The NHS needs to learn from its mistakes, and as Health Secretary I'm on a mission to make sure it does

We must learn lessons from other industries and give doctors the reassurance they need that it will be safe to speak out when there is a safety investigation

When I was appointed as Health Secretary back in 2012, one of the first things that came across my desk was the public inquiry into the Mid Staffs scandal. It was a watershed for the NHS – but also for me personally. How could an organisation so close to all of our hearts have been responsible for so many terrible lapses in care? 

My first instinct – as someone new to healthcare responsibilities – was to ask why we knew so little about the quality of care in different parts of the NHS. Parents know about how good schools are thanks to Ofsted, but there was nothing equivalent for health. So I introduced Ofsted-style inspections for every NHS organisation with new chief inspectors responsible for different areas. From June we will have Ofsted-style ratings on the quality of mental-health provision, dementia care, diabetes care, cancer care and care for people with learning disabilities.

This transparency has been highly effective, with 11 hospitals already removed from special measures and one study saying up to 450 lives are being saved annually by the programme. But culture change can never be enforced externally, it needs to come from inside. Which is where I found myself inspired by a book given to me by a couple whose son had died tragically due to an NHS mistake. They wanted a guarantee that lessons would be learnt so that no-one would ever have to re-live their heartbreak. The book they gave me was called Black Box Thinking.

The author, Matthew Syed, argues that real improvement only comes from a culture where everyone is able to learn from mistakes. He singled out healthcare as an industry that fails to do this because of a highly damaging culture of fear. This struck a chord. I have met too many patients and families who have faced a closed and defensive culture when they’ve tried to find out the truth about things that go wrong. 

I want us to be the first healthcare system in the world that truly learns how to make care as safe as possible by adopting a culture where we really are better at learning from mistakes.

So I will be announcing measures that learn the lessons from other industries and give doctors the reassurance they need that it will be safe to speak out when there is a safety investigation. Families will get the full truth faster, and the NHS as a whole will become much better at learning when things go wrong.

Jeremy Hunt is the Secretary for Health

Comments