T he NHS turned 75 years old on 5 July 2023 and there was a lot to celebrate. The NHS, rightly, is a greatly prized institution. Its 75th birthday caused me to reflect on its essential uniqueness within the context of patient safety – whether this uniqueness has had positive or negative impacts on efforts to develop a patient safety culture. On reflection, however, this is probably an impossible question to answer. There are so many factors and variables to consider and the question may be too general. In determining what is meant by ‘uniqueness’, this can be taken from facts about the NHS and its structure. We have a universal healthcare system, free for all.
‘Treating over a million people a day in England, the NHS touches all of our lives. When it was founded in 1948, the NHS was the first universal health system to be available to all, free at the point of delivery. Today, nine in 10 people agree that healthcare should be free of charge, more than four in five agree that care should be available to everyone, and that the NHS makes them most proud to be British.’
Snapshots of the NHS
The King's Fund (2023) highlighted another unique feature of the NHS. The NHS is one of the world's largest employers with around 1.26 million full-time equivalent staff in England, as of November 2022.
It is also a very busy system where there is an infinite demand for finite resources. The King's Fund (2023) gives some indication of what an average day in the NHS might look like, bearing in mind that daily activity is very fluid and affected by various factors. It would include more than 1.2 million people attending a GP appointment, nearly 260 000 people having an outpatient appointment and more than 44 000 people would attend a major emergency department.
Other statistics from the House of Commons Library (Baker, 2023) give more context on NHS care and activity. The report is a rather depressing read, as it clearly shows the challenges that the NHS must currently meet, including staffing problems, waiting lists and other issues:
‘The number of people on a waiting list for hospital treatment rose to a record of 7.2 million in January 2023. The waiting list rose consistently between 2012 and 2019 and has risen more quickly since early 2021. The 18-week treatment target has not been met since 2016.’
In terms of staffing the report stated that NHS staff numbers have increased, with 21% more doctors and 16% more nurses than 5 years ago but the NHS vacancy rate has risen from 8.3% to 8.9% over the past year.
Anandaciva (2023) for The King's Fund shows how the NHS compares with the healthcare systems in other countries and both positive and negative findings are highlighted. The report found that the UK healthcare system has:
‘… fewer key resources than its peers. It performs relatively well on some measures of efficiency but waiting times for common procedures were ‘middle-of-the-pack’ before the Covid-19 pandemic and have deteriorated sharply since … ‘The UK performs well on protecting people from some of the financial costs of ill health, but lags behind its peers on important health care outcomes, including life expectancy and deaths.’
The context of NHS care
These are all useful reports giving essential context for our NHS system of care and the challenges it faces. We need to take all these unique features of the NHS into account when discussing NHS patient safety culture development and practices as they will all need to be engaged with and negotiated.
In terms of the NHS care-delivery model, it is heavily centralised in terms of policy making, resource allocation, command and control, regulatory and governance structures. There is a very large workforce to manage, with centrally set policies that must permeate down to it. There is a politically set, largely centralised NHS budget. Integrated care systems (ICSs) have a localised role in budget management. The income of healthcare providers comes essentially from one source.
There are long waiting lists, and the service is very busy, which will impact on the time available for the individual nurse or doctor to reflect on matters in terms of updating, patient safety initiatives and so on. The NHS is the main national healthcare provider. Although there are private healthcare facilities, the main venue for many people will still be the local NHS hospital
Impact on patient safety culture development
This all has an impact on patient safety culture development. Staff work experiences can be largely in the NHS and the prevailing cultural norms of this go with the employee when they change employment to another NHS provider. There can be a set way of doing things, which is not always refreshed
Although we must all recognise the unique features of the NHS, that is the health service we have. We need to be realistic and work with it. The NHS care-delivery model is unlikely to change much – I would argue mainly for political reasons. There can be some tinkering around the edges but wholesale root-and-branch reform to a different model would be viewed as too politically risky for any political party.
The NHS does face major structural problems and these need to be dealt with effectively. However, they should not be seen as an excuse for poor and unsafe care standards. NHS uniqueness cannot be seen as a ‘get out of jail card’ for patient safety and care quality.
The end solution, in terms of developing a proper and effective NHS patient safety culture, might be seen as being a centralised political one - given the general nature of NHS resource allocation and the way health regulatory and governance strategies are developed. This is a narrow and unsatisfactory way of looking at matters.
Patient safety is not all about money and staff being told to practise safely by cascading down sets of centrally produced patient safety protocols and care standards. In relation to NHS patient safety culture development and health quality, it must be recognised that there is a limit to what centralised government and local NHS trusts can do given the scale and nature of operation of the NHS. Nurses and doctors at the work face must also engage with their own professional accountabilities and responsibilities to provide safe care.
Professional accountability and responsibility
As professionals, nurses and doctors need to keep up to date with changes in their professional practice area. They must practise safely and reflectively. All professionals in any discipline have this duty; it is central to being a member of a profession.
When discussing the professional accountabilities and responsibilities of individual nurses and doctors various factors can come into play. These include how they see their roles as professionals, their perception of the duty to update, keep informed about developments, how they feel they should communicate with colleagues, patients, showing empathy, compassion and so on.
It would seem relatively easy under the focused, centralised, command, control model of healthcare regulation and governance we have for the NHS for the role of the individual nurse or doctor in patient safety practice to get lost. In the professional patient safety literature, there seems to be a predominant focus on systems approaches – on how errors can be traced back to the system, that we practise in teams, a reduction of blame culture. Individual professional accountability for error appears to have been kicked out of touch when some patient safety policies and practices are discussed. The NHS Patient Safety Strategy is underpinned by the ‘systems’ approach:
‘Healthcare staff operate in complex systems, with many factors influencing the likelihood of error. These factors include medical device design, volume of tasks, clarity of guidelines and policies, and behaviour of others. A ‘systems’ approach to error considers all relevant factors and means our pursuit of safety focuses on strategies that maximise the frequency of things going right.’
NHS England/NHS Improvement, 2019: 8
Systems approaches are valuable in relation to NHS patient safety culture development, but I would argue, given the number of patient safety crises that we have had and continue to have, that the focus may have shifted too much to the systems approach. There also needs to be a strong focus on the professional accountabilities and responsibilities of individual health professionals themselves.
The system can be at fault, and this must be recognised. The individual responsibility and accountability must also be fully factored in and lessons learned and shared.
Poor professionalism was a key failing identified in the Kirkup (2022) report into maternity and neonatal services in East Kent. This report showed several failures including teamwork, compassion, listening, professionalism:
‘Professionalism means putting the needs of mothers and babies first, not the needs of staff. It means not being disrespectful and not disparaging other staff in front of women, who lose confidence in services as a result and may make poorly informed decisions about their care. It means not blaming women when something has gone wrong, and it means making decisions on who is best placed to care for an individual based on their clinical need, not on who belongs to which staff clique … We found clear and repeated failures to uphold these principles.’
Given the essential nature of the NHS, much more attention should be given in patient safety policy development and practice to the professional accountabilities and responsibilities of the individual nurse or doctor.
Conclusion
The NHS is a huge unique healthcare system, and I would argue is a great success. It is globally admired and rightly so. At the same time, it also faces acute resource problems, long waiting lists, acute staff shortages and so on. It has to square all these problems with offering high-quality care, free at the point of care delivery and based on clinical need. In order to advance the development of an NHS patient safety culture the unique features of the NHS discussed in this column need to be effectively addressed.
In a largely centralised model of healthcare delivery such as the NHS, patient safety culture development cannot be left solely to central government and local NHS trusts. Patient safety crises cases such as East Kent vividly show the need to take more account of individual health professional responsibilities and to emphasise these as well as system approaches when developing patient safety policies and practices.