Interview: Dr Aidan Fowler, National Director of Patient Safety for NHS England

A 5 minute read.

To mark World Patient Safety Day on Saturday 17 September the NHS Leadership Academy interviewed Dr Aidan Fowler, National Director of Patient Safety for NHS England.

In his foreword to 2019’s NHS Patient Safety strategy, NHE England’s National Director of Patient Safety Dr Aidan Fowler opens with a powerful quote from John F. Kennedy. “We are not here to curse the darkness, but to light the candle that can guide us through that darkness to a safe and sane future.” It’s a quote that sums up an approach towards patient safety that seeks not to lay blame at the door of individuals, but to create a system and culture that prioritises doing the right thing, learning from mistakes, and proactively and continuously reducing harm.

“Patient safety is important, but it doesn’t happen on its own,” says Aidan. “There are some deliberate things we need to do to get there. We [need to make the vision] something that appeals and that people want to buy into. Our role is to make it easy for people to do the right thing and empower them – not tell them what to do. I’ve got to sell [people] a way of working that makes their lives easier. Quality shouldn’t be harder than poor quality. We’re building a path to shorten the journey but building it safely.”

Aidan has been leading patient safety in the NHS in England since July 2018. A surgeon by profession, he developed an interest in quality improvement while practising as a consultant, and has worked in safety improvement and harm reduction, including as a teacher, in the UK and internationally. Before taking on his current role, he led quality improvement and patient safety across the Welsh NHS.  He has also held the role of Deputy Chief Medical Officer at the Department of Health and Social Care since his appointment but was seconded to that role full time during the COVID-19 pandemic, most significantly working on testing capacity and prioritisation.

“The patient safety journey is an interesting one,” he reflects, adding that the concept was rarely discussed when he was a medical student. “We went to work to do the best job and didn’t think specifically about it. And when things went wrong, you thought… you have to survive it.” Since then, much has changed with the publication of what Aidan refers to as “a few significant documents saying we’re repeatedly doing the same things and not learning from it”.

The journey now requires moving cultures of patient safety from pathological (“we’ll just sweep that under the carpet… normalising harm”) and reactive to something real-time and preventative. Aidan summarises the strategy as: “You have to learn what’s going on in your system. You then have to have a mechanism for processing that information and acting on it. And then you need to act and make changes to stop it happening again.”

He admits it remains something of a work in progress after being naturally “derailed” by the pandemic and his secondment. But that doesn’t make what has been achieved so far insignificant, including as it does a new patient safety syllabus, new training, the embedding of patient safety specialists across the system and changes to the way safety is investigated and reported on as well as increasing involvement of patients and families. However, COVID has also provided learning, such as through the setting up of Nightingale Hospitals where Aidan says, “We were able to do the work of going in and saying: we predict this will be a problem.”

When it comes to creating more preventative cultures of safety, Aidan uses the example of a ventilator disconnecting from a patient. “The alarm doesn’t go off because of the way the machine is set up, and the patient dies. But in a perfect world you wouldn’t have designed the machine [to set up] that way. In procuring equipment you would have realised it was going to be a problem and said we’re not procuring it until you’ve changed that. At least now though we pick that up in real time and are able to respond very quickly to prevent repetition” He also references a series of “never events” happening at the height of the pandemic due to activity moving site and setting but safety checking processes not moving with it.

One common question is whether patient safety is, or should be, the job of just one individual (and their team), or whether it is everyone within the system’s job. “Is it a separate discipline or is it what we all do? It’s both,” believes Aidan. Having a strong infrastructure of governance processes is critical, but there is a risk inherent in making it seem too much one person’s responsibility (“if you make it one person’s job, everyone else backs off and that’s not what it’s about”).

That’s why creating the right culture is as important as having the right processes, much of which comes down to psychological safety. “This is not about individual human failure,” Aidan explains. “This is about accepting that there are flaws in our processes. We have to assume that things are going to go wrong, and people are going to forget things when they are busy, to take account of that and try to mitigate it.” It’s also not about apportioning blame. “When trouble comes, and it does, you [as a leader] need to be there and be visible, supporting and helping. What you don’t need to do is jump on people who are already distressed.”

Having gone from being a practising surgeon to a leader inside the wider system helps, he believes, in identifying with clinical professionals. “I’ve got the scars on my back. I’ve been through the pain. I know why it goes wrong and I speak the language. That matters to people.” What advice, then, would he offer to others who might be interested in a broader leadership role? “You need to understand yourself. You need to understand humans, the psychology and the behavioural elements. If you don’t deliberately learn that you will struggle with leadership. And there’s no point carping from the side-lines: you have to step up if you want to change things.”

But most of all, in every leadership role including his current one, he sees culture and people as the most powerful lever. “The most important thing is the cultural shift. You learn that whatever you do is tokenistic if you don’t have enough people in the right environment who feel comfortable doing their work.”