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He looks at the following claims: “The NHS has has plenty of money pumped into it by this Government and well above inflation.” “We are funded as well, if not better than many/most systems now, so resource is not an excuse” "This Government has recruited X thousand additional nurses and Y thousand additional doctors” “We need to move towards a European style social insurance based model as those systems have better outcomes and no other country has copied the NHS” “The NHS wastes far too much money on useless, overpaid managers and people in non-jobs” “People should take more responsibility for their own health so we can become a wellness service not an illness service" The NHS is in need of root and branch reform but always resists it." Ten point plan to tackle the problems faced by the NHS Train enough staff at home to meet future workforce needs Have a proper short, medium and long term workforce plan for health and social care Treat existing staff better and more flexibly to help retention and morale Use ethical immigration policy to attract and keep key workforce groups who trained overseas or come here for lower paid but vital care work Reverse the cuts in bed capacity and invest more in capital expenditure on buildings, facilities, equipment and functioning IT Come up with a long term sustainable plan for social care funding and provision, reverse the cuts and plan for future rises in care needs Invest properly in public health and prevention policy – addressing wider determinants of preventable ill health across the life course, health inequalities and inequalities in access to healthcare and ensure that health is a key part of all public policy making Accept that this focus on prevention does involve state intervention in key areas around housing, education, food, drink, obesity, smoking and mental health. Level with the public about what can realistically be expected in terms of access, wait time, staffing and the time it will take to recover from the disruption caused by covid. Better to under promise and over deliver rather than vice versa Restore annual funding increases to the NHS to at least the historic average

Sabra Klein is deeply aware that sex matters. During her PhD research at Johns Hopkins University, Klein learned how sex hormones can influence the brain and behaviour. “I naively thought: Everybody knows hormones can affect lots of physiological processes—our metabolism, our heart, our bone density. It must be affecting the immune system,” she says. But when she graduated in 1998, she struggled to convince others that sex differences in the immune system were a worthy topic for her postdoctoral research. She ultimately found a postdoctoral position in the lab of one of her thesis committee members. And in the years since, as she has established a lab of her own at the university’s Bloomberg School of Public Health, she has painstakingly made the case that sex—defined by biological attributes such as our sex chromosomes, sex hormones, and reproductive tissues—really does influence immune responses. Through her research, Klein has helped spearhead a shift in immunology, a field that long thought sex differences didn’t matter. Historically, most trials enrolled only males, resulting in uncounted—and likely uncountable—consequences for public health and medicine. The practice has, for example, caused women to be denied a potentially lifesaving HIV therapy and left them likely to endure worse side effects from drugs and vaccines when given the same dose as men. Men and women don’t experience infectious or autoimmune diseases in the same way. Women are nine times more likely to get lupus than men, and they have been hospitalized at higher rates for some flu strains. Meanwhile, men are significantly more likely to get tuberculosis and to die of Covid-19 than women. Further reading Medicines, research and female hormones: a dangerous knowledge gap Gender bias: A threat to women’s health

There are a number of categories of cognitive bias described in more detail in these guidelines: Expectation bias, also known as experimenter’s bias, where the expectation of what an individual will find affects what is actually found. Confirmation bias is closely related to expectation bias, whereby people test hypotheses by looking for confirming evidence rather than for potentially conflicting evidence. Anchoring effects or focalism are closely related to both of the above and occur when an individual relies too heavily on an initial piece of information when making subsequent judgements, which are then interpreted on the basis of the anchor. Contextual bias is where someone has other information aside from that being considered, which influences (either consciously or subconsciously) the outcome of the consideration. Role effects are where scientists identify themselves within adversarial judicial systems as part of either the prosecution or defence teams. This may introduce subconscious bias that can influence decisions, especially where some ambiguity exists. Motivational bias occurs where, for example, motivational influence on decision making results in information consistent with a favoured conclusion tending to be subject to a lower level of scrutiny than information that may support a less favoured outcome. Reconstructive effects can occur when people rely on memory rather than taking contemporaneous notes. In this case people tend subsequently to fill in gaps with what they believe should have happened, and so may be influenced by protocol requirements when recalling events some time later from memory.

Martin has now passed the blog baton onto me. There will also be others contributing in due course to continue the thought-provoking and stimulating dialogue. Martin likes to quote Greek philosophy, but I rather like these words of Oscar Wilde: “Religions die when they are proved to be true. Science is the record of dead religions” As an agnostic Human Factors person, I’m not here to preach to the converted and I’m not evangelical about the ‘religion’ of Human Factors… it’s an important part of many things but the key word here is ‘part’ – it is vital that we understand things as being more than the sum of their parts and that we consider things from a number of perspectives. So, here’s the question… how can we take in many different perspectives when we’re fundamentally not wired that way? To illustrate this, I have a bad back. I was working in the garden before Christmas and managed to ‘twang’ it during some heavy lifting. Yes, there’s a sense of irony there with me being a Human Factors/ergonomics specialist and understanding about lifting things correctly and having some knowledge of biomechanics – it just goes to show it can happen to anyone! At the time it didn’t seem too bad. It has happened before and usually after a few days it begins to recover. However, that was back in December and I still have the pain in my back. Since then I have been going over what I did, where the pain is at the moment, and why I am not recovering as quickly as before. I’ve been doing this each time my back sends a shot of pain to my brain. I was moving some logs, I twisted round, I felt the pain in my back. That is about the extent of my processing because I keep going round in circles – never quite getting to a solution. We’re now into February and it is clear that this time my back injury does not fit with my idea of how it mends itself and so I have had to start looking for other explanations. A couple of years ago my wife also had a bad back but her’s was much worse than mine. She had a bulging disc in her lower back causing extreme pain and sciatic issues. Could I have done something like that? Could I have a minor disc issue? Does it feel more like a nerve or muscular problem? I’ve also continued to be very active outside, I’ve cleared a lot of ground, pruned trees, shifted railway sleepers around the garden, sawn the sleepers to make raised beds and filled them with over 3 tonnes of soil. I’ve conveniently forgotten that this activity might have hampered my recovery, or perhaps has caused new or continued strain on my back. Put simply, my initial assumption about my back has slowly proven to be incorrect and I have had to look for other explanations for why it still aches. Another example comes from a common case I investigate for the court. Imagine you’re driving on a motorway. There is a car ahead of you in the outside lane, some way off in the distance. It looks to be behaving normally, it is pointing in the right direction and so you might reasonably assume it is moving. What happens if you then realise it has stopped and you only have moments to react? You could be caught unawares by this sudden realisation that the vehicle you thought was moving is actually a static object that you might collide with. What has happened here is that you made an assumption based on an expectation that the car would be moving (how many parked cars do we expect to see in the outside lane of a motorway?). Everything else you then processed sought to confirm this was the case (pointing in the right direction, tick, no brake lights, tick, no hazard lights, tick, no people standing by the vehicle, tick, no other vehicles stopped or signs of a collision, tick). None of those things that you’ve just mentally ticked off would give you any reason to think that the car is stationary. From a Human Factors perspective, the key point here is that you would not have started out actively looking for evidence that the car was stationary. We call this aspect of human decision-making, ‘confirmation bias’. Confirmation bias refers to a well-documented fallibility of decision-making where we make an initial judgement about something and then seek to confirm that judgement is correct before we go on to look for other explanations. But it is more serious than that. We “tend to seek (and therefore find) information that confirms the chosen hypothesis and to avoid information or tests whose outcome could disconfirm it” (Wickens, 1984). This means that we might ignore conflicting information in preference to that which fits with our idea of what is happening. When we are faced with an uncertain situation, we will try to make sense of it as best we can. We may not have a clear idea of what is actually happening and, if our initial assumption is incorrect (i.e. the evidence eventually illustrates that our interpretation was wrong), we then have to find another explanation for the situation and begin collecting new evidence to support that. So, why can’t we just try to process everything and understand things more clearly? Well, in very broad terms, those studying human performance have concluded that us poor humans have limited mental resources and that we are not able to do everything all at once. We would quickly become overwhelmed by the sheer amount of data we need to process so we have to find quick and easy ways to try and make sense of things. Through experience we develop normally useful shortcuts (we call them heuristics) in our reasoning and decision-making processes. Typically, we will process information based on our experience of similar situations that we use as a template (or ‘mental model’) for how things are likely to be. This forms the basis of much of what we then ‘expect to happen’ in the world around us. Psychologists are still arguing about whether we build up our understanding of the world from a ‘top-down’ or ‘bottom-up’ perspective. In broad terms, this means do we have a general idea of things to begin with, that we then backfill with information, or do we make sense of things by building up the blocks of our understanding? Perhaps the answer is both – in some situations we might jump to an overall idea about something (i.e. it fits the pattern of our previous experience) and in others we may need to piece together things in new ways (i.e. we may not have a coherent model stored in our brains from previous experience). A key factor in this kind of decision making is our reliance on prior expectations. Drivers do not expect vehicles to be stationary in the outside lane of a motorway and therefore may not process the information about a vehicle they see ahead of them as that kind of potential hazard. In his younger years, Martin conducted a very interesting piece of research to investigate why drivers might collide with highly visible police vehicles. The findings highlighted two things – some careful drivers failed to notice the police vehicle completely and, when the police vehicle was parked in the direction as the traffic, drivers assumed it to be moving. From these results a recommendation was made that emergency vehicles should park at an offset angle to the flow of the traffic so it is more obvious that they are not in a ‘normal’ orientation to the traffic. So how does this translate to conducting investigations? At a simple level, we should always be cautious of our initial ideas about why something happened. Or if anyone else voices a solid understanding right at the start, maybe we should take a bit of time to step-back and try to survey the landscape from the highest vantage point we can find. Incidents and issues we investigate are rarely caused by one thing. As already stated, it is vital that we understand things as being more than the sum of their parts and that we consider things from a number of perspectives. However, investigations often take reductionist approaches to simplify things. By seeking out discrete factors composed of only one or two parts (at most) it is easy to start with human error as the root cause. Any investigation is a journey into unchartered territory so don’t be afraid to take time to get your bearings; look around you, what do you see? Look at the map (or perhaps any checklists or procedures) and don’t be scared of asking for directions from the locals (i.e. people close to the incident who may have valuable and unique perspectives on the issues). All too often investigations start by making assumptions ‘to get things moving’ because we have limited resources or ‘to show progress is being made’. If that is the starting point – be careful. While there can be organisational pressures to ‘get started’ and to ‘find out’ what happened, it can be dangerous if we run off into the woods without leaving a trail of pebbles to get home again (don’t use breadcrumbs, the birds tend to eat them!). It is possible that initial ideas can trap us in cycles of confirmation bias, searching out the evidence that fits with each interpretation of events. At best, we may realise it is more complicated or our initial idea is incorrect and then require more time and resources to search out other explanations. At worst, we may not realise we’ve missed something important and could even set forth recommendations which do not really address the issue or stop it from happening again. To counter this, always try to involve multidisciplinary experts in investigations. They will be people who have domain knowledge (not just qualifications on paper). But, perhaps more importantly, always keep an open but inquiring and critical mind. Never assume anything until you have discounted everything else. Regardless of what may have happened, I always start an investigation with the words of Sherlock Holmes in my head … “when you have eliminated the impossible, whatever remains, however improbable, must be the truth”. If anything, we should seek out the most unrealistic explanations rather than the most obvious ones. We are less likely to consider the least obvious ones later on and the obvious will always remain in plain sight. Before I sign off, we’ve covered how we might misinterpret information we process, how people can fail to see even highly conspicuous police vehicles and how we are programmed to find easy and convenient ways to make sense of things. Hopefully understanding our decision making in complex investigations can help us be more critical of our thinking and more aware that sometimes we might make the wrong decision when we think it’s the right decision. Read the other blogs in this series Why investigate? Part 1 Why investigate? Part 2: Where do facts come from (mummy)? Who should investigate? Part 3 Human factors – the scientific study of man in her built environment. Part 4 When to investigate? Part 5. How or Why. Part 6 Why investigate? Part 7 – The questions and answers Why investigate? Part 8 – Why an ‘It’s an error trap conclusion’ is an error trap Why investigate? Part 10: Fatigue – Enter the Sandman Why investigate? Part 11: We have a situation Why investigate? Part 12: Ethics in research

ECRI's top 10 list of patient safety concerns: Staffing shortages. COVID-19 effects on healthcare workers’ mental health. Bias and racism in addressing patient safety. Vaccine coverage gaps and errors. Cognitive biases and diagnostic error. Nonventilator healthcare-associated pneumonia. Human factors in operationalizing telehealth. International supply chain disruptions. Products subject to emergency use authorisation. Telemetry monitoring.

Policy highlights • For universal health coverage, “leave no one behind” means that countries should prepare equitable and gender-responsive health systems that consider the interaction of gender with wider dimensions of inequality, such as wealth, ethnicity, education, geographic location and sociocultural factors and implement them within a human rights framework. • Countries must consider the health inequities within and across groups and geographic areas, and learn how gender norms, unequal power relations and discrimination based on sexual and gender orientation impede access to health services. National health plans should consider equity and gender-related barriers. The opening times, staff composition and location of health facilities should be considered from an equity perspective, and services should be age and culturally appropriate. • Multisectoral cooperation is essential for reducing health inequities since some factors influencing disease burdens and barriers to access lie outside the reach of the health sector. Multisectoral involvement and coordination should be integrated in national health plans. Engaging civil society organisations and the public in decision-making and feedback is essential. • An equity, gender and human rights perspective in developing social health protection schemes is needed to address the differential risks experienced by people across the life course and to assist people in avoiding or coping with the financial costs of treating illnesses. Social health protection schemes should consider the health care needs of marginalised groups and incorporate mechanisms to remove the access barriers they face. • Effective, equitable and cost-efficient services can be delivered only when based on evidence. Further research using mixed methods – and quantitative and qualitative data – is needed to understand the mechanisms behind gender and equity barriers, which can vary by setting and population group. • Indicators for monitoring progress towards universal health coverage should enable monitoring progress for particular groups. At a minimum, indicators should be dis-aggregated by sex and age. Further dis-aggregation by ethnicity, migration status, wealth, education and geographic location is essential to identify and tailor interventions to reach groups living in situations of greatest vulnerability.

In this blog, Steven questions: Are we reducing the human to ‘human error’? Are we reducing the human to a faulty information processing machine? Are we reducing the human to emotional aberrations? Are we reducing human involvement in socio-technical systems?

This paper from the British Medical Journal, describes specific examples of HFE-based interventions for patient safety. Studies show that HFE can be used in a variety of domains.

The second edition takes a more practical approach with coverage of methods, interventions and applications and a greater range of domains such as medication safety, surgery, anaesthesia, and infection prevention. New topics include: work schedules error recovery telemedicine workflow analysis simulation health information technology development and design patient safety management. Reflecting developments and advances in the five years since the first edition, the book explores medical technology and telemedicine and puts a special emphasis on the contributions of human factors and ergonomics to the improvement of patient safety and quality of care. In order to take patient safety to the next level, collaboration between human factors professionals and health care providers must occur. This book brings both groups closer to achieving that goal.