app on his phone. Everything is digitised and electronic in the private sector. Yeah. So then what you've got is a situation where if you look at the board papers, for the next twelve months, they weren't even talking about what was going on on that ward. They were, you know, a number of babies then died. So we have one, two, three, then we have four, five, six, and still there's no dashboard, there's no flashing light to say. So when we talk about data, I think you're right. There's the data that you get, which is the historical stuff, which says, hey, this is what demand has looked like. There's the kind of data that you're talking about, which is the predictive stuff, which says, hey, it looks like Tom's about to have a heart attack, so we'd probably best call him.
Yeah.
Then for me, there's also that simple stuff which says what's visible to us now, what is it that leaders and managers should be looking at right now to keep people safe? Now, obviously, in the case of Lucy letbe, that wasn't what I would term, preventable, avoidable harm, you know, this was. These were criminal acts that were committed deliberately.
Yeah.
So I think they probably. They fall outside the scope of usual, let's put it that way.
Yeah.
But there's a lot that goes on that we would call predictable variance that goes on in the NHS, which people are blissfully unaware of. You know, when, if you look at the board papers for most NHS boards, when they meet, it's looking at the minutes from last meeting, it's looking at policies, procedures. There's generally between three and 500 pages of meeting minutes.
Yeah.
Of meeting notes to look at, which nobody can do in a three hour period. Let's be honest, nobody's looking at a dashboard, nobody's looking in real time and saying, what's happening here? And I think the absence of data is insane. For the NHS, which is tasked with delivering health and care. The fact that it still doesn't have joined up, it is absolutely crazy.
And to be fair, Tom, we've gone from pill to post a little bit here, talk about prevention, talking about data. you mentioned health leaders there and board members. Just to sum up, then, what would you say that from your perspective, health leaders need to focus on more? There's three things that they just need to do. It's critical. And in terms of patient safety, I mean, you're a patient safety partner. What are the things that you're directing them, telling them that this needs to happen, this needs to be done?
So, first of all, I think they need to sit down and say, right, what's the data that we need? And they probably need someone to help them with this, because I think when you're sat within a situation yourself, it's very difficult to see outside of it. So they need to say, what's the information that we need to help us do our jobs? That's kind of. That's the first. I think that's a prerequisite for every leader.
Yeah.
What's the information that I need to help me do my job? Am I being bombarded with information that's taking up my mental attention and space, but isn't any use?
Yeah.
And I think that's generally the case at the moment. If I decided, what's the information that I need to run this service properly, then where does that information live? And what efforts are being made to bring that information to life in real time?
Yeah.
And who is tasked with that? Who's dealing with that? Because it's not enough, in my opinion, for boards just to come along and sit and to meet. I mean, some boards only meet once every two months. Again, you're talking about running 100 million pound businesses here and they're meeting once every two months. They simply can't do the jobs that we're asking them to do. So in a sense, they're setting themselves up to fail. So if you want, let's have a quick think about this. So there's three things. Decide what information it is that you need to do your job.
Yeah.
I would perhaps even say, decide who your customer really is. Now, that might sound like an obvious thing to say, because everyone will go, oh, well, of course, it's the patient.
Yeah.
But the reality is it's the red carpet only gets rolled out for the regulator. The red carpet doesn't get rolled out for the patients.
Yeah.
What happens is we create reports and we do things which keep the regulator happy. We don't actually look at what our patients need.
Yeah.
So decide who your customer is. Decide what information that you need to manage your customers. And, think of that as a service business.
Yeah.
So what you're saying is, right, what's the type and frequency of demand? What are we dealing with? And what information do I need to understand the type and frequency of demand? And then I think, get out and talk to people. Get out and talk to people. You know, mbwa is, I think it was a Tom Peters phrase, wasn't it? Which is management by walking about. Now, a lot of people say that management by walking about doesn't work because people don't know the questions that they need to ask. And I think there's some truth in that, because I think, if you are a nurse and you are faced with a director who's come out to see you for the day, you've probably been briefed by somebody as to what answers they're looking for.
Yeah.
And that's where the culture change piece comes in. You have to eliminate fear out the system. Absolutely. Eliminate fear out the system, because people need to be able to have open and honest conversations about what is going on. So this is all about information flow.
Yeah.
And, who's across that, who's tasked with that, who's making sure that information flows right throughout the business to the places where it needs to get to. Whether that's the data, whether it's the anecdote, whether it's the story from the community nurse.
Yeah.
Whether it's the story from the mental health nurse on the ward that's struggling because of lack of capacity, who's bringing those stories to the board's attention. How are we making that happen? And I'm not just talking about that one little patient story that gets told to the board once every two months, where they all go, oh, wasn't that lovely? Thank you for your time. And then move on to other things. Yeah, you're asking for three things, and you probably can't boil it down into three things. If I'm being brutally honest, I would suggest that every board in the NHS and every manager buys a copy of my book, which is called no wealth but life. And if they can't be bothered to read the whole book, then I would suggest they buy the shorter version of it, which is called hope is not a plan. And my book, hope is not a plan, outlines twelve things that I think we should start to do in the NHS if we're going to save it and sustain it for the future.
And to be fair, if I can be cheeky enough to ask, can you give us a slap dash on what other twelve things? Very, very, Briefly.
Well, the first thing is a societal thing, it's a political thing, and it's that we should have a referendum on what we want from the NHS. So if I, wind you back through the mists of time, we had a referendum on this thing called Brexit. Nobody really understood what the heck they were voting for.
Yeah.
If there's one, let me. Let me bring this life for you. If there's one thing that's going to matter to you and I when we're lying on our deathbeds, yeah. We're not going to say, oh, I'm so pleased I voted for Brexit.
Yeah.
What we'll be thinking about is our health and well being. Right? Could we have had longer? Were we healthy? Were we happy? Did we live good lives? Did the people that we love, did the people around us, have they got the opportunity to live good, healthy lives? That's what will matter to us. So, I guess what I'm saying is, let's have a referendum on what we want from our NHS. Let's have a national referendum which says, okay, what are the things we want the NHS to do? What are the things we want it to stop doing? And how important is public health? And I think, rather than then living in a country which continues to focus on the growth of the economy as being the thing that will save us all, it will be the rising tide that lifts all the boats, trickle down economics, as they call it, which I think has been proved to be a busted flush, let's actually ask ourselves whether or not we want to hold our government accountable for the health and wellbeing of its citizens, unless we start there right at the top of the tree. So what's the responsibility of government? Sure, I appreciate we've got you know, we need. We need national security. We need that. That's completely understood. But what's the priority of government? Is it just to increase GDP? Or is it the health and wellbeing of its citizens? Because those two things are not actually the same. So my first recommendation is let's have a referendum. Then I have a number of other recommendations, which include mandatory training for managers. I have recommendations about amalgamating primary care. I think every GP should work for the NHS, in the NHS. I think we should scrap the Care Quality Commission and I think we should remove public relations departments from all hospital trusts and replace them with information departments. But I'm not going to tell you them all, because I want people to read the book.
And as ever, that, I think is good as a place to end.
Hey, thanks for having me. I appreciate it.
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