What have we learnt about keeping people safer?

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Despite the availability of well-evidenced guidance and the best intentions of health and social care staff, there is still an ‘implementation gap’ between what we want to do to keep patients and service users safe and what actually happens in practice. We need to have a better understanding of what sustains this gap and what we can do to narrow it.

Recently, 90 people from across the health and care system came together for an event run by The King’s Fund, the Sign up to Safety campaign and NHS Improvement, to talk about keeping people safer.

When planning this event, we deliberately avoided expert presentations and lots of ‘talking from the front’ and instead adopted a more interactive format. The day started with four people sharing ‘catalytic’ stories around their experience of working to keep people safer. These were not stories of perfection, but gritty tales of work in the real world where resistance to change is to be expected and understood; where dilemmas need to be noticed and managed; where authority to act has to be negotiated; and where things go wrong or sometimes people get hurt.

We then organised people into groups – with the intention of creating a supportive environment for individuals – and asked people to think about questions they could ask the storytellers. The intention was to search out assumptions not expressed in the narrative and then to have a conversation about how these ingrained ways of thinking and behaving, which feel so personal, also reflect how the wider system is working. Critically, we encouraged people to consider how they would translate the insights generated by their conversation into practical action, to be tested and revised in the reality of their everyday work.

So, during the course of the day, what did we notice and what did we learn?

To state the obvious, keeping people safer is not simple or straightforward. ‘Safety’ is a combination of knowhow: resources, patient situations, and the regulatory environment. Keeping sight of how this complex chain of interactions and events works is part of how we keep people safe, but keeping this complexity in mind when trying to understand why we fall short is a challenge.

There was a strength expressed in the stories we heard on the day – people’s willingness to shoulder a significant level of personal responsibility for keeping people safer. This attitude will get things done, but the serious downside is an unreasonable level of personal scrutiny and accountability when things go wrong. People spoke of feeling embattled and isolated working ‘in the implementation gap’ – and of the personal sense of shame when things go wrong. This in turn leads to self-silencing and a consequent lack of open conversation that could help to identify and tackle problems in the wider system. If one assumes that most care is characterised by complexity, then just focusing on individual behaviour is simplistic, unethical and part of the reason why there is an implementation gap in the first place.

We now know that if you make time to talk in a way that shows interest in others (more simply known as being kind) then we can begin to understand the ‘why’ of others’ stories and how they relate to our own. This sort of talking is about exploration, it’s not driven by the need for agreement. We think this sort of conversation contributes to keeping people safer because more of what is really going on – unintentionally shaped by people’s assumptions and behaviours – can be surfaced and evaluated, alongside the question: how does this way of thinking, behaving and organising keep people safer?

So, at the end of a day organised around talking, we re-affirmed our commitment to conversation as the means to understand what really goes on in relation to keeping people safer, and as a way to be heard when there may be pressure to keep silent.

At The King’s Fund, we provide a platform to question how and why people who are close to patients are often silenced. We aim to develop opportunities that help people to re-acquire skills in thinking, talking and listening; in managing anxiety; and in intervening in those unpredictable, dynamic situations where you never quite have enough authority.

Conversation has been described by Theodore Zeldin (1998) as the ‘way of the weak’ and this seems apt in a system that can act to silence those with less power – more often than not those on the front line, delivering care to patients. But a well-led conversation can sometimes enable those with less power to move the powerful, by helping them to change the way they see the world.


john kapp

Comment date
15 December 2016
Well done, David, and Kings Fund for naming the elephant in the room, eg 'implementation gap' (which is huge) and the reasons for it (shame, self silencing) I am trying to fill the gap, see paper 9,111 on www.reginaldkapp.org. Keep up this good work.

Andy Buttery

Patient Safety Project Lead,
Nottingham University Hospitals NHS Trust
Comment date
12 December 2016
"a well-led conversation can sometimes enable those with less power to move the powerful" true, and positive and full of hope, but my queries are ... more cynical.
Who leads? Can empowerment actually be 'passed down' or must it be grasped? - Thinking about Patient Engagement and challenging clinicians for example.
Who is honest? Tacit refusal to address herds of elephants because they are too big and too many or a fear that either party may be a Mahout. Thinking about patient safety conversations that are miles away from the idealized stop in a corridor and more like interviews with senior management.
Who takes action? The comfortable companionship of impotent raging.

- I do recognize that I may be obtusely (re)stating your starting premise; but my contribution to the conversation is as above, queries that just won't go away.
It was a very good day, and its work is not over.

Roger Steer

Healthcare Audit Consultants
Comment date
10 December 2016
If the theory doesn't work then it may be that the theory isn't very good.
Keep chatting, you may discover something.

Graham Reeks

Principal Engagement Officer,
Sunshine Coast Hospital & Health Service
Comment date
09 December 2016
This sounds like a very interesting process and i'm keen to learn more.
Unfortunately your link to the presentations takes me to a page on the event, but there's no sign of any presentations there.

Harpreet Gill

Anaesthetic Trainee/ Masters Student LSE,
Comment date
08 December 2016
Bring us all back to this event in a year and see if with time our perception of the barriers to change have been eroded in any way.

Pearl Baker

Independent Mental Health Advocate and Advisor/Carer/ Trust Governor,
Comment date
08 December 2016
I am currently helping the OPG Research how their system can be improved to help new Deputies.

The OPG Annual Return is not 'fit for purpose' in it's current format 'Safeguarding' is my main concern??

The forms asks 'do you have a 'Care Plan'? but does not request a copy?
No mention of Section 117 'Care Plan' Statutory Guidance says review at least once a year? This should be on their files, new 'Care Plan' each year??

Client has 'needs assessment' if lucky: this should be another question, (on their files) has it been implemented? now that's another 'story'

Were they placed into their current Accommodation as part of their 'Care Plan'? Section 117

Does this person have an Independent Advocate or Carer? many have neither, despite MCA2005 code of practice. ALL ignored by the OPG.

Does the Deputy have to record complaints on their returns? not that I am aware of? this should be recorded on the Annual Return.

Are Deputies ever checked to test their knowledge on current LAWS that would effect their ability to carry out their duties. NEVER, only by Lay individuals who don't have much idea either.

'Friends and Families' feedback forms could be useful, and helpful. Deputies would be required to send to individuals known to be in regular contact with their clients. These would be completed and returned to the OPG.

The Kings Fund have there next project already looking into the OPG and how unsafe it has become to those placed into the COP.

Another question have they been reviewed recently regarding their Capacity? Not that I know of.

'Deputies' responsibilities to their clients subject to a 'Property and Finance' order are most at risk, of neglect, financial abuse.

Deputies for the above are responsible for their clients under 'Safeguarding' now. CHC Funding is easy to get in Hampshire, Berkshire another story. Final stages of Dementia entitled to CHC, but the 'fight' continues.

Do they have a Personal Budget, and someone OUTSIDE the Statutory Authorities to support them (name please) you would be lucky.

The 'irony' of those placed into the COP via a DWP Appointee is based on SAVINGS and nothing more, you could be subject to an Appointee and not placed into the COP, however if the LA are involved they will make sure you end up in the COP, despite it saying if you only receive Welfare Benefits it's not necessary.

The VULNERABLE are most 'at risk'. Ask the EXPERTS the systems could improve much quicker.

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