in which I consider the NHS as an airline

Perhaps chair of the Mid-Staffs Public Inquiry Sir Robert Francis had something like this in mind when he asserted in an interview that,

“If we ran our airline industry on the same basis, planes would be falling out of the sky all the time.”

It’s an alarming depiction or an alarmist one, selected from the conversation and published to fit The Telegraph’s narrative of the NHS as wholly unsafe and unsound. However, it does put focus back on quality.

If the NHS were to match the safety safety record of the airline industry  (accepting for the moment Francis’ statement that it doesn’t), then both the decades of command-and-control management and the perpetual disorganisation of the Health and Social Care Act 2012 would have to be be abandoned.

It is strongly indicative of the distaste and distrust of public services which  permeated New Labour that it implemented Soviet style direction over them. Patients and pupils were made subject to failed methods of tractor production.

“English healthcare managers, (whose life was perceived to be nasty, brutish, and short even before the advent of targets) were exposed to increased risk of being sacked as a result of poor performance on measured indices”

The NHS – and every patient – was subjected to an experiment in management techniques already well-known to have failed.

A year before Bevan and Hood published that discussion paper, senior Conservatives were already promising an end to the NHS if restored to government. (Nick Clegg made public his antipathy toward the NHS and his support for the Tory view in 2005.) It should have surprised no-one that in Coalition, Lansley’s Act to turn the NHS in England from a healthcare service to a procurer of private providers became law, and perpetual fear, fragmentationand disorganisation established.

Lansley’s experiment was enacted while Francis was still writing his report, which was not published until nearly a year after the NHS it was describing had been swept away, and a new experiment begun. “Competition” is the new Lysenkoism.

Both these approaches, then, have to be swept away for the NHS to address safety, because at least the following would have to be the case:

  • It wouldn’t take nearly three years and several million pounds to prepare and publish a safety report. That looks like complacency and waste on an epic scale.
  • Such a report would not then be largely ignored by the organisation which commissioned it
  • Such a public Inquiry would not even be necessary, because there would be the equivalent of an AAIB 
  • Operators would be tightly regulated – and operators known to be unsafe – including those which were foreign-owned – would be prohibited
  • Unsafe parts of the organisation would cease operation until remediated
  • The organisation would be process-driven, not target driven.
  • The organisation would be quality driven, not inspection driven.
  • The organisation  would be safety driven, not profit driven.
  • Operational data would be transparent, not obscured by commercial-in-confidence contracts
  • The right measures would be used correctly to monitor and improve the processes used
  • Every single person in the organisation would hold themselves responsible for patient safety. Every single manager and leader would hold themselves and their teams accountable for patient safety
  • There would be continuous improvement instead of constant reorganisation
  • Absence of safety incident would never be interpreted as safety.
  • Prevention of accidents and errors would be highest priority. Do no (avoidable) harm.
  • No changes would be performed without thorough Root Cause Analysis or implemented without effective risk management and comprehensive – and of course, successful – testing
  • No change would be considered without a sound justification, including risks and impacts to patient safety
  • The organisation would have quality improvement experts supporting staff at all management levels
  • There would be sufficient project investment and operational budget to deliver the availability of the services required
  • All buildings and tools would be built with adequate systems redundancy and utilise redundant levels of accurate instrumentation

On that last point and aligned with this aviation theme, there is a succinct and brilliant illustration of the difference between targets and measures here.

The list is incomplete. What has to be understood are the differences between a passenger taking an airline flight and a patient being treated by the NHS. I leave that to the clinicians, but my sense is that delivering a person from airport A to airport B roughly on time and without incident may be relatively simple compared to diagnosis and treatment. The passenger flight is a repeatable and repeated task, which makes reducing variation – enemy of quality – much easier.

Finally, It should not be presumed that the passenger airline flight is always a pleasant or even safe experience. Not only are airline passengers subjected to absurd, wasteful, and even demeaning treatment pretending to be necessary for their security (another form of safety), but not all airlines are equal.

But then, maybe a barrister or a health editor doesn’t travel economy, let alone budget or low-cost.




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