It seems that there is never a week that goes by without a media report on a patient safety crisis event – and the frequency with which patient safety policy and practice reports are published is also notable. They emanate frequently from one of the myriad of national and international stakeholders in patient safety, an issue that is a global as well as an acute national problem.
The net result of all this patient safety publication activity is that it is increasingly difficult, if not impossible, for busy nurses, doctors and other health carers to keep up to date. There is seemingly not enough time to unpack and digest the latest report before another one comes along saying the same or similar things. A notable feature of patient safety and health quality reports over the years in the NHS is that they frequently say the same thing. These repeated messages include:
- For health carers' leaders to take patient safety more seriously
- The need to improve lesson learning from past adverse healthcare events
- Not to adopt defensive attitudes and practices when mistakes happen
- To move away from a blame culture
- To improve patient–health carer communication practices.
These are just some of the key messages that lie at the heart of efforts to develop an NHS patient culture. The message repetition pattern indicates that lessons have not been learnt properly. Practice has not changed sufficiently, with the same or similar mistakes being made again.
The patient safety merry-go-round
In the light of the above, is it fair to characterise NHS efforts to handle patient safety crises and develop policy and practice in the area as akin to being on a patient safety merry-go round? It is a never-ending circle of activity. I would argue that, given the history of patient safety in the NHS, this characterisation is accurate.
NHS patient safety history
Over two decades ago, the seminal report, An Organisation with a Memory (Department of Health, 2000), identified key patient safety themes – problems we are still trying to grapple with today. Chapter 5 included a discussion of data gathering, analysis, inquiries and investigations, understanding adverse events, learning culture, active learning.
Even though it was published in 2000, the report is as relevant today as it was then. It can be seen as a marker of the enormity of patient safety problems, the challenges that the NHS has had and still faces. The report (DH, 2000) can be used to show how far we have progressed – or not – in developing a patient safety culture over two decades or more. Many of the problems identified in the report are with us today. Sirrs (2023) provides a useful timeline showing historical developments, with a chronology of patient safety reports. This can be used alongside the 2000 report (DH, 2000) to track NHS patient safety culture development progress and identify milestones.
Danger of patient safety fatigue
It will be seen from Sirrs (2023) that many patient safety reports have been published over the years and continue to be published with alarming regularity. There is a danger that, when the same messages are repeated, time and again, message fatigue can set in. Nurses, doctors and others can become desensitised–they have heard all these messages before. The messages can slip into becoming well-meaning mantras.
Breaking the cycle
There are no easy answers to avoid nurses and doctors becoming overwhelmed and switching off from the important patient safety messaging in the reports. All health workers, including doctors and nurses, need time to reflect and refresh their knowledge on patient safety issues. Education and training are key facilitators for doing this. In an NHS that is constantly resource challenged there are cost and time implications, but investment in study days and conferences etc is crucial. It is a question of prudent use of resources.
A clinical negligence suit brought by a harmed patient will cost far more than sending a nurse or doctor on a study programme or holding a study day where patient safety and legal issues are discussed. The NHS Long Term Workforce Plan (NHS England, 2023) will hopefully help and the following statement is to be welcomed:
‘In addition to improving retention, embedding the right culture will mean the NHS supports staff to lead the transformation needed to provide sustainable, high-quality services. Evidence demonstrates that meeting three core needs of staff – supporting them to have a sense of autonomy, belonging and contribution – transforms working lives, facilitating better productivity and effectiveness and improved patient safety and care.’
Parliamentary oversight
The Parliamentary and Health Service Ombudsman (PHSO) (2023) recently published a report sharing insights from past complaint cases, which analysed 400 health complaint investigations over the past 3 years. In 22 cases the PHSO found that a death ‘was more likely than not avoidable’. By looking at past cases, it is possible to identify trends and themes that can feed improvements into NHS services and complaints processes.
The PHSO (2023) report is a hard-hitting one that reflects many of the points made previously in this column. It recognises that significant patient safety developments have been made in the NHS, but there is what can be termed a chasm, disconnect, an implementation gap between policy and practice. The report states:
‘There have been significant developments in patient safety over the last decade. But there is a concerning disconnect between increasing activity and progress made to embed a just and learning culture across the NHS.’
There is a well-recognised NHS disconnect, an implementation gap – one that was clearly outlined in Mind the implementation gap. The persistence of avoidable harm in the NHS, a report from Patient Safety Learning (2022).
It is useful to read the recently published report by the Professional Standards Authority (PSA) (2022) alongside the two from the PHSO (2023) and PSA (2022). PSA (2022) identifies what it describes as structural flaws in the safety framework – that the NHS patient safety system is fragmented, complex, and that issues can fall between organisations or are left unresolved:
‘Large-scale failures of care still occur frequently, and inquiries and reviews highlight similar themes and issues, with the system seemingly unable to prevent their recurrence. Each body looks at the problems principally through the lens of its own remit, often prejudging the nature of the solutions as a result.’
PHSO (2023) continues this theme of complexity and fragmentation. It has been a common theme over the years in several patient safety reports:
‘… political leaders have created a confusing landscape of organisations, often in knee-jerk reaction to patient safety crisis points.’
The PHSO (2023) report states that there are significant overlaps in functions of patient safety regulatory and health governance organisations, such as the Healthcare Safety Investigation Branch (HSIB), NHS Resolution and so on. This creates uncertainty about organisational remit and responsibility. The PHSO goes on to state that this leads to patient safety voice and leadership being left fractured.
Organisations, states the PSA report (2022), look at problems through their own prism and can prejudge issues. The PHSO (2023) report makes several recommendations, focusing on two areas:
- Accountability for a robust and compassionate response to harm, which supports learning for systems and healing for families
- An undertaking that patient safety is a top priority for both government and the NHS.
Recommendation 5 made in the PHSO (2023) report is particularly challenging:
‘The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like. The review must include meaningful engagement with NHS leaders, staff, patients, and families.’
No need for radical reform
I am not convinced the government would agree to adopt the above recommendation. The PSA's report (2022) also makes some far-reaching recommendations for structural change. Even though the NHS has a complex, fragmented and, arguably, overengineered health regulatory, governance and patient safety framework, significant progress has been made towards developing a patient safety culture, as discussed in previous BJN columns. The NHS Patient Safety Strategy (NHS England and NHS Improvement, 2019) and the initiatives that come under this are just one example.
It is not a good idea to throw the baby out with the bath water. It should also be noted that not all NHS trusts are at the same stage of patient safety culture development, with some being more advanced than others. We need a period of calm to let all the NHS patient safety activity under way and that undertaken over recent years to take root and become embedded. From government responses to reports so far this would appear to be the favoured option, rather than root and branch reform.
A wide area of patient safety traversed
The PHSO report (2023) traverses a wide ground of patient safety issues at broad policymaking level, as well as identifying the clinical failings in the 22 cases the report analyses. Four broad themes of clinical failings leading to, what the report terms, ‘avoidable death’ were identified, namely PHSO, 2023:8):
- Failure to make the right diagnosis
- Delays in providing treatment
- Poor handovers between clinicians
- Failure to listen to the concerns of patients or their families.
Conclusion
I have argued that patient safety policymaking and practice in the NHS can be likened to a merry-go-round, with endless attempts at producing well-meaning patient safety reports, and changes to health regulatory and governance infrastructures, but that the crises continue to occur on a worryingly frequent basis.
I have highlighted the danger that NHS staff could be turned off and desensitised to patient safety issues by the tide of literature that is constantly being produced, repeating the same core messages. There is a risk of patient safety fatigue setting in, with the result that the important recurring patient safety messages will be lost or simply be seen as well-meaning mantras.
There are no easy answers to the problems identified in this column. It is important, however, to raise them to keep the debate going. An agenda for change needs to be created and all the reports discussed make excellent contributions to achieving this.