The NHS in England is no sloth when it comes to the publication of reports into patient safety and health quality. Publications appear from the NHS and other stakeholders, nationally and globally, on an almost weekly if not daily basis. There cannot be said to be a dearth of practical and helpful advice in these areas. The difficulty here is also that patient safety itself has become a global service industry with a myriad of stakeholders promoting differing and, in some instances, competing agendas. Which do nurses and doctors hold to be authoritative?
The wealth of material produced poses a serious practical burden for nurses, doctors and others who need to distil this information and to work out the importance of the report or study. This must be done in an increasingly busy and short-staffed NHS and in a COVID-19 care environment with all the challenges that brings.
Even before the pandemic the Care Quality Commission (CQC) highlighted problems with the rising tide of patient safety and health quality reports:
‘Staff are struggling to cope with large volumes of safety guidance, they have little time and space to implement guidance effectively, and the systems and processes around them are not always supportive. Where staff are trying to implement guidance, they are often doing this in addition to a demanding and busy role. This makes it difficult to give this work the time it requires.’
Compounding this difficulty, the patient safety regulatory landscape is also both confusing and complex:
‘… with no clear understanding of how it is organised and who is responsible for what. This makes it difficult for trusts to prioritise what needs to be done and when.’
We rightly have high expectations of nursing and medical NHS staff, and most of the time our confidence is well placed and well founded. Nurses and doctors, as any other professional, are expected legally, under common law tort principles of negligence, and in line with their professional codes of conduct, to keep reasonably up to date. This places them between a rock and a hard place when it comes to patient safety and health quality education and training, with all these competing demands on them. With that caveat in mind, several important patient safety and health quality reports have been published recently.
Reform of the clinical negligence system
The Parliamentary Health and Social Care Committee, chaired by former Health and Social Care Secretary of State Jeremy Hunt, has launched an inquiry into the clinical negligence litigation system in England, which closed for submissions on 20 October 2021. The call for evidence stated:
‘The Committee has launched a new inquiry to examine the case for the reform of NHS litigation against a background of a significant increase in costs, and concerns that the clinical negligence process fails to do enough to encourage lessons being learnt which promote future patient safety. Figures show that in 2020/21, £2.26bn was spent from the NHS budget to settle claims and pay legal costs arising from clinical negligence claims.’
Health and Social Care Committee, 2021
The government is also currently looking into reforming the clinical negligence system. According to Hyde (2021), ‘the government has reiterated its commitment to reform the clinical negligence system but remained tight-lipped about the exact nature of its wishlist’.
Accountability, responsibility, deterrence, and education
There will soon be lots more discussion, activity and reports about reforming our clinical negligence system. The debate promises to be a healthy and vigorous one as the issues are complex.
There appears to be a tendency to fall back on the panacea of a no-fault-based system of liability, which would be, in my opinion, the wrong way for the government to go. The government and reformers need, as I have said previously in this column, to reflect more on the underpinning concepts of our adversarial tort-based system of compensation. Why should nursing or medical negligence be treated as a special case, regarded differently compared with the negligence of architects, veterinary surgeons, engineers and so on?
Also, our present tort system is, in my view, a useful mechanism of accountability and deterrence. The law exposes personal and system wrongdoing and holds people to account for the proven wrong that they have done. They need to take ownership and responsibility for their negligence. Yes, learning should proceed from the negligence, this is where an effective patient safety culture comes into play and any reforms made to the clinical negligence system also need to be considered within the context of the national NHS Patient Safety Strategy and syllabus (NHS England/NHS Improvement, 2019). Better learning from avoidable error and a safer NHS are expected outcomes of these measures.
Farrell and Rhiannon (2021) discussed no-fault compensation and reform of the clinical negligence system, drawing on examples from around the globe:
‘As highlighted in evidence given to the Committee about the Swedish approach, there are clearly enhanced opportunities for learning from mistakes under no-fault schemes, although whether this is fully realised in practice is open to debate. As highlighted in [the] New Zealand no-fault scheme, striking the “right balance in the trade-off between accountability and learning” has proved difficult.’
National survey of urgent and emergency care
Publications from the CQC are always to be welcomed because they provide insights into patient safety in the NHS in England. They are also very well written, easily understandable, and they get to the point. The CQC report on a national survey of urgent and emergency care follows this pattern (CQC, 2021). This is an independent data analysis that researches experiences of using type 1 and type 3 urgent and emergency care services. Type 1 is defined in the report as including accident and emergency (A&E) departments, also known as casualty, or emergency departments.
‘Type 3 services previously known as either urgent care centres, urgent treatment centres and minor injury units should now be known as urgent treatment centres.’
Both good and bad patient safety and health quality findings are revealed. Unfortunately, as so often is the case with these types of reports, poor findings often seem to eclipse the good ones. It is important to study and read these reports in their entirety—to see which are the good or bad findings and to attempt to balance these in terms of trends and outcomes. The report begins with the upbeat message that ‘most people surveyed continue to be positive about many important aspects of their urgent and emergency care’ (CQC, 2021: 3). This is clearly a leading good finding and there are other positive findings in the report, which include, for type 1 departments:
‘More than three quarters (79%) said doctors and nurses “definitely” listened to them and that they “definitely” had confidence and trust in the doctors and nurses (77% compared to 75% in 2016 and 76% in 2018).’
Other positive results included:
‘Respondents were also asked if a doctor or nurse (Type 1 services), or health professional for Type 3 services, explained their condition and treatment in a way they could understand. For Type 1 services, over two-thirds (69%) said “completely” to this, 24% said “to some extent” and 7% said “no”. These results are consistent with previous years. For Type 3 services, just under four-fifths (79%) of respondents said ‘completely’, 17% said “to some extent” and 4% said “no”.’
There are welcome findings in the report covering areas such as patients having trust and confidence in the staff treating them, the cleanliness of hospital rooms or wards, or patients receiving answers they could understand when asking nurses and doctors about their care.
On the other hand, there are some negatives, summarised as:
‘Survey findings were less positive, however, for areas of care including people's perceptions of pain management, emotional support, the availability of staff when they felt they needed attention or help, their involvement in care, and—during discharge—information about medication side effects, symptoms to watch out for and caring for their condition at home.’
Conclusion
It is an understatement to say that there is a lot going on in patient safety and health quality today. There has been a lot going on for a long time, over 20 years or more, by my reckoning. Progress is being made in developing a patient safety culture, but the pace needs to quicken and to become more ingrained within the fabric of the NHS.
Yes, there is a lot of good patient safety and health quality information out there for nurses and doctors to read, but we must always guard against them being swamped. Hopefully, over time, when the NHS patient safety strategy begins to kick in more, education and training will improve in this area. I fear, however, that the swelling tide of published information will not abate as it is such an important aspect of our daily lives and it is here to stay as a trend. Safety and health are fundamental to us all.
In terms of the reforms to our clinical negligence system we will have to wait and see. Hopefully, the baby will not be thrown out with the bath water and those in government will see the importance of the current tort system being an important mechanism of personal accountability for wrongs suffered.
I also hope that the deterrence and education aspects will be considered. There are significant academic articles examining the aims and effects of the tort system and some major reports. The government will need to reflectively and conceptually balance the pros and cons here and not simply make a knee-jerk decision to opt for a no fault-based system. There is a lot to think about.