There are several apparently intractable patient safety issues that currently plague the NHS and have done so for decades. These issues strike at the core of NHS care delivery. There is a patent failure of some nurses, doctors and other health carers to properly learn from past adverse healthcare events and to change practices. The NHS has a defensive nature when it comes to responding to complaints, claims of harm and patient safety error reporting. There is a lack of a comprehensive NHS patient safety culture and nurses and doctors fail to put the patient first.
Ensuring that the patient's interests and wellbeing are protected should be the guiding beacon for everything that is done in health care.
Patient safety crises
Current and past patient safety crises show that these issues have not been sufficiently addressed in the past and are constant themes that require urgent attention in the NHS today.
An almost stoic refusal by sections of the NHS to engage with these issues can be seen in many reports. Care Quality Commission (CQC) inspection reports often lament the lesson learning failures in trusts, with trusts failing to advance patients' rights and interests, along with predominantly defensive cultures. Major reports into NHS patient safety crises such as at Mid Staffordshire (Francis, 2013), Morecambe Bay (Kirkup, 2015), and now Shrewsbury and Telford (Ockenden, 2022) all tell largely the same story.
Groundhog day
Reading these reports gives rise to the inescapable feeling that the NHS is well and truly stuck in the same position over patient safety failures, and has been so for over two decades. It seemingly refuses to move on, despite the very best patient safety development efforts of successive governments and of the present government. And despite the best efforts of the regulators such as the CQC and NHS England/NHS Improvement and organisations such as NHS Resolution.
Over the years the NHS has built up an impressive patient safety infrastructure. The problem is that, despite this, and the best efforts of those mentioned above, key patient safety messages are not sufficiently permeating down to healthcare staff on the ground. Everything seems too centralised and top heavy and is missing the input of staff working at the patient-care interface.
That this is so can be borne out by the many published reports over the years and by two recent reports, the NHS Staff Survey (2022) and Ockenden (2022). The NHS seems to be stuck in a patient safety groundhog day.
Revisiting a report from 2000
Before reading these new reports, it is worth firstly reflecting on the seminal NHS patient safety publication, An Organisation with a Memory, published by the Department of Health in 2000, over two decades ago. It is important to ask whether the patient themes discussed in it have been fully addressed in today's NHS. Are the sentiments expressed in this report about NHS patient safety failures still largely the same today? I would argue that yes, essentially, they are.
DH (2000) discussed active learning.
‘The NHS does not, in our experience, learn effectively and actively from failures. Too often, valid lessons are drawn from adverse events but their implementation throughout the NHS is very patchy. Active learning is mostly confined to the individual organisation in which an adverse event occurs.’
Department of Health, 2000: 77
Several key patient safety system problems were identified, including (DH, 2000: 74-77):
- There are different, and potentially conflicting, views on the purpose of adverse event reporting systems
- There is no systematic mechanism for sharing more widely the learning from individual local adverse event investigations
- There is little basic research into the nature, causes and prevention of adverse events in health care
- There is too often a ‘blame culture’.
This DH report is over two decades old and yet is as relevant today as it was when first published.
Fast forward to 2018
Eighteen years later there was another seminal patient safety report, Opening the Door to Change by the CQC (2018), which stated:
‘There is no clear system for staff to learn from each other at a national level. Local reporting systems are often poor quality and do not support staff well. There are lessons that can be learned from other industries with simpler and more transparent reporting systems, backed up by a culture that drives good reporting.’
Care Quality Commission, 2018: 23
CQC (2018) also reported that, to improve reporting, there needs to be greater clarity in what should be reported, more feedback on reported incidents, including open and honest conversations about what happened, and more effective systems for reporting Never Events (CQC, 2018: 28).
To get a true sense of NHS patient safety progress over the years it is worth comparing DH (2000) and CQC (2018). Many common error themes and problems will be seen despite the reports being 18 years apart.
The NHS Staff Survey 2021
The annual NHS staff surveys provide a veritable treasure trove of key information about patient safety issues in a real-time context. Key patient safety headlines are reported in the 2021 report (CQC and Survey Coordination Centre, 2022: 17, 27):
- 75.6% of staff said that the care of patienets/service users is their organisation's top priority (q21a)
- 67.8% are happy with the standard of care provided by their organisation (q21d)
- 72.0% agree that their organisation acts on concerns raised by patients/services users (q21b) (74.9% in 2020).
In terms of staff speaking up about clinical safety, the report states that 74.9% of staff would feel secure raising concerns about unsafe clinical practice (q17a). This has improved from 72.5% in 2020. It also stated that 59.4% were confident that their organisation would address their concerns (q17b).
These are not high figures and are not in the top 80% or 90%. In terms of clinical safety, it is worrying that less than 60% of staff felt confident that their organisation would address their clinical safety concerns.
The Ockenden report
The Ockenden report (2022) into baby and maternal deaths and injuries has shocked the nation. The report was commissioned by the former health secretary, Jeremy Hunt. He is quoted as saying that the NHS has to get rid of its blame culture so that people could speak openly (BBC News, 2022). He added:
‘Even in this inquiry, doctors, midwives, nurses at Shrewsbury and Telford said they were silenced, they were told that there would be professional consequences if they co-operated with the inquiry.’
Comparing Kirkup and Ockenden
The Ockenden (2022) report is a distressing and deeply saddening read. It shows the NHS at its worst. There are echoes of past patient safety failings and scandals running throughout the report. It shows the patent failure of some staff and trusts to learn the well-publicised patient safety errors of the past.
The Morecambe Bay report (Kirkup, 2015) has alarming similarities to Ockenden (2022) and once again raises the fundamental question of why the NHS does not learn from the past.
It is a useful patient safety educational and training exercise to compare the patient safety themes, errors and the recommendations of Kirkup's and Ockenden's reports, side by side.
The findings and recommendations in both reports can well apply to all clinical specialties and are not solely related to midwives and obstetricians. Failings concern generic patient safety issues such as communication, leadership, professional conduct, interdisciplinary team working, staff updating, competence levels, candour, patient autonomy, rights and respect, regulatory systems, staff resources and so on. A myriad of issues relevant to nurses and doctors in all specialties are raised.
The Kirkup report (2015) begins with these salutary words:
‘The result was avoidable harm to mothers and babies, including tragic and unnecessary deaths. What followed was a pattern of failure to recognise the nature and severity of the problem, with, in some cases, denial that any problem existed, and a series of missed opportunities to intervene that involved almost every level of the NHS.’
The Ockenden report begins in a similar way.
‘However, this final report … is about an NHS maternity service that failed. It failed to investigate, failed to learn and failed to improve and therefore often failed to safeguard mothers and their babies at one of the most important times in their lives.’
The executive summary of the Ockenden report contains key thematic findings:
- Patterns of repeated poor care
- Failure in governance and leadership.
The report discusses learning from adverse outcomes and states that only 39 incident reports concerning obstetric anaesthesia were submitted in the Trust between 2008 and 2021:
‘The Trust must consider whether such a low reporting rate indicates staff acceptance of poor practice and complications, or a lack of faith that reporting can effect change.
In terms of the relationship between health staff and patients, the report states:
‘The review team noted that frequently the women themselves were blamed or held responsible for the adverse outcomes, without identifying underlying and obvious failings in care. A husband recalled how in 2011 his deceased wife was blamed when he was told: “[it was] difficult for the midwives to listen to baby's heart beat due to her size”.’
Ockenden (2022) contains valuable patient safety educational and training material. Behind the report, however, lies tragedy, sadness, and critical patient safety failings. Everybody in the NHS can learn from this report.
Conclusion
Sadly, history does not serve the NHS well when it comes to learning from the patient safety errors of the past. More than two decades on from An Organisation with a Memory (DH, 2000) we still have many of the same problems in NHS patient safety. This causes me to ask how much progress towards developing a patient safety culture have we made in over two decades of trying?
Francis (2013), Kirkup (2015), CQC (2018) and Ockenden (2022) are major markers in our lack of sustained patient safety system culture development progress. In fairness, we have made some major NHS patient safety system improvements over the years, but key patient safety messages are still not properly permeating down to staff at the workface.
The NHS must up its game and address the key patient safety failings discussed in this column. We all need to escape the feeling of the NHS being trapped in a patient safety groundhog day.