Going into 2019, the NHS patient safety debate is set to continue as strongly as it did in 2018. The Government is developing a patient safety strategy for the NHS, which it intends to publish this spring. A consultation paper has been issued (NHS Improvement, 2018) and responses are invited by 15 February.
The strategy will sit alongside the NHS Long Term Plan (NHS England, 2019) and will, hopefully, embed safety within it.
Draft patient safety strategy
The consultation paper has some thoughtful provisions. Three principles underpin the strategy: a just culture; openness and transparency; and continuous improvement.
Proposals include: clarifying and standardising safety critical advice and guidance; a cross-system, consistent patient safety curriculum for all current and future NHS staff; closer working between NHS England and NHS Improvement; a network of senior patient safety specialists in providers and local systems; and a dedicated patient safety support team that can be assigned to organisations that are failing in patient safety.
Towards a common understanding
There is an urgent need to educate the NHS workforce and leadership on patient safety (NHS Improvement, 2018). A common understanding is needed in the NHS of the concept of patient safety, which should be taken seriously. Many in the NHS see patient safety as some sort of notional, nebulous concept; it is much misunderstood.
The consultation is to be welcomed as it gives essential, practical direction. The issues are clearly identified:
‘… stakeholders believe we need to address several safety issues: the culture of fear and blame that stifles reporting and learning; the limited staff understanding of safety and associated topics like human factors and ergonomics; the administrative burden on clinical staff; insufficient support for staff and providers; and not enough staff overall.’
CQC view of NHS patient safety
The patient safety consultation paper (NHS Improvement, 2018) should be read alongside the Care Quality Commission's (CQC) report on NHS patient safety, Opening the Door to Change: NHS safety culture and the need for transformation (CQC, 2018). This gives essential context to the consultation. It says:
‘While safety needs to be part of what everyone does, and part of the culture of trusts, it is clear that the NHS does not yet have the right approach.’
This is a hard-hitting publication about patient safety in the NHS. The reader is left in no doubt of the huge difficulties of ingraining a culture of patient safety.
The CQC document (2018) shows a marked similarity to the seminal An Organisation with a Memory report (Department of Health (DH), 2000). The language in both reports is similar, as are the patient safety problems they identify. This poses the question: what has been achieved in NHS patient safety over nearly two decades between the publication of both reports?
Policy since 2000
The NHS has made reasonable progress since 2000 in patient safety policy development and implementation but significant, endemic problems stubbornly persist. Problems raised in 2000 are as relevant today:
‘The NHS does not … 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.’
CQC report
Never events and serious incidents
The CQC (2018) examined underlying issues that contribute to never events and applied its analysis of never events to the wider NHS. Many of the challenges trusts have in implementing guidance to prevent never events apply equally to other areas of patient safety. The CQC identified themes and made recommendations. It defined never events as:
‘… serious incidents that are considered to be wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.’
Never events include wrong site surgery, wrong implant/prosthesis, retained foreign object after a procedure and medication administration by the wrong route. Worryingly, never events continue to happen in the NHS: there were 468 incidents provisionally classified as such between 1 April 2017 and 31 March 2018.
Approximately two million patient safety incidents are reported to the National Reporting and Learning System annually; around 74% of these cause no harm to the patient. Some 21 500 serious incidents in the NHS in England were reported in 2017–2018 (CQC, 2018).
Errors: inevitable or exceptional?
A striking observation in the CQC report's foreword by Professor Ted Baker, chief inspector of hospitals, is on how differently healthcare thinks about safety compared with other high-risk industries. Safety training in these other industries is never optional. Errors are viewed as inevitable and everything is planned with this mindset. There is no hesitation in stopping operational processes if safety is thought to be in any way compromised. Conversely, in healthcare, the mindset is that safety is the norm and that things go wrong only exceptionally:
‘Staff are not expected to make errors. This leads to a search for quick fixes and technical solutions when Never Events occur.’
Guidance and alerts
Patient safety alerts are generally viewed in the NHS as an effective way to disseminate guidance (CQC, 2018). The problem is the context:
‘With the competing pressures on staff … implementing patient safety alerts can be seen as just one more thing to do, and can lead to staff taking a mechanistic and siloed approach to implementation.’
Implementing guidance can be done in an unsystematic manner and fall to multiple people. This can lead to too many adaptations of the same guidance and inconsistency. Trust boards also do not consistently prioritise discussions about never events and patient safety alerts.
Rigid hierarchies
Trust hierarchical structures can lead to unsafe care by harming safety cultures. Poor leadership styles are also an issue. Staff can be afraid to speak up when they see an error being made:
‘Frontline staff told us that some staff, such as junior staff, nurses, or bank staff, are often very reluctant to question surgeons, and some surgeons were known for speaking down to junior staff. We were told about one case where: “Forceps [were] left in the patient, but the nurse flagging the issue was completely dismissed. The patient was only X-rayed due to continued insistence by the nurse and the forceps were in the patient … no one ever apologised to the nurse.”’
Patient safety landscape
The patient safety landscape is confused and complex, with no clear understanding of how it is organised and who is responsible for what tasks. This makes it difficult for trusts to prioritise. Trusts also receive too many safety-related messages from too many sources (CQC, 2018). These issues are longstanding.
For as long as I can remember, the NHS patient safety landscape has been confused and complex. Myriad national and international organisations and stakeholders produce patient safety and healthcare quality information on an almost daily basis. Patient safety has become an industry. Busy NHS staff can find it very hard if not impossible to keep up to date. The internet and social media have compounded this problem.
While patient safety information is now more accessible, the learning burden on staff has commensurately increased. There is information overload and thought needs to be given to how to address this problem.
Education and trainings
Patient safety education is essential to developing an ingrained patient safety culture in the NHS, but this is not happening on the scale that it needs to. It is not easy to identify who is responsible for education or to make it mandatory. Training is needed in understanding human factors and ergonomics, but this has not been implemented. Patient safety training is not a priority for trust leaders in the same way that operational targets are (CQC, 2018).
Peer learning is a problem:
‘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.’
Poor learning from errors and problems in implementing change were also reported in 2000 (DH, 2000).
The ability of trusts to learn from incidents locally and beyond is hampered by slow, unresponsive reporting processes that can discourage staff from reporting incidents.
Recommendations
The CQC makes several recommendations.
First, NHS Improvement should work with Health Education England and others to make sure the entire NHS workforce has a common understanding of patient safety, and the skills, behaviours and leadership culture necessary are in place to make it a priority.
The patient safety strategy must support the NHS to make safety a top priority.
Leaders responsible for patient safety must have training, expertise and support.
Finally, NHS Improvement should work with regulators, royal colleges, frontline staff and patient groups to develop a framework for identifying where processes and other issues, such as equipment and governance processes, can and should be standardised (CQC, 2018: 8).
Conclusion
The reports discussed show the NHS is resolute in its desire to improve safety. Such a commitment has been consistently expressed by governments since at least 2000.
This is welcome but, in reality, it is much easier to think up policies than to implement them. The CQC (2018) says the NHS does not take the right approach; arguably, this has been the case since 2000 (DH, 2000).
Culture change does not happen overnight, but there should have been more progress made over nearly two decades. The CQC (2018) report is the best I have seen on patient safety policy development and what needs to be done to create an effective patient safety culture.