 I have to say I'm not used to standing avation, so thank you very much indeed, that's really appreciated. And now it gives me great pleasure to invite Liam Donelson on to the stage so that we can have some questions and Liam can answer about why don't you go and sit there and ask it here and then we can answer some questions. So who wants to go first with the questions. Yes, Umesh. Why don't you... Oh here we are. First and foremost, thank you very much Jeremy, for leaders it doesn't give up. Leadership is not easy, followership is very easy and I've been medical diet for 13 years and let me tell you, one day I'll be writing my book, it has not been easy at all. If you want to improve patient safety, you must have leaders very near to the patient care. That is how vegan was transformed because I've given an opinion on 23 children who have died, not in one should have died. If their parents' pain drives me to do what I am doing, the cover-up lies were shocking. Many junior doctors were referred to GMC regulator by the leaders of the organization and I have 400 doctors have contacted me, only 40% have been treated correctly. 27 doctors have committed suicide, 84 have died within the year of referral to GMC. That's a human tragedy I have seen. As you rightly said, the second victim. What I am asking is, how are you going to change this culture? How are we going to procure each and every department that are very good leaders who genuinely care for patients, put the patient at the heart of everything they do? Why don't I ask Liam to start on that one because Liam really started the campaign here in the UK and then I'll come in. Two points really. First of all, several people have mentioned leadership and it is absolutely vital but perhaps we spent less time talking about the nature of that leadership. It requires, as we heard, the leader keeping the staff's focus on patient safety but it also, I think, means engaging the curiosity and I talked to a lot of doctors around the world about safety and incidents and the majority are not particularly interested in it. That's fascinating because these incidents and these accidents that occur are classic detective stories and doctors in their clinical reasoning and diagnosis love detective stories. I've noticed in some of the best hospitals that I've visited around the world where the clinicians are engaged. They are engaged in leading the process of investigating and distilling the learning and action it. In too many places, it's the non-medical managers that lead it and the doctors just regard it as a chore to fill out the incident form. I think that's the first thing. The second point, on the second victim, very, very important. If you look at one of the examples I'll be giving later on of the rare but catastrophic error arising from injecting vincristine into the spinal fluid instead into a vein. There have probably been 100 cases reported in the world over the years. Some of the doctors involved have been quietly counseled and reeducated and allowed to return to their practice. Others have ended up in jail. Some have committed suicide. So the variability in approach to genuine error, as the Secretary of State said, in cases of willful misconduct, people do have to be held to account. And the media sometimes don't understand that difference. We're not saying that no one will ever be held personally to account, but we are saying that in the majority of the cases the error has been provoked by a weak system. And it's the system that we need to hold to account. I just had a very brief point. It seems an enormous task. But if you look at other industries, and I give you another example, the nuclear industry, which is also absolutely focused on making sure they have a learning culture because there is no worse catastrophe than a nuclear power plant having a safety breach. They have international cooperation where they send international teams of inspectors round on safety measures. And this means that American nuclear power plants are inspected by Russian inspectors and Russian plants by American inspectors. In fact, I think North Korea is the only country that doesn't participate in that program. But if you can get Russia and the United States to be cooperating on nuclear safety, then I think that shows it can be done if the will is there. We've probably got time for a couple more questions. Yes, sir. We'll come to you next. I just want to point about culture as the largest barrier to change. To have leaders in place is great. Leaders are effective often by their own personal trades in moving situations. But in societies like, as you can tell, I'm from Detroit for my accent. So in societies like United States where you have this entropic healthcare system with no clear message, in England they're lucky to have someone like you, Secretary Hunt. But in cultures where they have haphazard entropic environments, it's not so easy to get a singular message pushing towards change in a uni-directional fashion. So I think culture is a huge barrier to producing some of these changes in many societies. I can see there's a question just in front of you and a question to the left. I might take them together if that's all right, and then we'll come to the back before we stop. Secretary Hunt, you highlighted the importance of leadership, which I think is critical. But also I thought maybe you could touch on the importance of working from the bottom up as well and at the micro-system level of having that local staff own safety as well, and then the importance of psychological safety to what we're trying to accomplish. Thank you. Okay, and then just one more at the front here, and then we'll take some from the back before we stop. Thank you. Yeah, Kai Tsagoroski from Frankfurt. I worked in the NHS for over eight years and over 20 years in the German system. I admire your plans, but I'm asking myself you are trying to fix something which could be fixed earlier. We're doing too many interventions which are unnecessary. And the more we do, the higher is the risk that we do something wrong. And I think we should. The DIG system is a good example for that. The more you do, the more money you earn, and if we could reduce the unnecessary interventions, we have less problems with other things. Thank you. Okay, well three good questions. Maybe I'll just ask them and ask Liam for his views, but just taking them in reverse order. I think there is a real problem with payment systems, and we call it payment by results. We call it fee for service. We kind of introduced that market system here even though we have an NHS. And we are moving away from that because of the wrong incentives it gives. And we're moving to a system of having single budgets for population areas precisely to make sure that we give advice that is in the patient's interest and not in the institution's interest. But I agree with you that is a big problem. In terms of getting behaviour changed from the ground up, I think that is the big challenge. Because this can't be changed by what people at the top say on its own. When I talk in hospitals, I always say that I think the biggest influencer on anyone's behaviour is the behaviour of their line manager. Your immediate boss, that's the person who gives you all the signals. So if you really believe in patient safety, the single biggest thing you can do to change things from the bottom up is be open with your own staff about your own mistakes. And then that creates an atmosphere and an example which empowers people to speak up. And then the gentleman from Detroit with a very British accent, I think all healthcare systems have their strengths and their weaknesses. And we would be here for a very long time if we were going to be debating that particular issue. But I would say that I would not want the US healthcare system in this country and I'm proud of our NHS. But you do have innovation in the US which is truly outstanding and which we need to be open to. And I think that in particular you're a long way ahead of us in terms of use of IT systems in hospitals which can have a really big impact on safety. And you have some incredible examples like Virginia Mason, Intermountain, Kaiser Permanente where some really groundbreaking work on safety is happening that we absolutely want to learn from. Before I come to you, Liam, I've been asked to wrap up but I did say there was one lady at the back so we'll take that question and then I'll come to you before we wrap up. Thank you, Secretary of State for taking my question. I'm a patient representative so I was determined to say something. I'm the mother of a child who died as a result of a serious incident and I also sit on the Learning from Deaths program so I know about some of the good work that you're doing. But what I want to say to you is that there are some of us who have stories who don't get into these types of rooms. There are people like me who don't seem to represent the types of stories that people want to hear. My story is not about a simple human error. I'm a woman from a minority ethnic background. I believe that there was discrimination in my case and I believe that those issues were covered up and I believe that we don't talk about those issues. Today I've published an article, I'm proud of it in the health service journal, which is talking about why some groups who have the worst health outcomes are least likely to be involved in safety and quality improvement. And often those outcomes come about as a result of issues like discrimination. Discussions like that are invisible in these types of conferences and of course they affect staff which was the issue that Omesh raised. So Secretary of State, I know you're doing some good work. I know that you've met with a lot of families. I still would like to meet with you myself and I hope we can do that at some point. But I'd like us to be able to open up a wider debate about some of the issues I'm raising. Thank you. Well thank you for that very powerful intervention and of course I'd be delighted to meet you and I would just say that 40% of our staff in the NHS, 40% are from an ethnic minority. And so we absolutely must make sure that there is no discrimination and that that openness is something that we support everyone, whatever their background in. And of course we are a large organisation. Unfortunately these things sometimes do happen but they must never be tolerated. So please come and see me and I'm happy to talk about it. I just want to ask Liam if he wants to add anything before we wrap up. Well I could say the question on culture. I could say a lot about that but we are short of time. And so I'd just say one thing. I used to walk past on my way to St Mary's Hospital a few years ago Paddington Station and there was a construction site there and there was a huge banner there that said all harm is avoidable. And I've spoken to many CEOs in the UK hospital system and asked them would they put a banner like that up outside their hospital and almost all of them had said well that would be sticking our neck out a little bit too far. So in the spirit of the Oscar nominated movie Three Billboards I think we should be encouraging hospitals to say what they stand for. Because the very first thing about culture is you need to let everybody know what you stand for. And if you're prepared to put zero harm or all harm is avoidable upon a big banner then I think the culture is unambiguous and it's where we want it to be. We're going to break for coffee now but please come back promptly in I think is it ten minutes in ten minutes. We have an absolute treat with the director general of the World Health Organization and I just want to make this point about what we hear from the director general. We have discussions about patient safety that are very focused on the developed world and on hospital care. But what Dr Tedros has championed is that agenda in the developing world and the role of universal health coverage as being critical the role of primary care the role of rural clinics. And he has very particular insights into that it's a massive privilege to have him. So thank you for your fantastic work and we look forward to a fantastic presentation from the director general. Thank you very much.