Patient safety is a multifaceted concept and involves many academic disciplines and fields of expertise. There will always be a multitude of approaches to solving problems and dealing with important questions. Capturing these views, analysing them and seeking a consensus to drive forward change is inevitably going to be a challenge.
Patient safety policy development in the NHS historically has been marked by over-regulation, duplication and overlap of organisational functions. It has been hard to see where the system is going and its aims and objectives—it has been over-engineered for many years and there have been many competing agendas, which impeded progress.
Matters have improved significantly over recent years in terms of conceptual underpinning, and the aims and objectives are now much clearer. The NHS Patient Safety Strategy (NHS England and NHS Improvement, 2019) states a clear direction for patient safety policy travel in the NHS. However, policy development in some areas can still be seen to be less than satisfactory, such as in clinical negligence and patient safety where a siloed approach to policy development has been evident. The National Audit Office (NAO) (2017) argued that the government lacked a policy-based, coherent cross-government strategy to support measures to tackle the rising cost of clinical negligence, and that a ‘stronger and more integrated approach’ was needed. The latest annual report from NHS Resolution (2020) shows that this work is ongoing, and something the body is contributing to.
The pace of change
A key issue with policy development and culture change is always going to be the pace of change. I have said many times in my columns that this has been too slow and that systemic problems perpetuate. There have been some positives but the culture is still too defensive when errors are made. There is also, sadly, a blame culture prevalent in many areas, which inhibits reporting of errors.
‘Culture change cannot be mandated by strategy, but its role in determining safety cannot be ignored. ‘Just cultures’ in the NHS are too often thwarted by fear and blame. A consistent message in the consultation responses was that fear is too prevalent across NHS staff, particularly in relation to involvement in patient safety incidents.’
There is a clear recognition here that change cannot happen overnight and that there are major problems to overcome. The pace of change is to be a graduated one. It sets out how the NHS will continuously improve patient safety over the next five to ten years. The relative nature of safety is also recognised:
‘Our vision is for the NHS to continuously improve patient safety. Safety is not an absolute concept and has neither a single objective measure nor a defined end point. Rather, it responds to patient needs and system priorities.’
The inevitability of error
In discussing the concept of patient safety and its relative meaning, it is important to debate and try to rationalise the ‘inevitability of error’ argument. The argument is that mistakes in health care do inevitably happen—they are the consequences of the complex nature of healthcare treatment. Nursing and medicine depend on people and nobody is infallible, we all make mistakes. We could, controversially, add to the argument mix that adverse health events and errors are the cost of doing business.
The World Health Organization (WHO) discusses the emergence of patient safety thinking in a recently published first draft of the Global Patient Safety Action Plan 2021-2030 (WHO, 2020). In the period immediately after the Second World War, the idea of safety was limited to traditional hazards such as fire, equipment failure, patient falls, and the risks of infection:
‘There was also a belief that well-trained staff—doctors and nurses—would always behave carefully and conscientiously and seek to avoid or minimize what were inevitable “complications” of care.’
Historically unexpected complications have long occurred in health care, such as the transfusion of the wrong blood group, or surgery on the wrong side of the body.
‘For most of the 20th century, whilst such occurrences would occasionally hit the headlines, cause momentary public concern, and be a preoccupation of medical litigation attorneys, they aroused little interest amongst doctors and health care leaders. Why? Essentially, they were seen as the inevitable cost of doing business in the pressurized, fast-moving environment of modern health care that was saving lives and successfully treating many more diseases. Mistakes happen, it was argued.’
In recent times there has been a paradigm shift in thinking about safety in health care:
‘… The need to see human error as something to be mitigated and prevented rather than eliminated entirely …’
It is important to recognise that we cannot totally obliterate error in health care, otherwise we risk setting irrational objectives. For example, we can work to minimise the occurrence of pressure ulcers but practically could not set an objective to eliminate them completely. We can have total elimination in our sights as a goal but in real, practical terms they can happen despite the very best efforts. WHO (2020) has a framework for action, with seven strategic objectives including:
‘(1) Make zero avoidable harm to patients a state of mind and a rule of engagement in the planning and delivery of health care everywhere.’
This is an excellent mindset to adopt, one that effectively deals with the inevitability of harm argument and places it in a reasoned context. This point is also recognised in the NHS Patient Safety Strategy:
‘It is human to make mistakes so we—the NHS—need to continuously reduce the potential for error by learning and acting when things go wrong.’
The best we can do is to try to properly manage the risk of harm.
Identifying safety specialists
A key plank of the NHS patient safety strategy is for a patient safety specialist to be introduced in every NHS organisation in England. NHS England and NHS Improvement (2020) has recently published a role specification. Each NHS trust, foundation trust and clinical commissioning group will identify one or more individuals as their patient safety specialist(s) and notify the national patient safety team who these individuals are by the end of November 2020:
‘Patient safety specialists will be the lead patient safety experts in healthcare organisations, working full time on patient safety. They will be ‘captains of the team’ and provide dynamic, senior leadership, visibility and expert support to the patient safety work in their organisations. They will support the development of a patient safety culture and safety systems and have sufficient seniority to engage directly with their executive team. They will work in networks to share good practice and learn from each other.’
Patient safety specialists have the potential to make a real and positive contribution through their role, which gives a valuable and direct NHS institutional focus to developing a safety culture.
Safety culture and COVID-19
The challenges faced by the NHS in dealing with COVID-19 have indelibly affected how patient safety and risk is assessed. NHS staff continue to work in extremely challenging circumstances and working practices have had to change to deal with the pandemic. A key issue is whether the NHS has become more risk tolerant because of COVID-19. If it has, then to what extent? The Healthcare Safety Investigation Branch (HSIB) has recently produced a report on COVID-19 transmission in hospitals, which states on risk:
‘The response to COVID-19 required the reference trusts to increase their tolerance for organisational risk to ensure rapid response to emerging COVID-19 concerns.’
Findings in the report include:
‘It is recommended that NHS England and NHS Improvement investigates and evaluates the risks associated with the potential impact of staff fatigue and emotional distress on nosocomial transmission of COVID-19.’
The question of risk tolerance will have to be judged on future events—it is much too early to say. COVID-19 has forced some positive changes in care such as flexibility and adaptability in some areas of service provision, but there have also been some negatives.
The fourth COVID-19 Insight report, from the Care Quality Commission (CQC) focuses on the good and bad of infection prevention and control in different health and care settings. One of the positive findings points to trusts uniting with local systems to ensure a coordinated response to the pandemic, with ‘joint working and consistent messaging’ (CQC, 2020: 5).
Conclusion
The concept of patient safety is a relative one. Change has been slow but positive recent steps have been taken to address systemic failings in the patient safety system. The concept of risk is an important one and can also be seen as a relative concept. NHS responses to COVID-19 show how this has been managed in dealing with the pandemic.