Reading recent press reports of investigation outcomes and other matters relating to patient safety, it is easy to think that all is doom and gloom – that a patient safety culture in the NHS is an unattainable dream. Often, when we read reports of investigations by the Care Quality Commission (CQC) and others, we can see that there are noteworthy good healthcare practices, but that these are so often eclipsed by the poor practice identified. There is a danger of developing a jaundiced view of patient safety in the NHS.
Maintaining a balanced view on the patient safety problems facing the NHS and the solutions available is no easy task. There is a need to steer away from the view that the NHS patient safety system is crumbling. Clearly it is not, but improvements can be made. An ideal standpoint on issues is to strive to become an honest broker of ideas. We need to debate, look at the evidence, balance the issues and hopefully all this will contribute to a good patient safety change agenda.
This is difficult when there are so many stakeholders in patient safety and competing agendas. Being aware of the multitude of factors that drive the debate can help balance views. For one thing, most NHS care episodes go perfectly satisfactorily, which can influence perceptions. On the other hand, there is an infinite demand for scarce NHS resources, and a growing elderly population often presenting with serious interlinked health conditions. The demand on resources is also linked to the fact that medicine does not remain static.
Times Health Commission and cultural problems in the NHS
Rob Behrens, the Parliamentary and Health Service Ombudsman (PHSO), gave evidence to the Times Health Commission (Sylvester, 2023a; 2023b). This was a controversial session during which the PHSO issued some hard-hitting critical statements on several aspects of patient safety in the NHS. Issues discussed included what he termed the ‘toxic’ behaviour of doctors in the NHS. The PHSO also pointed out serious failings in sepsis treatment, maternity services, sexual harassment and so on:
‘The ombudsman warned of a “Balkanisation” of health professionals, with rivalries between doctors and nurses or midwives and obstetricians harming patient care. “For all the brilliance of clinicians quite often they're not very good at working together,” he said.’
The PHSO also argued that patient safety was being undermined by entrenched cultural problems in the NHS (Sylvester, 2023a). The professional duty of candour was discussed and the PHSO said that there are lots of examples of people not being told the truth.
The office of the PHSO occupies a unique position and vantage point in the NHS. The PHSO makes the final decision on complaints that have not been resolved by the NHS in England and he has a vast experience of patient safety matters. These are views that need to be listened to, but there was an important caveat:
‘An NHS spokesman said: “Cases where patient safety is put at risk by culture are very rare in the NHS. The vast majority of care is well delivered by dedicated staff who put patients first, and it's not possible to extrapolate based on a few extreme examples.”’
Acute NHS patient safety problems
There are acute patient safety problems in the NHS, which the PHSO has identified along with many other commentators. These problems are well known, but many stubbornly persist, such as Never Events, and others as discussed by the PHSO. One commentator, the charity Patient Safety Learning, identified a patient safety implementation gap:
‘We consider that a key reason for the persistence of avoidable harm is an “implementation gap” in patient safety in the UK, the difference between what we know improves patient safety and what is done in practice.’
Patient Safety Learning, 2022:6
This gap is a key factor that influences certain perceptions of NHS patient safety and, indeed, a report by the PHSO (2023) has addressed this implementation gap forcefully.
I would argue that it is patently clear that we know what the patient safety problems are, we design good regulatory structures and policies to deal with them, but they persist. Patient safety lessons have not been learnt properly, neither by some organisations nor by certain staff. The healthcare adverse events then recur, another investigation at a national or local level is convened, which makes the same or similar recommendations. The recommendations are ignored or not fully implemented, and we go around and around again.
Daily Mail/MailOnline and hospital Never Events
Ely (2023) discussed the common problem of Never Events in hospitals, but before I discuss the media article it is important to set the contextual scene.
Never Events: official reports
The NHS, in my view, is plagued by patient safety events that should never happen, such as wrong site or wrong-person surgery, foreign bodies left in patients or wrong blood being transfused. The NHS reports these events in regular data summaries.
The latest report (NHS England, 2023) states that there were 179 Serious Incidents that appeared to meet the official definition of a Never Event between 1 April and 30 September in provider organisations such as hospitals and other care facilities. According to the report (NHS England, 2023) there were 92 wrong-site surgery Never Events and 32 recorded cases of a retained foreign object post procedure. There were 7 transfusion or transplantation of ABO-incompatible blood components or organs Never Events recorded, 6 cases where the wrong blood was transfused. Reading the table of Never Events by provider, some have a surprisingly high number.
‘Never Events continue to happen despite the hard work and efforts of frontline staff. 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.’
This is an interesting quote from the CQC, which acknowledges the continued appearance of Never Events but also the pressures that the NHS is working under. That being said, a Never Event by definition should never happen, such events are unforgivable, and patients have suffered serious injury and death because of them.
After reading regular NHS Never Event data summaries, I find they do tend to morph into what could be termed ‘Common Never Events’. The CQC (2018) gave a balanced assessment of the issues, as would be expected of a national regulatory organisation, and the patient safety perceptions discussed in this column can be seen to be present.
Another example would be the report from the Healthcare Safety Investigation Branch (HSIB) (2021) on Never Events. This is an excellent report that brings together valuable insights and perspectives, but to some extent we can find the issues become more diffuse and obscured as other factors come into play and are discussed in detail.
Reporting for the general public
In the MailOnline report by Ely (2023) we can see a sense of moral outrage and indignation over Never Events, and it is difficult to disagree with the sentiments expressed and the tone of the article.
Reports from health regulatory organisations and other stakeholders use different language to the general media, because the audiences and purposes of the report are different from that of, say, a newspaper article read by the population in general. The advantage of reading an article prepared for the public is that the full force and impact of the problem is driven home in clear and unambiguous language. The issues are well and truly stripped down to their basics. There is a clarity of issue and purpose in newspaper articles such as Ely's, which can be missing in the reports by stakeholders.
The full horror of what is happening with Never Events is conveyed excellently by Ely (2023), who quotes data figures on the number that occur. The figures themselves speak volumes and tell the story, along with the description of the type of events. The title and subtitle of the piece gives a taste of what is going to come:
‘Scandal of the NHS “never-events”: Bungling hospital medics are wrongly removing ovaries and leaving drill bits INSIDE patients once a day, shocking audit reveals… so is YOUR trust one of the worst offenders?’
Ely states that a MailOnline audit on NHS data found 4328 Never Events occurring in England since 2013, equating to roughly eight a week. He begins his article by saying:
‘Bungling NHS staff are carrying out the equivalent of one “never-event” every day, figures show.’
He points out they cost an estimated £800 million in compensation each year. The article contains a pictogram listing the ten NHS Trusts and private healthcare providers with most recorded Never Events in the last decade, and another showing the types of Never Events. Ely (2023) also notes the repetition:
‘Officials have repeatedly decried the level of never-events occurring in the NHS and called for bosses to improve patient safety.’
Wrong-site surgery was recorded, he states, on average three times a week in the NHS in 2022–2023. Ely (2023) discusses some past cases and provides commentary from regulatory organisations, stakeholders, and others.
Conclusion
The NHS does seem to get a bad press when patient safety is discussed. That is in reports professionals can be seen to be trying to defend the indefensible. This is not intentional, but is done through detailed analysis, research and consideration of all the factors, themes and perspectives that a patient safety issue raises. In trying to achieve a balanced, well-researched view we perhaps inevitably obscure the central issue.
In discussing the mix, the central problem can sometimes be moved to the back burner. Never Events are a case in point. HSIB (2021) provided an excellent report bringing together key perspectives on Never Events. To the public's mind, however, there can be no excuse for performing the wrong clinical procedure on somebody and getting names mixed up.