Written evidence submitted by the Royal College of Anaesthetists (NHL0075)

About the Royal College of Anaesthetists

The Royal College of Anaesthetists (RCoA)[1] has 24,000 members and represents anaesthetists in the UK. We act as the voice for the profession, oversee standards for training, set exams, set clinical standards, conduct research, and develop evidence-based policy.

How effectively does NHS leadership encourage a culture in which staff feel confident raising patient safety concerns, and what more could be done to support this?

The College believes that more needs to be done in this area, as evidenced by the recent reports into maternity services at Shrewsbury and Telford Hospital NHS Trust[2] and East Kent Hospitals University NHS Foundation Trust.[3] Specifically, we would call for a top-down change in culture to promote confidence and ensure greater support is available for those coming forward with concerns. We are aware that this will take time to achieve, however, ensuring implementation ofthe recommendations of the reports from the review of the independent investigations into the problems encountered at these two trusts would go some way towards achieving this goal. Currently it would appear that implementation of these recommendations is patchy and incomplete.

Chapter one of the RCoA’s Guidance for the Provision of Anaesthetic Services documents[4] describes what is required to develop a cohesive department that is able to provide a safe and high quality anaesthesia service. Most of the points made about leadership and culture are true not just in anaesthesia services, but in any clinical service. It calls for leaders to lead with compassion and to foster a learning culture within the service that they manage (1.17), for departments to collaboratively review the structure and performance of the leadership team as a whole and for clinical leaders to have annual reviews of performance in leadership and management duties (1.19). In relation to safety, it calls for a culture that proactively promotes safety, by emphasising what goes right rather than what went wrong, and emphasising incident prevention rather than solely focusing on making changes after an incident has occurred (4.17), and states that learning from negative episodes should be promoted within an ethos of support and avoidance of blame (4.18).

Finally, we would like to point out that financial constraints hinder the implementation of many patient safety initiatives. Often this is because the NHS lacks capital funding to plan and implement these initiatives, that will often save money in the longer term.

How could better regulation of health service managers and application of agreed professional standards support improvements in patient safety?

It would increase confidence in NHS leadership, which would facilitate the change in culture that would be required to support improvements in patient safety.

How effectively do NHS leadership structures provide a supportive and fair approach to whistleblowers, and how could this be improved

The actions of leadership in the case of Lucy Letby,[5] and in other high profile cases, such as the handling of whistleblowing at West Suffolk NHS Foundation Trust[6] have profoundly eroded faith in a supportive environment and fair leadership in respect to whistleblowers. The Lucy Letby case illustrates that in complex situations, HR concerns (such as employment tribunal risks) and professional protectionism may distract from patient safety and whistleblower support. 

Staff, both senior and junior, must feel that they are safe should they need to raise concerns. Those who have become whistleblowers in the past have reported been poorly supported and vulnerable, which in turn discourages others from putting themselves in that position.

How effectively does the NHS complaints system prevent patient safety incidents from escalating and what would be the impact of proposed measures to improve patient safety, such as Martha’s Rule?

There is not enough learning that is disseminated from the NHS complaints system to prevent future threats to patient safety. The new incident reporting system that NHS England has recently rolled out[7] addresses this issue and the College supports its implementation, to improve learning and supportive oversight.

The College supports the implementation of Martha's rule, and we are very hopeful that it succeeds in improving patient care. However, insights from our membership continue to highlight where the Long Term Workforce Plan[8] falls short for our specialty, which will be among the most impacted by the change in legislation. We must ensure that the anaesthesia and critical care workforce are front and centre of these plans as they progress, and that the initiative is piloted carefully to ensure that it is used effectively, and to ensure that any unintended negative consequences can be mitigated at an early stage.

What can the NHS learn from the leadership culture in other safety-critical sectors e.g. aviation, nuclear?

The aviation sector has a culture where safety is everybody's business and learning from near misses is part of everyday business and that should equally be the culture in the NHS. The NHS’s leadership culture needs to have a greater understanding of human factors science in order to reduce the need to rely on exceptional human performance to improve the safety of patients. The College recently endorsed guidelines from the Difficult Airway Society and Association of Anaesthetists on “Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals”[9] which addresses this for anaesthesia and likely applies to other specialties across healthcare. Among its recommendations is: to fully integrate non-technical skills training into anaesthetic working practices, so that it becomes a routine part of the work of anaesthetists and the teams that they work with, with appropriate time and resources allocated.