When I was asked if I’d like to attend the Patient Safety Congress in Manchester in September, I saw no reason not to say yes. Why ever not? I thought. Who wouldn’t want to meet people concerned with keeping patients safe? What’s not to like, as they say? I didn’t realise at that point I would also be listening to people talking about how patients are not kept safe, but at least it wasn’t all about suicide.
When I turned up, I didn’t know whether any of it would make sense to me. I don’t work in healthcare, what’s patient safety got to do with me? I had no clear view of what I was supposed to get out of it. Okay, there were sessions under the rubric “Putting Patients at the Centre” that looked as if they should be relevant, but it was strange simply being there. I just let it hit me. I had the uneasy feeling I should know stuff, and that all the other people knew so much more than me, just like my first day at university. Sadly, unlike university, I have been drawn into this world against my own volition and introduced to concepts and terms such as “patient pathways” and “patient safety culture”. Although I barely understand half the detail or even have an inkling where the strapline is leading, I now have some sort of stake in it.
I can’t provide a professional assessment of the conference. Did it deal with the right issues? I think so, but I have no expertise. I just cherry-picked what I understood and related it to my experience. It was certainly superbly organised. So this is a personal response, by its nature a partial one.
There was a lot to like, definitely. There were many enlightening sessions. I didn’t skive one (which can’t be said for other conferences I’ve attended in the past). Unfortunately, there was also stuff not to like. The first shock came at 10.48. I noted the time because it was the first mention of training. This was almost two hours into the first session, the keynote panel discussion. I thought training might have come up earlier – after all, I was there at the invitation of MFC, a training organisation.
To my consternation, training wasn’t given a good rap. I heard that “Training is a poor barrier to safety” and “Mandatory training is a total turn off” and “Training is a word that raises antibodies”. Perhaps what the speaker really meant was bad training. It does exist. I’ll give her the benefit of the doubt, although it seemed a bit of a snub for MFC who had a stand there and a presentation slot and their express aim is to “improve patient safety and reduce harm and ensure better learning for everyone” and the title and theme of the conference was (checks notes) patient safety.
There were other things I didn’t enjoy hearing; the seemingly countless stories of incompetence, maltreatment, lack of transparency, toxic culture, bullying, and even downright lies told by the NHS to protect their reputation. There were whistleblowers galore and ordinary people severely let down by the NHS. I was puzzled before the congress and hoped to find an answer to my question – why does the NHS prioritise organisational reputation over patient safety? I’d heard the Ombudsman Rob Behrens make this claim on several occasions recently in the media. I genuinely didn’t understand – surely if you prioritise patient safety your reputation will improve? I had the opportunity to put this question to him. The answer is quite dispiriting. It seems that some NHS Trusts are more bothered about the regulators than the patients. Convince the regulator to believe you’re doing your job and the rest takes care of itself. Unfortunately, it doesn’t necessarily take care of the patients.
You can tell from reading this that I began to wonder, from a very early point in the Congress, whether I would find anything positive or in the least bit helpful by being there. I was shocked. I’d learned things I didn’t know. I started to question myself. Indeed there were sessions when it occurred to me that my attempts to change behaviour might be a futile waste of time, for example, when I listened to Dr Josephine Ocloo talk about her 26-year-struggle for justice (“I have never stopped fighting”) following the death of her daughter due to medical negligence (http://www.thekristaocloocampaign.com). I admire her bravery and tenacity and feel ashamed that I might have chosen the wrong path and worried that I’m not calling to account those responsible for my daughter’s death. Listening to Josephine’s harrowing contribution, it felt wrong that I’m not fighting the authorities as she continues to do, after all this time, that I’m treating the NHS as an ally in this, one that wishes to admit and then correct its mistakes. Should I consider the NHS a foe? The useful idiot voice enters my mind again and the doubts return. Is it worth it? I fluctuate between an overwhelming feeling of foolishness and total conviction. Foolishness that concentrating on changing individual minds, by persuasion and co-operation, is pointless; total conviction that it’s the best way of saving just that one life that has become the point of my existence since my daughter died. Am I doing the right thing?
I may never find a conclusive answer to that question but despite these reservations, there were other sessions at the Congress that painted a more hopeful outlook and helped me towards a better understanding of my motivations and actions. I still feel reasonably confident that I’m doing the right thing.
About Trevor Stevens
Trevor’s career has been spent teaching in schools and working as a publisher and trainer for educational publishers, and he is now self-employed. His daughter Tobi took her own life in December 2020 whilst in the care of the Norfolk and Suffolk NHS Foundation Trust. Trevor’s focus since Tobi’s death has been to tell her (and her parents’) story so that the importance of including families in the treatment of young people with mental health problems is recognised and valued as a potentially life-saving resource.
You can read Part 2 of his impressions of the 2023 Patient Safety Congress in Manchester here.
Thank you Trevor…what a helpful summary – of content as well as your own responses.
I suppose it can only be a good thing that these sensitive issues are being addressed. I am not in favour of blaming individuals – after my father died, I was pressed to complain (because otherwise things would never get better) but was advised I could only complain about an individual/ individuals, not the hospital as a whole. I didn’t want to do this, as angry as I was, because his poor treatment was systemic. I didn’t want blame, I wanted change.
My daughter, like yours, was also let down, over many years, by many agencies. But along the way there was also kindness and understanding. Clearly there is no simple answer, but it sounds like there are a lot of people wanting change and that has to be a good thing.
I completely agree with two of the main strands here. I spent much of my early career in teaching surrounded by those who rejected and despised training, believing that it was all a matter of naturally owned and honed personal skills and this led to substantial problems in the supposedly [ but often not ] superior world of independent education. I suspect that attitude is repeated in what you are describing although you are of course right, training must be appropriate, improving and developmental. Secondly, I think it is possible that we have taken too far the concept of the NHs being a perfect jewel in the crown of public service and the welfare state. So much of course is good but there are great weaknesses too and insufficient progress is made in rectifying these because of defensiveness and possessiveness, shown particularly by management. I know little about mental health provision but I can imagine a similar story there. Thank you for some most interesting thoughts.